The below article delves into the NTSB Group Chairman’s Report on Operational Factors involved in the November 29, 2013 crash of a Hageland Aviation d/b/a Era Alaska Cessna 208B Caravan at St. Mary’s, AK. This is NOT the final findings of the Board, but the information contained in this document should be noted.
Aviation in Alaska is different. In part, it is driven by the unique weather conditions experienced in the 49th state and that along with Hawai’i, it depends on aircraft as their primary form on intrastate transportation. At the same time and partially in recognition of both of these factors, it is home to the Capstone Program, which brought ADS-B to the airspace, earlier than the lower 48 states. None of these observations can justify this crash.
The Report makes it clear that the company’s pilots were loose in their adherence to procedures defined in its operational control procedures. An FAA representative characterized it as a “Bush Pilot” mentality.
The airline implemented a requirement that the pilot, before departing, must meet with the flight coordinator to assess the risks of the flight and to determine if mitigations would make the operation within safety parameters. The flight coordinators did the required assessment, assigning a level 2 because of the IMC conditions, contaminated runway and night situation. The pilot did not engage the flight coordinator in a review of the risk assessment.
The flight departed, it encountered heavy fog, it accumulated ice and the pilot was unable to locate its original or secondary location. The plane impacted into a ridge several miles past the airfield.
Clearly, the company’s procedures, designed to avoid the specific risk encountered, were not followed. During the early NTSB investigation, an “urgent safety recommendation” was issued declaring that the airline must improve its regulatory compliance and safety of its operations. The NTSB office manager there is quoted as saying has made “monumental” upgrades including an operations center which insures that all procedures will be followed.
While the company had a risk assessment procedure in place it must have had gaps that allowed the PIC to bypass a risk review requirement. If the company had implemented a Safety Management System before the accident, which included a Flight Risk Assessment protocol to be completed by the PIC and, signed off by operations/dispatch that accident may have been avoided. Maybe this PIC had a history of disregarding internal safety procedures, something that an SMS can help identify, especially if a strong safety culture and reporting system is in place. A good SMS program and manager could have designed a response to the pilots’ failure to use the risk assessment and resulted in the preflight consultation between the pilot and the flight coordinator. Finally, these remediations would be implemented due to the SMS discipline, not the tragic consequences of the November 29 flight.
Another theme of the article is the FAA manager points out that the company had 1,200 flights a week with 56 aircraft. He also mentions that the FAA only had three inspectors to surveil this large schedule. That staffing level is the outcome of Congressional reduction of the agency’s budget; thus it is not likely that this office or any other FSDO will receive increased manpower.
Senior management recognizes this unfortunate reality and has created a methodology for its organization like SMS. System Approach for Safety Oversight Program (SASO) relies on the information generated by the airline’s SMS and then prioritizes the task of the office’s personnel. The days of inspectors randomly surveilling the certificate holders and instead SASO’s statistical analysis points their focus to the areas needing the most attention. The theory is that such methodology would have increased the likelihood of Era Alaska’s closer adherence to its procedures.
The combination of the airline’s’ SMS process and of the FAA’s implementation of SASO will doubly reinforce the safety culture which fosters constant efforts to reduce the risk margin. SMS and SASO are intended to compel all involved in aviation safety to find and address potential problems before they occur—from reactive to proactive.
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