ANC08FA050

NTSB accident investigation · Grumman G-21A · Unalaska, AK · April 10, 2008

Accident · Serious injuriesField investigationFinal report
Date
April 9, 2008, 16:30 local (Apr 10, 2008, 00:30 UTC)
Place
Unalaska, AK
Injuries
1 serious, 8 minor
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N741Grumman G-21A
Weather
Visual (VMC) · Day
Status
Completed · report July 28, 2009
Report
Approved by Office Director
NTSB office
Alaska Regional Office
Parties
Peninsula Airways, Inc., Federal Aviation Administration (Operations)
FAA report
20080409831909A
Case key
67801

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 pilot's failure to maintain clearance from a truck while landing, and the vehicle operator's decision to ignore runway warning signals. Contributing to the accident was an inoperative vehicle gate system and the failure of airport management to adequately maintain the gate system and issue a NOTAM.

Findings · 6

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Object/animal/substance: ground vehicleEnvironmental issues › Physical environment · Contributed to outcomeGrumman G-21A: 1 caseAll aircraft: 132 cases
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Airport personnelGrumman G-21A: 1 caseAll aircraft: 320 casesProbable cause
Object/animal/substance: wall/barricadeEnvironmental issues › Physical environment · Not specifiedGrumman G-21A: 1 caseAll aircraft: 29 casesProbable cause
Performance/control parameters: descent/approach/glide pathAircraft › Aircraft oper/perf/capability · Not attained/maintainedGrumman G-21A: 1 caseAll aircraft: 809 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotGrumman G-21A: 3 casesAll aircraft: 9,295 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The airline transport pilot was on an approach to land on Runway 30 at the conclusion of a visual flight rules (VFR)scheduled commuter flight. Through a series of radio microphone clicks, he activated threshold warning lights for vehicle traffic on a roadway that passes in front of the threshold of Runway 30. Gates that were supposed to work in concert with the lights and block the runway from vehicle traffic were not operative. On final approach, the pilot, who was aware that the gates were not working, noticed a large truck and trailer stopped adjacent to the landing threshold. As he neared the runway, he realized that the truck was moving in front of the threshold area. The pilot attempted to go around, but the airplane's belly struck the top of the trailer and the airplane descended out of control to the runway, sustaining structural damage. The truck driver reported that, as he approached the runway threshold, he saw the flashing red warning lights, but that the gates were not closed. He waited for about 45 seconds and looked for any landing traffic and, seeing none, drove onto the road in front of the threshold. As he did so, he felt the airplane impact the trailer, and saw it hit the runway. The accident truck's trailer is about 45 feet long and 13 feet tall. The Federal Aviation Administration (FAA) Facility Directory/Alaska Supplement recommends that pilots maintain a 25-foot minimum threshold crossing height. The NTSB's investigation revealed that the gate system had been out of service for more than a year due to budgetary constraints, and that there was no Notice to Airman (NOTAM) issued concerning the inoperative gate system. The FAA certificated airport is owned and operated by the State of Alaska. According to the Airport Certification Manual, the airport manager is responsible to inspect, maintain, and repair airport facilities to ensure safe operations. Additionally, the airport manager is responsible for publishing NOTAM's concerning hazardous conditions. A 10-year review of annual FAA certification and compliance inspection forms revealed no discrepancy listed for the inoperative gates until 16 days after the accident.

Factual narrative

History of flight

On April 9, 2008, about 1630 Alaska daylight time, an amphibious Grumman G-21A airplane, N741, received substantial damage when it collided with a trailer van while on approach to Runway 30 at the Unalaska Airport, Unalaska, Alaska. The airplane was operated by Peninsula Airways, Inc., Anchorage, Alaska. The flight was conducted under Title 14, CFR Part 135, as scheduled commuter Flight 325, when the accident occurred. Of the nine people on board, the airline transport pilot and seven passengers sustained minor injuries, and one passenger sustained serious injuries. The flight originated at the Akutan Sea Plane Base, Akutan, Alaska, about 1615, and was en route to Unalaska. Company flight following procedures were in effect.

Airplanes landing at the Unalaska Airport on Runway 30 pass low over Ballyhoo Road before reaching the approach threshold of the runway. Ballyhoo Road provides the only access between the city of Unalaska and the city dock facility, north of the Unalaska Airport. Trucks transporting large container vans between the trailer yard and the city dock facility routinely use the road. There are two remotely controlled gates with warning lights on each side the runway threshold designed to block vehicle traffic while airplanes are landing on Runway 30. When the gate and warning light system is activated, the runway end identifier lights (REIL) are also supposed to be activated. Prior to landing, pilots are instructed to activate the remotely controlled gate and warning light system.

During a telephone interview with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) on April 10, the truck driver reported that he was transporting a 45-foot long by 13-foot tall trailer van from the Horizon Lines trailer yard to the city dock facility. He said that as he approached the part of the road where it crossed under the approach path of Runway 30, he saw that the warning lights were flashing, but the gates were not closed, so he stopped the truck to wait for the warning lights to go out. After waiting for about 45 seconds, the driver looked to see if he could see any landing traffic, but he did not see any. He reported that with the red lights still flashing, he drove onto the road in front of the threshold.

Shortly after passing the flashing warning lights, he heard a loud bang and the truck rocked to the left. He then saw the airplane collide with the runway on the left side of his truck.

The truck driver noted that he had worked in Unalaska for only 4 months, but during that time, the traffic gates at that intersection had never worked. Additionally, he said that the flashing warning lights would routinely activate with no arriving traffic, and remain activated, which would block traffic for long periods of time.

According to the Unalaska police officer assigned to the accident case, the accident truck driver did not have a valid driver's license. Also, his commercial driver's license (CDL) was suspended.

During an interview with the NTSB IIC on April 11, the accident pilot said that as he started his initial approach to Runway 30, he activated the remotely controlled traffic warning devices as required. He said that as he flew towards Runway 30, he could see the REIL strobe lights, which are simultaneously activated when the gate and warning light system on the road is activated. Concurrently, he said he could see a large truck and trailer rig stopped at the intersection, adjacent to the southern traffic gate. During the approach, the pilot continued to watch the truck to be sure that it did not start moving. He then configured the airplane for landing by lowering the airplane's landing gear and flaps, and then completed his final prelanding checklist. The pilot said that as the airplane approached the runway threshold, he realized that the truck was now moving, and it was well onto the road in front of the threshold area. He applied full engine power in an attempt to go-around, but as the airplane began to climb, the nose of the airplane pitched up slightly, and the aft section of the airplane's belly and empennage struck the top of the trailer van.

The pilot said that immediately after the initial collision, he had no elevator control, and the airplane descended uncontrollably, nose down. It collided with the surface of the runway, and slid for several hundred feet.

The NTSB IIC asked the accident pilot if he used the visual approach slope indicator systems (VASI) while landing on runway 30. The pilot explained that at the time of the accident he was not using the VASI because he was attempting to shorten his ground roll after landing in order to avoid an unfavorable crosswind condition further down Runway 30.

The NTSB IIC asked the accident pilot if he was aware that the gates were out of service. The pilot said that he was aware that the gates had not been working for a long time.

The pilot reported that there were no preaccident mechanical anomalies with the airplane.

Personnel information

Pilot Information

The pilot held an airline transport pilot certificate with airplane multiengine land and sea ratings. He also held commercial pilot privileges with airplane single-engine land and sea ratings. His most recent first-class medical certificate was issued November 28, 2008, and contained the limitation that he must wear correcting lenses.

According to the NTSB Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1) submitted by Peninsula Airways, dated April 15, 2008, the pilot's total flight time was 7,040 hours, of which 320 were in the accident airplane make and model, and 2,532 in multiengine airplanes. In the preceding 90 and 30 days prior to the accident, the report noted that in the 30 days before the accident, the pilot flew about 9 hours. His flight time in the previous 90 days was about 22 hours. His most recent airman competency/proficiency check (CFR Part 135.293) check ride was on May 30, 2007, and a company check airman administered the check ride in the same make and model as the accident airplane.

Aircraft information

The airplane was equipped with two Pratt & Whitney R985-AN-14B radial engines, each rated at 450 horsepower.

The airplane's maximum gross weight was 9,200 pounds, and the estimated gross weight at the time of the accident was 8,833 pounds, or 367 pounds below its maximum gross weight.

The airplane was not equipped with a cockpit voice recorder, or a flight data recorder.

The airplane was maintained under the operator's Approved Aircraft Inspection Program (AAIP), which requires inspections to be performed approximately every 50 and 100 flight hours. The airplane had accumulated 12,228 hours in service at the time of the accident, and 10.2 flight hours had elapsed since the most recent "A" check inspection.

Meteorological information

The closest official weather observation station is located at the Unalaska Airport. At 1616, an Aviation Routine Weather Report (METAR) was reporting, in part: Wind, 30 degrees (true) at 9 knots with gusts to 15 knots; visibility, 10 statute miles; clouds and sky condition, 2,200 feet overcast; temperature, 30 degrees F; dew point, 21 degrees F; altimeter, 29.98 inHg.

Communications

Review of the air-ground radio communications tapes maintained by the FAA at the Kenai Automated Flight Service Station (AFSS), revealed that as the accident flight neared the Unalaska Airport, about 3 minutes before the accident, the pilot announced his intentions to land on Runway 30 over the airport's Common Traffic Advisory Frequency (CTAF) on 122.6. The pilot then keyed his radio microphone 7-times, to activate the remotely controlled vehicle gate and warning light system.

No further radio communications were recorded from the accident airplane.

Aerodrome and ground facilities

The Unalaska Airport is owned and operated by

Aircraft

Registration
N741
Reported as
Grumman G-21A
Category
Airplane
Serial number
B-97
Airframe hours
12,228
Engine
Pratt & Whitney R985, 450 horsepower, reciprocating
Damage
Substantial damage
Flight
Part 135
Operator
Peninsula Airways, Inc.
Registered owner
Peninsula Airways, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · March 25, 2008 · 10 hours before
Departed
KQA · Akutan, AK
Destination
DUT · Unalaska, AK
Flight plan
VFR
Airport
PADU · Unalaska Airport, runway 30, 3,900 × 100 ft, asphalt

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
37
Injuries
Minor
Certificate
Airline transport
Airplane ratings
Multi-engine sea, Single-engine sea, Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
May 30, 2007
Seat
Left
Flight hours
7,040 total · 320 in this make and model · 6,500 as pilot in command · 22 in the last 90 days · 9 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
300° at 9 knots, gusting 15
Visibility
10 statute miles
Lowest ceiling
2,200 ft overcast
Temperature
30 °F, dew point 21 °F
Altimeter
29.88 inHg
Observed at
PADU

Docket · 12

The files NTSB released with the investigation on June 1, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.7 MB in all.

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 N741 · 1

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