Opinions

In the 2019 Dutch Harbor crash, the final report minimizes the impact of decision-making

On Nov. 19, the National Transportation Safety Board, or NTSB, released its final report on the 2019 accident involving PenAir flight 3296, in a Saab 2000 aircraft, at Dutch Harbor airport in Alaska. This was the second fatality accident of a large passenger air carrier in the U.S. in a decade. The board assigned probable cause to the manufacturer’s mis-wiring during overhaul of the left main landing gear two years previously. Factors included the manufacturer’s design, and the crew’s decision to land with an excessive tailwind. Unfortunately, by relegating pilot actions to factor status, and minimizing management’s assignment of a captain who did not meet company minimum flight time requirements for Dutch Harbor, the board purposefully deemphasized decision-making’s impact on flight safety and weakened the report’s relevance.

PenAir was owned by Ravn Air Group, following purchase via bankruptcy court in 2018. Before that, it was owned by the Seybert family for 60-plus years. Its most recent accident prior to Flight 3296 was in 2008.

Ravn Air Group dates to a 2008 merger of Frontier Flying Service and Hageland Aviation. Initially Frontier Alaska, it was rebranded Era Alaska after the 2009 purchase of Era Aviation — later named Corvus Airlines — then, in 2014, rebranded as Ravn Air Group. Between 2008 and 2014, the company crashed 14 times, sparking urgent safety recommendations from the NTSB and the FAA’s unsuccessful attempt at emergency certificate revocation for Hageland. In 2015, the two minority owners were bought out and Lehman Brothers came in as majority partner. Ravn crashed four more times. Then came Flight 3296.

PenAir brought the Saab 2000s on line in 2016 with a 300-hour minimum for captains at three airports, including Dutch Harbor, due to “special requirements” such as mountainous terrain. The minimums remained in the general operating manual, or GOM, after the sale to Ravn, with no exceptions.

The captain of Flight 3296 was hired over from Ravn in May. He had 14,761 hours of total time and 131 hours in the 2000; the co-pilot had 138 in the aircraft. The post-Ravn GOM permitted PenAir’s chief pilot, Crystal Branchaud, who was hired from Ravn in February and was not signed off for Dutch Harbor operations, to provide a written waiver to the minimum with a check airman’s written recommendation. This paperwork did not exist for Flight 3296′s captain. Branchaud told investigators she was “unaware of the letters” requirement and acknowledged she had “an incomplete understanding” of the waiver and that when it came to reading the GOM she “didn’t take the care that I needed to.”

There is a consistency to discussions of the minimums in the accident docket. Certain management personnel wanted to reduce them and the pilot group did not. Deke Abbott, Ravn’s senior vice president of flight pperations and a former FAA manager, had only been into Dutch Harbor once, as a passenger, but urged removal of the minimums. (Abbott worked daily with Branchaud and told investigators a new chief pilot might need to be put “on a very short leash.”) According to one longtime PenAir pilot, in a meeting of check airmen the minimums and Dutch Harbor were discussed with Branchaud and Abbott and it was declared that “an airport is an airport;” the airmen responded, “No, it’s not ... this one is special …” For his part, PenAir Director of Operations Richard Harding was unaware of the issue and told investigators he had no idea these discussions occurred concerning the minimums.

FAA personnel charged with oversight of PenAir professed satisfaction with the company but, after the accident, its principal operations inspector told investigators the captain’s approval process for special operations was not followed. In its report, the NTSB noted pilot safety concerns and concluded FAA oversight was insufficient.

Dutch Harbor has an automated weather system and onsite weather observer with 18 years of experience who provides updates from anemometers. She first spoke with Flight 3296 as it attempted landing at Runway 13, aborted, and conducted a go-around. On its second attempt, at 5:37 p.m., she reported winds from 290 degrees at 16 knots, gusting to 30; the crew did not respond. At 5:38 p.m., she reported midfield winds from 300 degrees at 24 knots. The co-pilot said, “Oh God,” and asked the captain “Do you wanna ... back out ... do it again?” Seconds later, the captain said, “Last try;” they landed at 5:40 p.m. with 20 degrees of flaps, (full flaps is 35 degrees), indicated airspeed of 127 knots and groundspeed of 142 knots. The NTSB asserted the aircraft touched down with a 15-knot tailwind based on this data from the flight data recorder. The weather observer noted in her records, “he was going too fast ...” The tailwind performance standard for the Saab 2000 is 15 knots. The captain and co-pilot told investigators they had no serious concerns with the winds.

After touchdown, the crew applied brakes, a tire blew, the aircraft overran the runway, passed through a fence, crossed a road, hit rocks and stopped at the edge of the bay.

The decision of the NTSB’s four board members to emphasize a longtime mechanical issue over pilot and company decision-making reduced the accident’s cause to its most basic element, and ignored the machinations of management personnel who sought expediency over flight safety and exhibited a glaring lack of respect for institutional knowledge. Absent the decision to land with the excessive tailwind, a choice experienced captains most likely would not have made, the accident would not have occurred.

In January 2020, Ravn Air Group crashed one last time. Three months later, it declared bankruptcy, citing $90 million in debt. Its final safety record was 21 accidents and incidents causing 13 fatalities and 36 injuries in 12 years of existence. There were also many inspections and investigations; the docket for Flight 3296 alone includes more than 1,500 pages of interviews. They should be required reading for anyone seeking to understand how a company can appear to be operating at optimum safety when, in truth, many things have already started to go wrong. Decisions made behind a desk do migrate to the cockpit, and although the board members failed to recognize their significance in this accident, they can also bring down an aircraft.

Colleen Mondor is the author of “The Map of My Dead Pilots: The Dangerous Game of Flying in Alaska.” Find her at chasingray.com or on Twitter @chasingray.

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