The pilot, operational flaws within Hageland Aviation, company employees and the Federal Aviation Administration all share the blame for a fatal 2013 crash near St. Mary's, says a final report on the accident.
The Nov. 29 crash killed four people, including the pilot and an infant, and seriously injured six others.
Released Friday morning, the National Transportation Safety Board report mirrors the agency's factual report on the crash released earlier this week and outlines the factors that led to the crash.
The Cessna 208B had departed late from Bethel for the two-stop flight, the report says. When weather around the first airport deteriorated, pilot Terry Hanson diverted the plane to the St. Mary's airport. As it approached, Hanson tried to activate the pilot-controlled runway lights, but his radio was on the wrong frequency, tuned to air route traffic control instead.
Without runway lighting and under limited visibility, "the pilot likely lost situational awareness of the airplane's geographic position," the NTSB writes.
Witnesses described seeing the airplane fly over and away from the airport as the weather deteriorated into fog. The airplane began descending a mile from the runway, turned right and hit the ground.
"The pilot appeared to be in control of the airplane up to the point of the right descending turn," NTSB writes.
Witnesses found the airplane about an hour later after accessing the company's flight-tracking software. Hanson, 68, died in the crash, as did passengers Richard Polty, 65, Rose Ann Polty, 57, and 5-month-old Wyatt Coffee.
Two flight coordinators who did the preflight assessment also erred, the NTSB concludes. According to company policy, they should have talked to the pilot about risks, including weather, associated with the flight, but neither did.
Hageland's inadequate training program and lack of operational oversight contributed to the crash, the report concludes.
"Neither of the flight coordinators working the flight had received company training on the risk assessment program. At the time of the accident, no signoff was required for flight coordinators or pilots on the risk assessment form, and the form was not integrated into the company manuals," the report says.
The FAA also failed in its oversight of Hageland, the report said. The FAA had repeatedly noted deficiencies in the company's operational procedures and training. Yet while FAA inspectors had opened investigations into Hageland, those investigations "were closed after only administrative action had been taken."
"The FAA did not hold the operator sufficiently accountable," the NTSB writes.
Hageland is now one of three airlines that fly as Ravn Alaska. The company has made "monumental changes" since the St. Mary's crash, NTSB Alaska regional chief Clint Johnson said Friday.
The FAA has also made multiple safety improvements, says the NTSB's factual report released earlier this week.
Alaska Dispatch Publishing