[Peetwo]

NTSB ANC14MA008 - A classic Reason model (causal chain).

Courtesy AvWeb:

NTSB: Chain Of Choices Behind Alaska Crash


By Mary Grady | February 29, 2016



A fatal crash in Alaska in November 2013 was initiated by one small mistake by the pilot -- a missed frequency change, which meant the lights failed to come on as expected at the destination airport -- but in the NTSB's final report, issued on Friday, the safety board said a chain of events and decisions by the pilot, the company he worked for and other company employees all contributed to the accident. "The pilot's decision to initiate a visual flight rules approach into an area of instrument meteorological conditions at night and the flight coordinators' release of the flight without discussing the risks with the pilot … resulted in the pilot experiencing a loss of situational awareness and subsequent controlled flight into terrain," the NTSB said. Witnesses found the airplane an hour after the crash, but the pilot and three passengers died, including an infant being carried by his mother. 


The pilot was flying a Cessna 208B Grand Caravan with nine passengers on board as a VFR scheduled commuter flight. The flight coordinator noted several risks -- instrument meteorological conditions, night conditions and contaminated runways at both destination airports -- but these were never discussed with the pilot, as company policy required, the NTSB said. About 18 miles from the first destination, the airplane encountered thick fog, and the pilot diverted toward an alternate airport. Post-accident examination of the pilot's radio showed that the Caravan's audio panel was still selected to the ARTCC frequency rather than the destination airport frequency, so the pilot-controlled lighting would not have activated. Witnesses on the ground saw the airplane fly over the airport at a relatively low altitude, about 300 to 400 feet. The airplane impacted the top of a ridge about 1 mile southeast of the airport at an elevation of about 425 feet MSL in a nose-high, upright attitude.

Probable cause(s), from NTSB summary:

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:

• The pilot's decision to initiate a visual flight rules approach into an area of instrument meteorological conditions at night and the flight coordinators' release of the flight without discussing the risks with the pilot, which resulted in the pilot experiencing a loss of situational awareness and subsequent controlled flight into terrain. Contributing to the accident were the operator's inadequate procedures for operational control and flight release and its inadequate training and oversight of operational control personnel. Also contributing to the accident was the Federal Aviation Administration's failure to hold the operator accountable for correcting known operational deficiencies and ensuring compliance with its operational control procedures.
  

 
For a point of comparison between ATSB/CASA v NTSB/FAA complimentary actions in AAI & regulatory oversights, here is the organisational & management section off the FR:

ORGANIZATIONAL AND MANAGEMENT INFORMATION


Hageland Aviation Services is a 14 CFR Part 135 air carrier that holds on-demand and commuter operations specifications and is authorized to conduct business exclusively under the business names "Hageland Aviation Services, Inc." or "Era Alaska." The company headquarters are located at the Ted Stevens Anchorage International Airport, Anchorage, Alaska. The president, director of operations, and chief pilot in place at the time of the accident all resided in Anchorage. The director of maintenance resided in Palmer, Alaska.



At the time of the accident, Hageland operated 56 airplanes and employed about 130 pilots. The company had 12 bases located throughout Alaska at Anchorage, Palmer, Aniak, Barrow, Bethel, Deadhorse, Fairbanks, Galena, Kotzebue, Nome, St. Mary's, and Unalakleet.



According to the company's GOM, the flight coordinator had operational control for the accident flight, and the flight coordinator and pilot-in-command (PIC) were jointly responsible for preflight planning, flight delay, and release of the flight, which included the risk assessment process. Authority for operational control is specified in federal regulations, the company's operations specifications, and the procedures outlined in the GOM. In all, about 80 flight coordinators and 96 company pilots were allowed to release flights and exercise operational control on behalf of the company.



A review of the company's FAA-approved operations training manual revealed that flight coordinator training was required for personnel authorized to exercise operational control. Initial flight coordinator training consisted of 8 hours of classroom time, and recurrent training consisted of between 3 and 4 hours, depending on the student's experience. Both of the flight coordinators working at the time of the accident had completed the initial flight coordinator training.



In addition, the company used a basic risk assessment form containing a four-tiered numbered system to determine the level of operational control needed for a specific flight, with 1 being the lowest risk and 4 being the highest risk. A risk level of 1 required no risk mitigation, a level 2 required a discussion between the PIC and flight coordinator about the risks involved, a level 3 required a phone call to management for evaluation and approval, and a level 4 required canceling the flight. At the time of the accident, no signoff was required for flight coordinators or PICs on the risk assessment form, and the form was not integrated into the company manuals. According to the company, the risk assessment was part of its operational control and flight release system and was presented to and accepted by the FAA but was not incorporated into the GOM, training program, or other company manuals.



An FAA principal operations inspector in the Anchorage FSDO was assigned to oversee the company. He had been employed with the FAA for about 7 years at the time of the accident and had been temporarily assigned to the Hageland certificate from October 2012 to April 2013 and permanently assigned to the certificate in September 2013, about 3 months before the accident.



A query of the FAA Program Tracking and Reporting System found that from July 16, 2013, to October 22, 2013, FAA aviation safety inspectors conducted five operational control inspections of Hageland. The inspections noted deficiencies in the company's training, risk management, and operational control procedures.



ADDITIONAL INFORMATION



In the months following the accident, both the FAA and the operator initiated numerous safety improvements, including but not limited to, increased FAA surveillance, changes to company training programs, changes to company management, addition of established routes and increased limits for special VFR operations, and the establishment of a company operations control center to handle release and dispatch of flights.

 
Now compare that to the P9 Sunday ramble narrative on the strange, vindictive, embuggerance of Avtex sister companies Skymaster & Airtex intitiated by former CASA Bankstown Regional Manager Wodger & his dodgy mates - Second and final verse.   
MTF...P2