Investigation Summary
The investigation highlighted significant deficiencies in the operator's operational control structure. On the morning of the accident, the office manager exercised first-tier operational control as the duty officer, despite not being qualified or listed in the company's General Operations Manual (GOM) for such a role. Neither the pilot nor the office manager obtained an official weather briefing, which would have revealed a METAR for Port Alsworth (TPO) estimating that the critical Lake Clark Pass was closed due to weather. Instead, the office manager relied on a private camera showing blue skies in a residential area and misinterpreted FAA weather camera images showing fog as a localized phenomenon. The FAA Principal Operations Inspector (POI) assigned to the operator reported being saturated with duties, which prevented adequate oversight that might have identified these operational control weaknesses. The aircraft was not equipped with a terrain awareness and warning system (TAWS) or onboard weather radar, nor was it certified for instrument flight rules (IFR).
Final Conclusions
The National Transportation Safety Board determined the probable cause was the pilot's decision to continue visual flight into instrument meteorological conditions, resulting in a loss of visual reference and subsequent controlled flight into terrain. Contributing factors included inadequate preflight weather planning by both the pilot and the duty officer, the operator's inadequate operational control structure, and the Federal Aviation Administration's insufficient oversight of that structure.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Commercial pilot, instrument rated. Had 20 hours of actual instrument experience.
Systems & Failure Modes
Spidertracks Spider 6
A satellite-based tracking system that provided the operator with location, altitude, and airspeed data at 10-minute intervals.
406-MHz ELT
The Emergency Locator Transmitter activated upon impact, allowing search and rescue to locate the wreckage within approximately one hour.
Interesting Facts
- 01The pilot was an instrument-rated commercial pilot with 873 total flight hours, but this was his first season flying in Alaska.
- 02A METAR issued 1 hour and 10 minutes before departure for a station 12 miles from the site included the remark 'estimate pass closed'.
- 03The aircraft was destroyed by impact and a post-crash fire; no pre-impact mechanical anomalies were found.
- 04The operator did not have an operational control training program in place at the time of the accident.
- 05The aircraft was carrying 334 pounds of lumber and insulation as cargo.
Safety Actions & Advisories
Safety Recommendation A-17-039
The NTSB recommended the FAA establish minimum initial and recurrent training requirements for personnel authorized to exercise operational control, including approved subject knowledge areas and qualification modules.
Location
NO VERIFIED COORDINATES · This position predates coordinate provenance tracking. Treat it as an approximate marker for the area, not the accident site. No map is shown, because a marker here would imply a precision the record does not have.
Reported location: Port Alsworth, Alaska, United States