Before I start, I had the privilege of attending this NTSB investigation hearing with my Director of Operations. NTSB held a very rare local hearing in Anchorage. If you ever have the opportunity to attend one I highly recommend it!
In 2016 a Cessna 208B Operating as Hagelend (Under Ravn Connection) had a Controlled Flight Into Terrain (CFIT) near Togiak, Alaska. NTSB determined that the pilots were perfectly healthy before the accident, but blame Ravn for their training
Shaun Williams (Special investigator) found shortcomings in Hageland Aviation Services’ pilot training. He came to the conclusion that in this particular crash, pilots turned off their Terrain Awareness and Warning System.
The NTSB identified the following safety issues as a result of this accident investigation:
- Inadequacies in Hageland’s Federal Aviation Administration (FAA)-approved
crew resource management (CRM) training program
- Inadequate FAA oversight of Hageland’s CRM training program.
- Lack of FAA requirements for CFIT-avoidance training programs for Part 135
- Lack of effective TAWS protections and nuisance-alert mitigations for flights that
operate under VFR at altitudes below the TAWS RTC.
- Hageland’s inadequate guidance for pilots’ use of the terrain inhibit switch for the
- TAWS design limitations that require pilot action to uninhibit the alerts after they
have been inhibited.
- Need for safety management systems (SMS) for Part 135 operators.
- Need for flight data monitoring (FDM) programs (and supporting devices) for
Part 135 operators.
- Lack of assurance that operators implemented Medallion Foundation programs
- Need for improved infrastructure to support IFR operations in Alaska.
- Lack of a requirement for crash-resistant flight recorder systems capable of
capturing cockpit audio and images for Part 135 operators.
- Need for improved sharing of pilot weather reports (PIREPs) in remote areas in
You can read the causes and other NTSB recommendations at
The National Transportation Safety Board determines that the probable cause of this
accident was the flight crew’s decision to continue the visual flight rules flight into deteriorating
visibility and their failure to perform an immediate escape maneuver after entry into instrument
meteorological conditions, which resulted in controlled flight into terrain (CFIT). Contributing to
the accident were (1) Hageland’s allowance of routine use of the terrain inhibit switch for
inhibiting the terrain awareness and warning system alerts and inadequate guidance for
uninhibiting the alerts, which reduced the margin of safety, particularly in deteriorating visibility;
(2) Hageland’s inadequate crew resource management (CRM) training; (3) the Federal Aviation
Administration’s failure to ensure that Hageland’s approved CRM training contained all the
required elements of Title 14 Code of Federal Regulations 135.330; and (4) Hageland’s CFITavoidance
ground training, which was not tailored to the company’s operations and did not address
current CFIT-avoidance technologies.
So you’re asking yourself, “Mark, why does it get worse?”
Today Hageland yet once again crashed one of their 208Bs near Barrow, the pilot survived and was the only surviour, thankfully he’s okay!