ANC00LA008

NTSB accident investigation · Cessna 207 · Bethel, AK · October 27, 1999

Accident · No injuriesLimited investigationFinal report
Date
October 27, 1999, 13:42 local (21:42 UTC)
Place
Bethel, AK
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N207SECessna 207
Weather
Instrument (IMC) · Day
Status
Completed · report May 17, 2001
Report
Approved by Office Director
NTSB office
Alaska Regional Office
FAA report
19991027041879A
Case key
47765

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The NTSB’s determination of the probable cause, and any contributing factors.

The pilot's inadequate evaluation of the weather, and his decision to initiate flight into adverse weather conditions. Factors in the accident were adverse weather consisting of low ceilings and icing conditions, inadequate supervision by company management, and airframe icing.

Analysis

The commercial certificated pilot arrived at his company offices and conducted a preflight inspection of the accident airplane at 0815 in preparation for a VFR scheduled domestic passenger flight to a remote village. The flight was delayed due to poor weather conditions that included visibilities between 1/2 to 3/4 mile in mist and freezing fog. The ceiling varied between 100 feet, to 1,100 feet. During the delay, two company representatives were in the dispatch office. When the weather conditions improved to 500 feet broken, and a visibility of 4 miles in patchy fog, the pilot departed at 1309 with a Special VFR clearance. The pilot encountered worsening weather about 4 miles from the airport, and decided to return. Instrument meteorological conditions prevailed in the Class E airspace around the airport, and the pilot had to hold, out of the surface area awaiting a Special VFR clearance. Once cleared into the surface area, the pilot said he could not see the runway because the windshield of the airplane was iced over. He could see hangars out the side window. The pilot decided to proceed toward the southeast and began a left turn, but said the engine began to run rough and lose power. The pilot said that application of full power was unable to prevent the airplane from losing altitude. He lowered the flaps in preparation for an emergency landing, and the airplane touched down on snow-covered terrain. During the landing, the nose gear was sheared off, and the right wing received rib damage to the outboard end. At the accident scene, an FAA inspector noted about 1/8 inch of ice on the airplane. Three minutes before the accident, the weather conditions at the airport included a visibility of four miles in light snow and patchy fog; sky condition, 100 feet scattered, 400 feet overcast, with occasional localized lower visibility, and the ceiling varyied between 300 to 600 feet. Examination of the airplane after the accident did not reveal any preimpact mechanical malfunction. The engine produced 2,750 rpm on an engine test stand.

Factual narrative

The factual narrative1,319 words

On October 27, 1999, about 1342 Alaska daylight time, a wheel equipped Cessna 207 airplane, N207SE, sustained substantial damage after colliding with snow-covered terrain, about 2 miles west of Bethel, Alaska. The airplane was being operated as a visual flight rules (VFR) scheduled domestic passenger flight under Title 14, CFR Part 135, when the accident occurred. The airplane was operated by Hageland Aviation Services Inc., Anchorage, Alaska, as Flight 70 from Bethel, to Akiak, Alaska, to Tuluksak, Alaska, and return to Bethel. The commercial certificated pilot, and the sole passenger, were not injured. Instrument meteorological conditions prevailed in the area of the accident. VFR company flight following procedures were in effect. The flight originated at the Bethel Airport, at 1309.

A terminal forecast for Bethel, issued on October 27, 1999, at 0716 and valid from 0700 to 0200 on October 28, stated, in part: Wind, 040 degrees at 5 knots; visibility, 5 statute miles in light snow; clouds and sky conditions, 1,200 feet scattered, 4,000 feet overcast. Temporary conditions from 0700 to 1000; visibility 1/2 statute mile in freezing fog; ceiling, 100 feet broken. From 1000, wind, 020 degrees at 9 knots; visibility greater than 6 statute miles; clouds and sky conditions, 2,500 feet scattered, 5,000 feet broken. Temporary conditions from 1000 to 1400; visibility, 3 statute miles in light snow and mist; ceiling, 2,500 feet broken. From 1400, wind, 350 degrees at 12 knots; visibility greater than 6 statute miles; clouds, 3,500 feet scattered, 8,000 feet broken.

An amended terminal forecast for Bethel was issued on October 27, at 1227, and was valid from 1200 to 1000 on October 28, stated, in part: Wind, variable at 3 knots; visibility, 1 1/2 statute mile in mist; clouds and sky condition, 100 feet scattered, 1,500 feet scattered. Temporary conditions from 1200 to 1400; visibility, 3/4 statute mile in mist, ceiling, 1,200 feet broken. From 1400, wind, 360 degrees at 7 knots; visibility greater than 6 statute miles; clouds and sky condition, 2,500 feet scattered, 4,500 feet broken. Temporary conditions from 1400 to 1700; visibility, 1 statute mile in mist. From 1700, wind, 010 degrees at 8 knots; visibility greater than 6 statute miles; clouds and sky condition, 4,500 feet scattered, 8,000 feet broken.

On October 27, from about 0600 to about 1200, Aviation Routine Weather Reports (METARs) from the Bethel Airport included visibilities between 1/2 to 3/4 mile in mist and freezing fog. The ceiling varied between 100 feet, to 1,100 feet. At 1253, a METAR report included a visibility of 2 miles in mist, few clouds at 100 feet, and broken clouds at 700 feet. At 1300, the visibility was 4 miles in patchy fog, few clouds at 100 feet, and broken clouds at 500 feet.

At 1300, the Bethel Automated Terminal Information System (ATIS) was reporting, in part: Bethel tower information Sierra, 2053Z; wind, calm; visibility, four miles in mist; ceiling, 500 feet overcast; temperature, 8 degrees F; dew point temperature, 6 degrees F.

Instrument meteorological conditions prevailed in the Bethel Class E airspace. At the time of the accident, airplanes were arriving and departing with Special VFR clearances. At 1309, the pilot was cleared for a Special VFR departure toward the east by the Bethel Air Traffic Control Tower (ATCT) local controller. At 1312, the pilot reported he was clear of the Bethel Class E airspace.

At 1321, the pilot contacted the Bethel ATCT and inquired whether the airport was VFR or IFR. When told the airport was IFR, he requested a Special VFR clearance to return to the airport, and said he was 9.3 miles southeast of Bethel. The pilot was told to maintain VFR, and report one mile southeast of the Bethel Class E surface area. At 1330, the pilot reported he was holding just south of Napaskiak, Alaska, (5 miles southeast of Bethel), and at 1331, he was cleared into the Class E surface area to enter right traffic for runway 36.

At 1333, the Bethel METAR was reporting in part: Wind, calm; visibility, 4 statute miles in light snow and patchy fog; sky condition, 100 feet scattered, 400 feet overcast; temperature, 10 degrees F; dew point, 8 degrees F; altimeter, 29.73 inHg; remarks, occasional localized lower visibility, ceiling varying between 300 to 600 feet. Snow began 27 minutes past the hour.

At 1334, the pilot was cleared to land, but at 1335, he reported that he had flown over the runway and never saw it. He said he was entering a left downwind for runway 36. At 1336, the pilot said he was 1.6 miles northwest of Bethel. The Bethel ATCT controller turned the runway lights up to maximum. At 1340, the controller requested to know the pilot's intentions. He replied that he would head to the southeast and try to get into Napakiak (6 miles south of Bethel).

At 1340, several pilots waiting to depart Bethel began to cancel their Special VFR clearances, and one pilot asked if the weather had changed. The Bethel ATCT controller replied that the weather conditions were rapidly decreasing, but he did not have a current report. At 1341, the Bethel local controller made a radio broadcast, stating: "Bethel tower broadcasting in the blind, due to rapidly decreasing conditions, the weather is posting a 100 foot ceiling, at this time 100 foot broken."

At 1343, the pilot contacted the Bethel ATCT and advised he lost engine power, and was down on the tundra, 2.4 miles west of the airport.

At 1343, the Bethel ATIS was reporting, in part: Bethel tower information Tango, 2142Z; wind, calm; visibility, four miles in patchy fog; ceiling, 100 feet overcast; temperature, 10 degrees F; dew point temperature, 8 degrees F.

A Federal Aviation Administration (FAA) operations inspector, Anchorage Flight Standards District Office (FSDO), was at the Bethel Airport when the accident occurred. He reported the cloud condition at the airport was 100 feet overcast. He traveled to the accident scene, and interviewed the pilot. The inspector reported the pilot said he departed Bethel under VFR conditions, after waiting most of the day due to low visibility at the airport. The pilot encountered worsening weather conditions and decided to return to Bethel. The pilot had to hold out of the Bethel surface area for a Special VFR clearance. Once cleared into the surface area, the pilot said he could not see the runway because the windshield of the airplane was iced over. The pilot decided to proceed toward the southeast, but said the engine began to run rough and lose power. He said that application of full power was unable to prevent the airplane from losing altitude. He lowered the flaps and the airplane touched down on snow-covered terrain. During the landing, the nose gear was sheared off, and the right wing received rib damage to the outboard end. At the accident scene, the FAA inspector noted about 1/8 inch of ice on the airplane.

In the Pilot/Operator report (NTSB Form 6120.1/2) submitted by the operator, the pilot included a written statement. In the statement, the pilot reported, in part, that he conducted a preflight inspection of the accident airplane at 0815. He said the airplane's left fuel tank was empty, and the right fuel tank was full. He sumped the right fuel tank, and indicted he had two hours of fuel for a 40 minute flight. The pilot said he was dispatched on Flight 70, and that two company representatives were in the dispatch office.

During a telephone conversation with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC), on October 28, 1999, the pilot reported he was about 4 miles northeast of Bethel when the weather conditions worsened. When he contacted the Bethel tower to inquire about the weather, he was told the airport was IFR. He returned to the airport area, and held on the 135 degree radial of the Bethel VOR, one mile outside the surface area, near the vil

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight encounter with weatherCruise
Weather condition - low ceilingFactor
Weather evaluation - inadequatePilot in commandCause
Supervision - inadequateCompany/operator managementFactor
Weather condition - icing conditionsFactor
Flight into adverse weather - initiatedPilot in commandCause
Airframe - iceFactor
Altitude - not obtained/maintained
In flight collision with terrain/waterEmergency landing
Terrain condition - snow covered

Aircraft

Registration
N207SE
Reported as
Cessna 207
Category
Airplane
Serial number
20700237
Airframe hours
15,043
Engine
Continental IO-520-F27B, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Part 135
Operator
Hageland Aviation Services Inc
Registered owner
Gussic Ventures
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · October 21, 1999 · 18 hours before
Departed
PABE
Destination
AKI · Akiak, AK
Flight plan
Company VFR
Airport
PABE · Bethel

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
33
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
1,300 total · 100 in this make and model

Weather

Conditions
Instrument (IMC) · Day
Wind
Calm
Visibility
4 statute miles
Lowest ceiling
400 ft overcast
Temperature
10 °F, dew point 9 °F
Altimeter
29.00 inHg
Observed at
PAB, 2 nm away

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N207SE · 1

Matched to the same aircraft by N-number and date.