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What causes pilot error? Searching for reason in plane crash chaos

Colleen Mondor
Bright, clear and ready to fly! Another spectacular October day in Anchorage.
Alaska Dispatch Staff
Can you guess what kind of plane this is?
Alaska Dispatch
October has been good to the Anchorage bowl.
Alaska Dispatch
A beautiful sunset at Merrill Field airport on Oct. 18 with a waxing crescent moon just above the pink glow of the horizon.
Alaska Dispatch Staff
Bizarre weather settled over much of Southcentral Alaska in mid-January 2013 as a tropical system known as the "Pineapple Express" blew in from the Pacific. Snows melted but sunsets were absolutely brilliant.
Eric Adams photo
Merrill Field sunrise at -3 degrees. Nov 29, 2012
Loren Holmes photo
Merrill Field sunrise at -3 degrees. Nov 29, 2012
Loren Holmes photo
The sun sets through the fog at Merrill Field. Nov. 12, 2012
Loren Holmes photo
Airplane taking off at Merrill Field with full moon. Nov. 27, 2012
Loren Holmes photo
Snow plowing at Merrill Field. Nov. 14, 2012
Loren Holmes photo
Winter settles in as the sun sets early on Anchorage in early November. Merrill Field, centrally located just east of downtown Anchorage, offers breathtaking views of the city and Chugach Mountains.
Eric Adams photo
First big snow of the year: Oct. 30 brings new fluff to Merrill Field.
Alaska Dispatch
A pretty, but chilly, day for flying in Southcentral Alaska.
Alaska Dispatch
Tire tracks in new snow at Merrill Field in Anchorage. First real snow of 2012 on Oct. 30.
Katie Medred
Merrill Field is a small airplane, public-use and commercial service airport in downtown Anchorage, Alaska. The field was established in 1930 and remains a unique feature to the downtown Anchorage cityscape.
Alaska Dispatch Staff

In 1995 a friend of mine departed the Northwest Alaska hub village of Kotzebue for Kivalina on a clear day in a single-engine Cessna 207. He was flying for Yute Air, hauling an all-cargo load of bypass mail, when he flew into a box canyon at a low altitude. His aircraft impacted the ridge line and cart-wheeled down the backside; my friend did not survive.

In the weeks and months following the accident the overwhelming question was "why." This was a question I was accustomed to asking in the wake of a crash. Why did a pilot seek to overtake one of my classmates on final approach at an uncontrolled airfield resulting in a fatal mid-air collision when I was in college? We will never know. Why did one of my co-workers at a Fairbanks commuter crash into the Yukon River when one engine failed on a twin engine aircraft? We will never know.

Why did the pilot of a Cessna 182 recently choose to navigate the Rainy Pass area in marginal weather? In all likelihood, we will never know. And why did the two commercial pilots operating a Beech 1900 under instrument flight rules -- cleared by Anchorage Center to fly the approach into Dillingham -- collide with the nearby Muklung Hills at an elevation far below the published altitude for that segment of flight?

Again, in all likelihood, we will never know.

Why?

Alaska is famous for its treacherous landscape and unpredictable weather, but those conditions alone aren't excuse for a difficult flight safety record. It's much more obtuse. Since Russ Merrill and Ben Eielson died in 1929, the state's bush pilot lore has produced a steady stream of stories about pilots who "died for Alaska."

What we never asked then and still struggle with today is why pilots sometimes abandon the most fundamental of flight safety lessons for nebulous chances at success.

According to the National Transportation Safety Board (NTSB), the ACE Air Cargo Beech 1900 was not equipped with a cockpit voice recorder and so there is no way to review the crew's discussion as they flew (or attempted to fly) the approach.

From early reports the Cessna 182, during a flight out to Takotna, a checkpoint along the Iditarod Trail Sled Dog Race, apparently had no communication with other aircraft following its departure from Merrill Field. If the aircraft it was reportedly scheduled to meet in Takotna had contact during the flight, NTSB investigators may gain insight as to why the C182 flew down the path it did.

But this will not be revealed until the NTSB issues a factual narrative on the accident. Multiple fatalities in both crashes, coming within days of each other and during the 2013 Iditarod, will likely delay final reports from the NTSB for at least nine months.

Piecing together the puzzle

The NTSB is only tasked with determining what happened in an accident. Investigators gather information on the weather, the equipment, the pilot(s) and any other circumstances that might shed light on how a plane crash happened. In the two recent fatal crashes in rural Alaska, investigators will speak to ACE Air Cargo management and personnel who were with the pilots that morning and seek out any other pilots who might have spoken with them over the radio while they were en route to Dillingham. The investigators will research the events of these flights and attempt to put the puzzle presented by these accidents together.

With luck, all the pieces will align and help explain what happened to bring about these tragedies.

But even then, when the Probable Cause reports are completed, investigators won't know why those last choices were made. Only the pilots have those answers. And all too commonly, even in nonfatal accidents, pilots cannot explain such decisions to anyone, least of all themselves.

In 1995, the NTSB concluded that my friend was flying at a low level on the way to Kivalina because he was following a wolf pack. We never found out why he let the wolves lead him into a canyon he was unfamiliar with at an altitude that gave him no opportunity to escape. The investigators determined the accident was caused by his "decision to enter a box canyon area at an altitude inadequate to maintain terrain clearance."

In his case there was no bad weather to blame, only an enduring mystery about what a pilot was thinking as he made the last choice that took him to his death.

Contact Colleen Mondor at colleen(at)alaskadispatch.com