BETHEL -- Serious operational flaws within Hageland Aviation -- by far the busiest airline in Alaska in terms of flights -- and struggles within the Federal Aviation Administration to fulfill its oversight responsibilities contributed to a fatal crash in 2013 near St. Mary's, documents released Thursday suggest.
The Nov. 29, 2013, Cessna 208 crash killed four of the 10 people aboard, including the pilot and a 5-month-old boy.
The reports and interviews released by the National Transportation Safety Board paint a picture of a Western Alaska airline with loose controls and a bush pilot culture, in which untrained workers were involved in decisions on whether flights should go or not go, and where a new risk-assessment procedure failed to involve pilots.
"But the hardest thing is to get this company to police itself. If we're not there to watch them, you know, we're not really sure half the time if they're doing it right," Dale Hansen, a frontline manager in the FAA's Anchorage-based Flight Standards District Office, told the NTSB investigators.
FAA inspectors were overwhelmed and unable to provide adequate oversight of sprawling, fast-growing Hageland, which operates 1,200 flights a week, the documents say.
At the time of the accident, Hageland Aviation, together with Frontier Flying Service and Era Aviation, was part of the Era Alaska group. The group has since re-branded itself as Ravn Alaska, a move already in the works before a series of crashes, a Ravn spokesperson said.
Hageland is the largest commuter aviation company in the nation, according to news reports based on information from FAA databases. It has grown rapidly by absorbing routes from smaller air carriers that went out of business, and also by combining with Frontier Flying Service in 2008.
The newly released records don't include a determination of what caused the wreck, which happened during deteriorating weather. A final NTSB report on the cause is expected in a couple of months.
The single-engine turboprop left Bethel at 5:41 p.m. that day headed for Mountain Village and then St. Mary's as a scheduled flight. But it began icing up in thick, cold fog and the pilot diverted directly to St. Mary's. The plane crashed into a ridge. Killed were Richard and Rose Ann Polty, infant Wyatt Coffee and the pilot, Terry Hansen, 68.
The St. Mary's crash was one in a string of Hageland crashes in a short window, including one in April 2014 that killed two pilots on a training flight near Bethel and another in November 2013 that substantially damaged a plane at the Badami Airport in Deadhorse.
Dale Hansen told the NTSB that he only had a team of three inspectors assigned to Hageland even though "they are the largest operator in Alaska, by far." Other commuter airlines that don't make as many flights are monitored by more inspectors, he said.
Three inspectors weren't enough given Hageland's size and problems overseeing itself before the St. Mary's crash, the FAA's Hansen said. He pushed -- unsuccessfully -- for more, he told the NTSB. Hageland since has responded to recommendations and improved operations dramatically, he said.
Hansen "stated that he had tried every avenue he could think of to request additional inspectors be assigned to the Hageland certificate, and he felt the accidents may have been avoided if the operator had done a better job of policing itself, or if the FAA had been able to provide better oversight," according to a factual report by NTSB air safety investigator Brice Banning, who is leading the investigation's examination of the airline's operations.
The FAA team overseeing Hageland now has three principal inspectors and two assistants overseeing Hageland, the agency said in a statement Thursday evening.
Overall, more than 40 FAA inspectors from across the country have been involved since late 2011, the agency said.
"We have used our findings, which include enforcement actions, to work with the carrier to make changes in its safety and systems culture," the FAA said.
Hageland has been working to improve, said Charlotte Sieggreen, a spokeswoman for Ravn Alaska and the airlines under it.
"Our thoughts and prayers continue to be with the families affected by the incident in St. Mary's. We have always, and continue to work with both the NTSB and FAA to improve the operations of our airline, as well as in their investigation into this incident," Hageland Aviation said in a written statement Thursday. The company declined to answer other questions.
As regulators saw it, before the crash, "it was a constant battle to get them to change anything," Hansen told investigators, according to a transcript of his interview. "The new people that are in there, they understand how important their jobs are and they have made some incredible and very important changes."
For one, the airline established an office in Palmer that monitors all flights and watches the weather, the NTSB was told.
That is among the significant improvements being made at Hageland and the FAA, said Clint Johnson, head of the NTSB Alaska office.
The night of the crash near St. Mary's, the Hageland worker watching the weather left for the day at 5 p.m., as was usual then.
Some of the troubles in Hageland's safety culture came from the pilots themselves, Hansen said, describing a time when a pilot eager to fly in rough weather was told "no" by the chief pilot and then called the assistant chief pilot on the same thing.
"So they're shopping to try to get permission to go fly, you know. And how do you change that safety culture?" Hansen told investigators. "So that's one of the things we try to constantly overcome with this outfit. And that's not driven, as best as we can tell, by the management or the ownership of the company, you know, it's just the mentality of the people.
"It's like what I call the bush pilot mentality."
He told investigators that he was told Hageland had fired 15 pilots since the St. Mary's crash. It had 130 pilots, almost 60 airplanes, and 10 bases of operations with ticket counters and crews, the NTSB was told.
FAA safety investigators had noted a series of problems in the summer of 2013, the documents said.
At the company's base in Nome, for instance, a new manager and four ticket agents were coordinating flights during a July 16, 2013, inspection. "They had not received any formal training, and were attempting to manage customer service, flight manifests, flight coordination and other duties at the same time," the NTSB operations group report said.
The next day in Kotzebue, an FAA safety inspector found that Hageland's new risk assessment format was being used. Flights were ranked on a scale of 1 to 4, with a rating of 1 when there was no identifiable hazard and 4 when it was too dangerous to fly. But the inspector noted the program "is not functioning correctly due to non-involvement of the pilots."
Then on Oct. 22, 2013, about a month before the fatal crash, the FAA's principal operations investigator contacted Hageland's director of operations to outline "issues involving failures of the risk assessment program." The company was directed to complete a timeline to implement the program and train staff by Dec. 1, 2013.
By then, it was too late.
The crash at Badami in November 2013 of a twin-engine turboprop Beech foreshadowed the one near the St. Mary's airport exactly one week later. In both cases, the flight coordinators who were leading the decision on whether the planes should fly were not trained. In both cases, weather was deteriorating. In both crashes, the inadequacy of Hageland's risk assessment program may have played a role, the NTSB said in an earlier letter to the FAA.
In May 2014, after six crashes and one incident in 19 months, beginning in September 2012, the NTSB issued two safety recommendations -- one a highly unusual "urgent" recommendation -- to the FAA to improve flight operations, training, safety management and other key areas of the operators of the now re-branded Ravn Alaska, all under the parent company HoTH Inc.
The NTSB concerns stretched past the operators to "the FAA's surveillance and oversight programs that failed to detect and correct these numerous and long-standing issues of noncompliance with FAA regulations and policies," the May recommendation said.
Before the St. Mary's crash, an FAA inspector, Danny Larson, had put together an enforcement case targeting Hageland, the newly released records reveal. He also was trying to get Hageland's director of operations removed from that job.
"The case was not pursued, and he received no feedback as to why," according to a summary of his interview with the NTSB. After his interview, Larson called the NTSB and said he found out procedures for assessing risk before flights were not in company manuals, so the FAA was unable to hold Hageland accountable for failing to institute them.
The three airlines of the rebranded Ravn Alaska fly to dozens of small communities in Western and Northern Alaska.
Hageland, now operating as Ravn Connect, is the busiest. Over the course of a week, its planes make 1,200 trips in Alaska. Village flights often carry medical patients, government workers, representatives of Native corporations and tribal organizations -- and lots of discount-rate cargo.
Three lawsuits were filed Bethel against Hageland as a result of the St. Mary's crash. One was brought by the estate of the couple killed, the Poltys. Another was filed on behalf of Garrette Moses, who was severely injured. The third is on behalf of Keith Andrews, the father of the baby killed.
The child's mother, Melanie Coffee, was on the plane and walked away, holding her dead baby, a witness told the NTSB. Then in October, she was killed in a four-wheeler crash.