Premium on Safety - Issue 40, 2021 - 6

LESSONS LEARNED

When Conditions Conspire
BY DAVID J. KENNY
Regulations, company procedures, and recurrent training all
function as guardrails limiting the potential damage arising from
individual misjudgment or indecision. Constraining the scope
of pilot decision-making serves to remove (or at least reduce)
temptation to press on despite deteriorating weather, dwindling
fuel reserves, or lack of sleep. But the primary safeguards
remain pilot-in-command responsibility and the instinct for selfpreservation. Unfortunately, institutional restraints don't entirely
eliminate the risk of momentary lapses at very inopportune times.

him 11 months earlier, and his 6,465 hours of career experience
included 765 hours make and model, 257 of them in the preceding
90 days. During that time, he'd flown between PATG and PAQH in
one direction or the other 26 times. A colleague described him as
" an exceptional pilot, " extremely intelligent, with " supreme " handeye coordination. His wife recalled that he'd become " even more
safety-conscious, " taking no chances, after losing several friends
in airplane accidents. Both pilots were healthy and reported to be
well-rested.

Ravn Connect Flight 3153, a Cessna 208B Grand Caravan operated
by Hageland Aviation Services, departed from Bethel, Alaska
(PABE) on October 2, 2016, at 9:27 Alaska Daylight Time. The
scheduled five-leg commuter flight landed at Togiak (PATG)
at 10:29 and took off on the second segment 15 minutes later,
arriving at Quinhagak (PAQH) at 11:25. It remained on the ground
for just eight minutes while the crew unloaded cargo and boarded
a single passenger, then took off again to return to Togiak. A
second company Caravan followed about two minutes later.

The trailing flight landed at PATG at 12:16 and found that 3153 had
not arrived. At 12:08, the Air Force Rescue Coordination Center
had detected its 406-MHz ELT signal and contacted Hageland's
Director of Operations, who pulled up its Spidertracks data. The
last location update was some 20 minutes old. The company's

Although Hageland usually operates its Caravans single-pilot
under VFR, both of these flights had two-pilot crews. A safety
pilot had been assigned to the trailing flight because its PIC had
less than 50 hours in type. Flight 3153 (the mishap flight) had a
29-year-old, 273-hour commercial pilot serving as SIC, helping
wrangle cargo while building flight time. Another company pilot
described him as " smart and experienced, " if a little rough on the
controls, and receptive to advice.
The PIC was a 43-year-old commercial pilot and single-engine,
multiengine, and instrument instructor. He'd already logged some
4,300 hours of PIC time in Alaska by the time Hageland hired

The accident airplane's initial impact was on the opposite
side of the ridge and the main wreckage and right wing were
found on the southeast slope.

6

State troopers arriving on foot found scrape
marks suggestive of a propeller strike and
fragments of the airplane's belly cargo pod
on the northwest side of a steep, rocky ridge
at an elevation of about 2,300 feet.
Operations Control Center in Palmer verified that, and a search
began. The second Caravan took off at 12:31 but found the area
from which the ELT signal originated obscured by clouds; an
Alaska State Police helicopter was dispatched from Dillingham at
14:30, but weather likewise prevented its crew from finding the
site for two more hours.

Topographic map depicting accident flightpath in red and the
path flown by the second company crew in blue. Note: The
large dots on each depicted path (excluding the dot for the
accident site) are based on Spidertracks data, and the small
dots are interpolations. The blue lines represent ADS-B data
(where several closely clustered data points formed a line).



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