1977 — Sep 6, Alaska Aeronautical Industries flight 302 Plane Crash, Mt. Iliamna, AK– 13

–13  Liefer. Broken Wings: Tragedy & Disaster in Alaska Civil Aviation. 2003, pp. 199-208.

–13  NTSB. AAR-Alaska Aeronautical Industries, inc…Iliamna, Alaska, September 6, 1977. p. i

 

Narrative Information

 

NTSB abstract: “About 1452 Alaska daylight time, on September 6, 1977, Alaska Aeronautical Industries, Inc., Flight 302 crashed into a glacier on the southwest side of Mt. Iliamna, Alaska, about 7,000 feet above mean sea level.[1] The aircraft crashed in level flight in instrument meteorological conditions while en route from Iliamna, Alaska, to Anchorage, Alaska. There were 2 crewmembers and 11 passengers aboard the aircraft; there were no survivors. The aircraft was destroyed. Because of the rapidly changing environmental conditions on the glacier face, recovery of bodies or wreckage was not possible.

 

“The National Transportation Safety Board determines that the probable cause of the accident was the failure of the flightcrew to use proper navigational procedures for the route to be flown, especially their failure to use the available backup means of navigation to verify the position and the progress of the flight.” [Abstract, p. i.]

 

“….History of the Flight. On September 6,  1977, Alaska Aeronautical Industries, Inc., Flight 302, a DeHavilland DHC-6-20…operated as a scheduled flight from Iliamna, Alaska, to Anchorage, Alaska….

 

“Flight 302 departed Iliamna at 1419 with 11 passengers and 2 crewmembers on board. In was cleared to Anchorage on an instrument flight rules (IFR) flight plan… The flight was to maintain 7,000 ft….” [p. 1.]

 

“After several unsuccessful attempts to contact Flight 302 by several air traffic control facilities between Iliamna and Anchorage and after the flight could not be detected on radar in the areas where radar coverage was available, Anchorage Center initiated the required actions to alert and notify appropriate authorities of a possible aircraft accident. U.S. Air Force search and rescue aircraft located the wreckage site at 1643 on September 7, 1977. The aircraft had struck a glacier face on the southwest side of Mt. Iliamna[2] at the 7,000 ft. elevation. [end of p. 2.]

 

“….Aircraft Information. The aircraft was certified and maintained in accordance with Federal Aviation Administration (FAA) requirements….The aircraft was not equipped with sufficient low frequency (ADF) navigational radio receivers for the flight from Iliamna to Anchorage. [end of p. 3.]

 

“14 CFR 135.159(a)(5) states:

 

• No persons may operate an aircraft under IFR or in extended over-water operations unless it has at least the following radio communications and navigational equipment appropriate to the facilities to be used and able to transmit to, and receive from, at any place on the route, at least one ground facility…

 

(5) Two independent receivers for navigation.

 

“The safety Board requested that the FAA furnish an official interpretation of this regulation. In their reply the FAA stated, ‘under these circumstances (those of this accident), it is our opinion that operation of the aircraft with only one low frequency navigational receiver available in the aircraft did not comply with the requirement…Statements made by company personnel during the accident investigation and at the public hearing disclosed that the company and its flight crewmembers had the same understanding of the regulation, and flight operations were to be conducted accordingly….

 

“Company policy was to schedule the aircraft with two DF receivers on the flights to Iliamna. This was the case on the day of the accident; however, the aircraft originally scheduled had maintenance difficulties early in the day. A decision was made by a company representative, whose responsibilities did not include the dispatch of aircraft, to substitute N563MA to fly the trips of the originally scheduled aircraft, including the trip to Iliamna. The captain accepted this decision. [End of p. 6.]

 

“Investigation revealed that the properly equipped aircraft originally scheduled for the Iliamna flight was repaired and available for the flight. However, as far as could be determined, the captain was never informed of this nor did he inquire as to the other aircraft’s maintenance status…. [p. 7]

 

“Company Maintenance Practices. A review of the company’s maintenance practices disclosed that aircraft spare parts were not tagged or otherwise identified as to their operational status. Serviceable parts were intermixed with unserviceable parts. The ompany’s Chief of Maintenance stated that he knew the exact condition of each item in stock and, therefore, there was no need to tag them. He stated further that if replacement parts were needed, he could determine the condition of the item. At the public hearing, company pilots and company maintenance personnel were confused as to the correct use of the maintenance logbook. Their opinions varied when asked to determine from  logbook page entry the status of individual parts which had been reported deficient or the airworthiness of an aircraft to be flown on a particular flight.

 

“Company Training Practices. A review of the company training records and testimony at the public hearing disclosed that often crewmembers did not receive training required by the company training manual before they became a first officer or a captain. When training was received, it was usually the minimum required by the manual, which was the case for the two crewmembers of the accident aircraft…. [p. 13]

 

“Analysis….The Safety Board concludes that the operational control exercised by company management was deficient because N563MA was dispatched for the flight from Anchorage to Iliamna by a company representative who had no knowledge of the navigational equipment requirements for the flight and whose responsibilities did not include the assignment or the dispatch of company aircraft. Company personnel with this knowledge and responsibility were available, but were not consulted. The aircraft originally scheduled for the flight was equipped with two ADF receivers.

 

“The FAA regulations give the pilot the ultimate responsibility to accept or refuse an aircraft for a flight based on his own judgment of the situation. The Board was unable to positively identify the reason or reasons why the pilot did not exercise his authority to refuse this aircraft. He was either not aware of the requirement for two ADF receivers on the route to be flown or he knowingly disregarded it. In view of the pilot’s experience and qualifications, and the company’s stated policy in this regard, it is unlikely that he was not aware of the requirement. It is equally unlikely that he would willingly disregard the requirement without reason. One reason for the pilot’s acceptance of the aircraft could have been his desire to complete the day’s flights. This was his last trip after a long day of flight in adverse meteorological conditions. Also, the flight to Iliamna was already late leaving Anchorage. These two factors could have been inducement enough for the pilot’s actions.

 

“Another possibility was pressure placed on him by the company to complete the assigned flight in the assigned aircraft. Testimony at the Safety Board’s public hearing revealed that, on at least one occasion, a captain was dismissed by a company official for his refusal to accept a flight because of adverse weather which was forecast for the proposed route of flight. Other instances of company pressure of this kind were reported to the Board during the investigation….

 

“During its investigation and public hearing, the Safety Board realized that the company’s management of operations, its training program, its maintenance practices and procedures, and FAA’s surveillance of these areas were inadequate. Improper aircraft scheduling and dispatch procedures and the failure by management to assign these responsibilities to key company personnel places an undue decisionmaking burden on the individual pilots. This burden is increased when other pressures, such as the threat of disciplinary action, are brought to bear on the pilot when company management does not agree with his decisions….”   [pp. 18-19]

 

Safety Recommendations

 

“As a result of this accident, the National Transportation Safety Board recommended that the Federal Aviation Administration:

 

Revise the surveillance requirements of commuter airlines by FAA inspectors to provide more stringent monitoring… [p. 21]

 

…insure that an adequate number of inspectors are assigned to monitor properly each operator….

 

(NTSB. Aircraft Accident Report — Alaska Aeronautical Industries, inc., DeHavilland DHC-6-200, N563MA, Near Iliamna, Alaska, September 6, 1977. 1978.)

 

Liefer: After reviewing the list of problems uncovered by the NTSB investigation, Liefer writes: “There was not one problem or error that stood out among the others as a direct cause of the accident, but rather a combination of several mechanical, operational and human errors, which came together and magnified until they resulted in a terrible tragedy.” (p. 202.)

 

Sources

 

Liefer, G. P. Broken Wings: Tragedy & Disaster in Alaska Civil Aviation. Blaine, WA: Hancock House, 2003.

 

National Transportation Safety Board. Aircraft Accident Report — Alaska Aeronautical Industries, inc., DeHavilland DHC-6-200, N563MA, Near Iliamna, Alaska, September 6, 1977 (NTISUB/D/104-005). Washington, DC: NTSB, May 4, 1978, 31 pages. Accessed 1-1-2018 at: https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR7805.pdf

 

[1] Liefer notes this “was almost thirty miles off the IFR [instrument flight rules] route…” (p. 203.)

[2] NTSB footnote indicates that “Mt. Iliamna is located about 58 nmi east-northeast of Iliamna Airport…”