Last Friday the National Transportation Safety Board released final reports for two multiple-fatality accidents in St. Mary's (2013) and Kwethluk (2014). Both aircraft were operated by Hageland Aviation as part of the family of airlines known previously as Era Alaska and now Ravn Alaska. While the Kwethluk crash occurred during a training flight and was determined to be due to the check airman's actions, the board found that in St. Mary's the pilot, flight locators, company and Federal Aviation Administration were at fault.

These crashes were the last in a line of accidents and incidents over two years that prompted the NTSB to issue an urgent safety recommendation to the FAA in 2014 regarding Ravn's safety and regulatory compliance. The FAA was also directed to audit its own oversight of the air group. A review of recent commercial aviation accidents in Alaska reveals that the agency's struggles with Ravn were not an isolated case.

In an interview following the St. Mary's crash, FAA principal operations investigator (POI) Danny Larson was asked why the agency continued to allow Hageland to operate even though it had many documented failures and violations of "procedures and processes." Larson replied that "... he did not know what else he could have done. He felt they were doing all they could with current staffing levels, which he believed to be insufficient."

According to the investigation, there were only three investigators assigned to Hageland, which operated 56 aircraft at the time and averaged 1,200 weekly operations. (Based on fleet size, it is the largest scheduled small commuter airline in the U.S.) The Anchorage FAA office made multiple requests to increase staffing but were denied, as Hageland did not meet the minimum FAA fleet requirements. This was a source of frustration for Alaska FAA frontline manager Dale Hanson, who told investigators: "They are the largest operator in Alaska, by far. Even the 121 operators (large air carriers) don't have as much activity or as much flights per week and carry as many passengers. I've tried to use those statistics to show that we need more people. I know they'd like to give them to me if the budget would allow it, but --"

This disconnect between oversight requirements and available resources was also evident following Alaska Central Express's (ACE) fatality crash in March 2013. The ACE POI, Dee Rice, told investigators she was also responsible for Yute Air Alaska, three flight schools, five Part 91 operators and the designated pilot examiners in the Anchorage district. Rice further stated she was unsure how ACE conducted operational control of its flights and had not observed specific crew training in her three years as POI. The NTSB also noted that Rice was not qualified to fly any of the aircraft operated by ACE.

During the investigation into the July 2013 accident in Soldotna that killed all 10 people on board, Rediske Air's POI stated that he visited the airline, located in Nikiski, "a couple of times a year." He was also responsible for 37 other air taxis and commuters.

Most recently, in 2015, two fatality accidents occurred in Southeast Alaska that are still under investigation. Wings of Alaska and Promech Air were operating under regional requirements of "cue-based training," which mandates pilots maintain certain visibility standards in addition to standard regulations. The FAA was responsible for oversight of this training. For Wings of Alaska, then owned by SeaPort Airlines, the company POI was based 1,900 miles away in Portland, Oregon.

Historically, the high number of plane crashes in Alaska were blamed on weather and geography, but in the 21st century this is no longer valid. In the St. Mary's accident, for example, the aircraft was equipped for, and the pilot rated for, instrument flight. The airport had the necessary navigational aids for an instrument approach. The pilot did not file an instrument flight plan, however, even though instrument meteorological conditions prevailed at his destination.

What failed in St. Mary's was the decision-making of the people entrusted with making the best choices both in the air and prior to departure. That the FAA was part of that failure, and others, has been determined by the NTSB, and the FAA's struggles are cause for concern to all Alaskans who fly. Modern technology can do only so much to improve the state's safety record; human factors in the air, and on the ground, are what will make the difference now.

Colleen Mondor is the author of "The Map of My Dead Pilots: The Dangerous Game of Flying in Alaska." Contact her at colleen@chasingray.com.

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