1987 — Nov 23, Ryan Air Flight 103 (Beechcraft 1900C) approach crash, Homer, AK– 18

–18  Aviation Safety Network. Accident description. “…Beechcraft 1900C…Ryan Air Service.”

–18  B3A (Geneva, Switzerland). “Crash of a Beechcraft 1900C in Homer: 18 killed.”

–18  NTSB. AAR. Ryan Air Service, Inc., Flight 103, Beech Aircraft Corp. … 12-20-1988, ii.

–14  OJP, DOJ. Community Crisis Response Team Training Manual: 2nd Ed. (Appendix D).[1]

 

Narrative Information

 

ASN: “Location:         Homer Airport, AK…

“Phase:                        Approach.

“Nature:                      Domestic Non Scheduled Passenger

“Departure airport:      Kodiak Airport, AK…

“Destination airport:   Homer Airport…

“Flight number:           103

“Narrative:                  Flight 103 was fully loaded (all 19 seats occupied; 1437 pounds of cargo) when it took off from Kodiak runway 07. The aircraft lifted off the runway, fell back and accelerated for about another 15 knots before it became airborne. The aircraft was approaching Homer at 18:19 when it was cleared for the localizer/DME approach to runway 3. The crew reported a 2-mile final 5 minutes later. On short final the wings were seen to rock back and forth; the aircraft then dropped steeply to the ground in a rather flat attitude, struck the airport perimeter fence and slid to a stop on its belly….” (ASN)

 

NTSB: “Abstract: About 1825 on November 23, 1987, a Beech Aircraft Corporation 1900C (Be 1900), N401RA, operated by Ryan Air Service, Inc., crashed short of runway 3 at the Homer Airport, Homer, Alaska. Flight 103 was a scheduled Title 14 Code of Federal Regulations Part 135 flight operating from Kodiak, Alaska, to Anchorage, Alaska, with intermediate stops in Homer and Kenai. Both flight crewmembers and 16 passengers were fatally injured; 3 passengers were seriously injured

 

“The National Transportation Safety Board determines that the probable cause of this accident was the failure of the flightcrew to properly supervise the loading of the airplane which resulted in the center of gravity being displaced to such an aft location that airplane control was lost when the flaps were lowered for landing.” (p. ii.)

 

“Executive Summary:  About 1825 on November 23, 1987, a Beech Aircraft Corporation 19OOC (Be 1900), N401RA, operated by Ryan Air Service, Inc., crashed short of runway 3 at the Homer Airport, Homer, Alaska. Flight 103 was a scheduled Title 14 Code Federal Regulation Part 135 flight operating from Kodiak, Alaska, to Anchorage, Alaska, with intermediate stops in Homer and Kenai. Both flightcrew members and 16 passengers were fatally injured; 3 passengers were seriously injured….

 

The safety issues discussed in the report include:

 

• The performance of the Beach 1900;
• The Federal Aviation Administration’s oversight of Ryan; and
• Ryan’s management of its operation.

 

“Safety recommendations were addressed to the Federal Aviation Administration and the National Fire Protection Association.” (p. v.)

 

“History of the Flight…. On November 23, 1987, Ryan Air Service, Inc. (Ryan), was operating a Beech (Be) 19OOC, N401 RA, as a regularly scheduled, passenger flight from Kodiak, Alaska, to Anchorage, Alaska, with intermediate stops in Homer and Kenai, Alaska. N40l RA, as RYA 102, departed Anchorage, where its fuel tanks were filled at 1605, and it arrived in Kodiak at 1709.

 

“In Kodiak, the airplane was redesignated as RYA 103 with the same flightcrew. Seventeen male passengers, many of whom were hunters, and 2 female passengers, boarded the airplane and occupied the 19 available seats.

 

“The airplane was emptied of cargo and no fuel was added. The Kodiak station agent stated that the first officer asked that the airplane be loaded “with 1,500 pounds of cargo.” The agent thought the first officer’s request was unusual because previous Be 1900 pilots, when operating with a full passenger load, had asked for 1,100 or 1,200 pounds of cargo. The station agent also said that the first officer told her, “Before we could get the 1,500 pounds on board, it would bulk out.”

 

“The baggage loader stated that, with the assistance of the captain and first officer, he loaded cargo into the compartments. In addition to suitcases, gun cases, frozen crabs, and two dogs in kennels, the cargo included “approximately 13-14 pieces” of packaged venison that weighed 795 pounds. The venison, which was destined for Kenai, had been stored overnight. The teletyped loading information from the Kodiak station agent to the Homer station agent indicated that 160 pounds of cargo was destined for Homer, 1,010 pounds for Kenai, and 267 pounds for Anchorage (a total of 1,437 pounds).

 

The baggage loader stated that, after loading the cargo, the tailstand was “about 1 inch from the ground,” and the lowest to the ground that he had ever seen a tailstand. He stated that typically the tailstand came to within “3 to 4 inches, maybe more” of touching the ground…. [p. 1.]

 

“A passenger on RYA 103 testified that he thought the airplane would “never become airborne” during the takeoff. He said that after the main gear lifted off the runway, the airplane then fell back to the runway and “accelerated for about another 15 knots” before it became airborne. The passenger stated that the airplane then seemed to climb out rather steeply….

 

“Ground witnesses described RYA 103 when it was on a short final approach to the Homer airport. Its wings began to rock back and forth and then it dropped steeply to the ground in a rather flat attitude. The airplane struck the airport perimeter fence before sliding to a stop on its belly…. [p. 2.]

 

“Wreckage and Impact Information…. According to rescue personnel, none of the passenger seats were found attached to the floor or side wall seat tracks. Seat back frames were twisted and bent, and several had separated from the pivot bracket that attached them to the seat pan frame. Seat pan frames had separated and were bent downward. The seat pan fabric that supports the seat cushion was torn through. Several seats were missing one or both seat legs, while some seats had separated legs. The seatbelts were found attached to the seats and were fully operational…. There was no fire.

 

“Medical and Pathological: The captain and 13 passengers were found fatally injured at the wreckage. The first officer and 6 passengers were alive. They were transported to local hospitals where their conditions were stabilized. The seven survivors were then transported by air to hospitals in Anchorage. The first officer and one passenger died en route and two passengers died in the Anchorage hospital on November 24. The 18 who were killed died as a result of the blunt force musculoskeletal and internal injuries that had been sustained during the impact sequence.” [p. 8.]

 

“Three passengers who survived had sustained serious injuries. A 16-year-old male in seat 3-B, a

26-year-old male seated in either seat 7A or seat 8A, and a 22-year-old female who had been in seat 6B….” [p. 10.]

 

“Crash:  The passenger seats were certificated according to the inertia loads in 14 CFR 23.561, i.e., 3.0 G. upward, 3.0 G. downward, 9.0 G. longitudinal, and 1.5 G. lateral. These values are increased by 1.33 to take into account the strength of the fittings or attachments for the seats. Beech exceeded the requirements 14 CFR Part 23 and statically tested the seats to the following criteria: 5.25 G. upward, 8.25 G. downward, 12 G. longitudinal, and 2.85 G. lateral. The three-place bench seat was tested to 4.2 G. upward, 7.2 G. downward, 12 G. longitudinal, and 2.4 G. lateral.

 

“Using the airplane’s attitude at impact, an assumed impact velocity, and the crush damage to the fuselage, the Safety Board determined the values of the average accelerations that occurred at initial impact along the airplane’s longitudinal, lateral, and vertical axes. The range of those accelerations were 7.01 to 10.40 Gs. longitudinal, 4.8-7.23 Gs. lateral, and 19.80-35.7 Gs. vertical. The vertical velocity change was about 42 feet per second….” [p. 10.]

 

 

“Flight 103 Weight and Balance…. The landing weight of RYA 103 at Homer was calculated at 184.3 pounds over the maximum allowable landing weight, with a CC located 11.20 inches aft of the limit….” [p. 13.]

 

“Ryan Air Service, Inc. …. the person who was appointed in 1984 to be the director of operations was dismissed in February 1987. He told the Safety Board that he personally investigated employee allegations of improper weight and balance determinations and disciplined employees when they failed to follow correct procedures. For example, he disciplined a station agent who, according to several company pilots, attempted to coerce pilots to fly overweight aircraft…. [p. 16.]

 

“FAA Surveillance…. The FAA recorded 22 enforcement actions against Ryan from December 1980 to the time of the accident. Ten letters of corrections concerned pilot recordkeeping (3), airport security (2), hazardous materials (l), operations specifications (2); a forward observer seat

(1), and multiengine operation with inoperative instruments or equipment installed (1). Six warning letters concerned recordkeeping (2), maintenance (2), use of noncurrent aeronautical charts (l), and airport security (1)…. On March 3, 1985, Ryan Air Service, Inc., paid a $9,000 civil penalty for using the services of a nonqualified pilot-in-command for commuter air carrier operations. This penalty was the most that Ryan had actually paid in fines for violations of FARs.

 

“On September 17,1986, an FAA inspector was contacted by a former Ryan Air Service mechanic. The Ryan employee stated that he was representing three Ryan pilots who alleged that Ryan was pressuring its pilots to fly overweight/unsafe aircraft. The pilots were willing to cooperate with the FAA by providing documentary evidence of alleged instances of Ryan’s overweight operations and direct testimony that Ryan’s management condoned and encouraged the overweight operations. However, they were willing to cooperate with the FAA only on the condition that they be granted immunity from prosecution by the FAA. One of the pilots was the captain of RYA 103, who was a first officer at the time.

 

“The FAA inspector forwarded the request for immunity to his superiors in the flight standards division of the FAA’s Alaska Region. In turn, that request was forwarded to the Alaska Regional Counsel. The request for immunity was denied. The FM inspector was told of the decision, and he informed the former Ryan Air Service mechanic who had made the request. The Regional Counsel said that after deliberating the matter, only the U. S. Attorney was empowered to grant immunity. He did not contact the U.S. Attorney because he considered it a third party request with “little or no support.” There is no evidence that he took other action on the request. However, in response to the allegations, the FAA’s FSDO inspected Ryan’s weight and balance procedures and examined records of weight and balance calculations of Ryan flights performed during the prior 30-day period. The result of this inspection was the finding of one incorrect weight and balance determination of a Ryan flight. As a result, the FSDO processed a violation against Ryan.

 

“At the time of the accident, one FAA Enforcement Investigative Report relating to recordkeeping, pilot training, and testing was in progress. Findings were a result of a February 1987 base inspection of Ryan. The POI, who had documented the alleged violations, characterized the violations as “flagrant” and testified that he initially had recommended a total of $250,000 in civil penalties against Ryan. He based the size of the recommended civil penalty on a FAA formula which provided the maximum civil penalty of $1,000 for each violation, multiplied by the number of months that each violation existed. The POI had submitted the recommended civil penalty with what he considered sufficient supporting documentation through his superiors within the FSDO-63 and the flight standards division of FAA’s Alaska Regional Office. All recommended penalties were then forwarded to the FAA’s Alaska Regional Counsel. The Regional Counsel’s office twice returned the violation enforcement case to the POI. They asked for additional documentation to support the recommended penalties. In reconsidering the sanction, the POI stated that he had considered recommending that Ryan’s Air Carrier Operating Certificate be suspended; however, such action would have seriously affected Ryan’s work force and would have disrupted air service to a number of small communities in Alaska. As a result, the POI decided to propose a large civil penalty, which he believed would have as much of an impact on Ryan as a certificate suspension but without impact to its employees or passengers. In addition, he believed that a civil penalty was consistent with previous FAA actions against similar alleged violations which were upheld in various appeal processes.” [end of p. 20.]

 

“After the second disapproval of the recommended penalty, the POI recalculated his recommended sanction against Ryan, using a formula provided to him by the Regional Counsel and then resubmitted the violation enforcement case along with a new recommendation that Ryan be assessed a $25,000 civil penalty. The Regional Counsel’s office subsequently reduced the amount of the recommended civil penalty to $16,500 because it believed the supporting evidence was inadequate….

 

“Following the accident and after allegations about the safety of Ryan’s operations and the degree of its compliance with Federal Aviation Regulations (FARs), the Alaska Regional Counsel, on December 30, 1987, issued an Order of Investigation of Ryan Air Service, Inc., to determine Ryan’s compliance with FARs. The FAA assembled a team of inspectors to conduct a special inspection of Ryan Air Service, Inc. The inspection began in early January 1988.

 

“During its inspection of Ryan’s maintenance facilities, the special inspection team found that during the previous 6 months, Ryan’s airplanes had not been maintained in accordance with an FAA-approved maintenance manual. That is, Ryan’s methods of rounding the number of hours accrued by an airplane at times resulted in required inspections being performed several hours after the inspection has actually been required. The leader of the inspection team stated that violations found by the team were “sufficiently obvious” and that he believed Ryan’s intent to violate FARs could be discerned. As a result of the team’s findings, the evidence from the November 23, 1987, accident, and previous documented deficiencies, the FAA discontinued the inspection and initiated a consent order. Under this order, Ryan agreed to cease operations until changes in company management and procedures had been carried out. Ryan agreed to the consent order and ceased its operations in January 1988. Ryan resumed operations, on a considerably smaller scale than before the accident in the summer of 1988….

 

“Accident History: According to the Safety Board’s accident/incident data, Ryan airplanes were involved in 10 accidents with 12 fatalities to the time of the accident….” [p. 21.]

 

 

“Aircraft Performance…. The results of the investigation indicate that the loss of control of Ryan Air flight 103 resulted directly from an excessively aft CG [center of gravity]. The out-of-limits CG occurred because the aft cargo compartment had been loaded with from 1,600 to 1,800 pounds of cargo. With the passenger and fuel load present on RYA 103, any cargo weighing more than approximately 850 pounds in the aft compartment would have displaced the CG beyond the aft limit. The CC would have moved still further aft as the airplane consumed fuel.

 

“The investigation indicated that the total weight of the cargo including carry-on articles and the two hunting dogs was 2,283 pounds. Assuming an allowance of 150 pounds for carry-on articles,

then RYA 103 was overloaded about 600 pounds beyond the first officer’s request. This resulted in a CG that was 8 to 11 inches aft of the aft limit.

 

“The Safety Board believes that the baggage handler may have become confused when the first officer said, “Before we get the 1,500 pounds on board, it would bulk out.” Had the airplane been loaded in accordance with the first officer’s request of 1,500 pounds, the accident might have been avoided. A 1,500-pound cargo load, assuming that 250 pounds was placed in the forward compartment, would have resulted in a CG about 3.5 inches aft of the rear limit, and according to the results of the flight test, even with the CG this far aft of the limit the airplane could have been controllable….” [p. 23.]

 

“….the Safety Board believes that because of the extreme aft CG, and pilot actions to regain airplane control following flap extension, the airplane stalled as the pilot raised the flaps….”

 

“Pilot Performance: The evidence indicates that the flightcrew of RYA 103 disregarded company procedures in loading the airplane. They failed to properly complete the weight and balance card before they began to taxi, and they failed to accurately determine within an acceptable CC range the amount of cargo that should have been loaded into the airplane. Further, they recorded an incorrect CG in the airplane log. Because Ryan developed and the FAA accepted crew procedures for each of these steps, the Safety Board attempted to examine why the crew failed to follow them.

 

“The evidence indicates that the first officer, within proximity to the captain, gave improper directions to the ramp agent on the amount of cargo to place on the airplane. The captain failed to counter the direction of the first officer as he should have. It is possible that the first officer’s status within the company, a managerial figure involved in training, may have influenced the captain to keep silent when prudence should have dictated otherwise.

 

“Yet, given the first officer’s position in the company, as someone responsible for the training of others, the Safety Board is concerned about his disregard of regulations and procedures. As a training instructor, he should have been especially sensitive to the need for strict adherence to [end of p. 24] procedures concerning weight and balance. However, he was a relatively junior pilot on the Be 1900 with considerably less experience on that airplane than he had accrued on single-engine and light, twin-engine airplanes. It is possible that his direction to the ramp agent reflected more his knowledge of other, less sophisticated airplanes with their considerably smaller cargo capacities and where such procedures, while improper, may not have had the same effect on airplane control as they had on the more sophisticated Be 1900. Moreover, in the Alaskan aviation environment, such attitudes often characterize what the Safety Board has referred to in the past as the “bush pilot syndrome” This syndrome describes “a pilot’s casual acceptance of the unique hazards of flying in Alaska to a pilot’s willingness to take unwarranted risks to complete a flight.” The Safety Board believes that, given the first officer’s extensive experience flying light, relatively unsophisticated aircraft in remote areas of Alaska and his relative inexperience in flying sophisticated aircraft in scheduled 14 CFR Part 135 operations, he may have manifested this attitude in giving directions to the ramp agent in Homer….” [p. 25.]

 

 

 

 

Sources

 

Aviation Safety Network. Accident description. “…Date: Monday 23 November 1987. Time: 18:25. Type: Beechcraft 1900C. Operator: Ryan Air Service…Fatalities: 18 / Occupants: 21.” Accessed 10-23-2016 at: https://aviation-safety.net/database/record.php?id=19871123-0

 

B3A (Bureau of Aircraft Accident Archives, Geneva, Switzerland). “Crash of a Beechcraft 1900C in Homer: 18 killed.” Accessed 10-23-2016 at: http://www.baaa-acro.com/1987/archives/crash-of-a-beechcraft-1900c-in-homer-18-killed/

 

National Transportation Safety Board. Aircraft Accident Report. Ryan Air Service, Inc., Flight 103, Beech Aircraft Corporation 1900C, N401RA, Homer, Alaska, November 23, 1987 (NTSB/AAR-88/11). Washington, DC: NTSB, 12-20-1988, 93 pages. Accessed 10-23-2016 at: http://libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-reports/AAR88-11.pdf

 

Office of Justice Programs, United States Department of Justice. Community Crisis Response Team Training Manual: Second Edition (Appendix D: Catastrophes Used as Reference Points in Training Curricula). Washington, DC: OJP, U.S. Department of Justice. Accessed at:  http://www.ojp.usdoj.gov/ovc/publications/infores/crt/pdftxt/appendd.txt

 

 

[1] Have no explanation of OJP fatality error. OJP erroneously notes 12 survivors when in fact there were three.