ANC08IA026

NTSB incident investigation · Beech 1900 · Aniak, AK · December 17, 2007

Incident · Minor injuriesIncident investigationFinal report
Date
December 17, 2007, 19:40 local (23:40 UTC)
Place
Aniak, AK
Injuries
1 minor, 1 uninjured
Damage
No damage
Phase of flight
Takeoff
Aircraft
N111AXBeech 1900
Weather
Visual (VMC) · Night/dark
Status
Completed · report July 30, 2008
Report
Approved by Office Director
NTSB office
Alaska Regional Office
Parties
FAA-AL-ANC FSDO 03
FAA report
20071217828769I
Case key
67272

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

On this page

Probable cause

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

A hazardous leak from carbon dioxide cylinders due to the failure of the flight crew to properly load and secure the cylinders, resulting in crew incapacitation. Factors contributing to the incident were improper hazardous materials procedures used by the shipper, and a failure of the operator to properly train the flight crew in hazardous materials procedures.

Analysis

The flight crew of a cargo airplane had previously loaded a cargo of carbon dioxide cylinders, and then flew to an intermediate airport for fuel. The cylinders had a screw type valve, and a threaded metal safety cap to protect the valve. During the takeoff run after refueling, the crew aborted the takeoff, and taxied back to the airport ramp after hearing a "hissing" sound from the cargo area. Once on the ramp, the captain shut off the engines, but the flight crew lost consciousness before they could exit the airplane. Since the crew filed an IFR flight plan that was not activated, air traffic control personnel contacted the freight office to inquire about the status of the airplane. A freight agent noticed the airplane sitting on the ramp. He opened the door of the airplane, and found the first officer unconscious, inside the door. The captain was unconscious at the controls. He pulled both crewmembers out of the airplane, and ran for help. The flight crew regained consciousness while lying on the ramp, and walked to the freight building. The flight crew were treated at a hospital and released the following day. The first officer reported that as the captain was taxiing back to the airport ramp, he felt the effects of the gas release, and he and the captain opened the cockpit windows. Once stopped, he got up to open the forward door, but collapsed at the door. An FAA inspector examined the airplane, and discovered that the cargo compartment had two tank racks containing five bottles each, standing vertically along each side of the airplane. Two of the cylinders in the left side rack did not have any safety caps installed. Three of the cylinders in the right side rack also did not have any safety caps installed. The caps were found on the floor of the airplane. The inspector found that the middle tank of the three in the right side rack, had a partially open valve. The open tank valve was about 1/2 turn open, and was positioned against the interior side-wall of the cargo compartment. The FAA inspector also indicated that nine carbon dioxide tanks were lying on the floor of the cargo area. They were braced by chocks, but were not strapped down. The crew oxygen masks were not utilized, and the crew oxygen supply tank was full. An FAA Hazardous Materials Division inspector reported that cylinders of carbon dioxide are considered hazardous material because they are pressurized in excess of 40 psi. The inspector noted that the shipper had a responsibility to properly identify and declare hazardous materials that they were shipping, the carrier had a responsibility to properly train airplane crewmembers to identify and accept hazardous materials, and the flight crew had a responsibility to properly secure hazardous materials during transport.

Factual narrative

The factual narrative776 words

On December 17, 2007, about 1940 Alaska Standard time, the crewmembers of a Beech 1900 airplane, N111AX, aborted their takeoff from Aniak, Alaska, and taxied back to the airport ramp, when they heard a "hissing" sound from the cargo area. Once on the ramp, the captain shut off the engines. The captain and first officer lost consciousness before they could exit the airplane. The airplane was being operated as an instrument flight rules (IFR) cross-country nonscheduled cargo flight under Title 14, CFR Part 135, when the incident occurred. The airplane was operated as Flight 81, by Alaska Central Express, Anchorage, Alaska, and was not damaged. The airline transport certificated pilot was not injured. The airline transport certificated first officer received minor injuries. Visual meteorological conditions prevailed, and an IFR flight plan was filed from Aniak, to Anchorage, but was not activated.

During a telephone conversation with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) on December 17, the director of operations for the operator reported that he received a call from a ramp agent at Inland Aviation, Aniak. Inland Aviation personnel provided ground handling and fueling for the flight. The agent reported that after the airplane left the ramp, he paid no further attention to it until he received a telephone call from Anchorage Air Traffic Control Center (ARTCC) personnel. ARTCC was inquiring about the airplane, as the crew had not radioed that they were airborne. The agent looked out of the freight building and noticed the airplane sitting on the ramp. The engines were stopped, and the airplane lights were "on" but dim. He opened the door of the airplane, and found the first officer unconscious, inside the door. The captain was unconscious at the controls. He pulled both crewmembers out of the airplane, onto the ramp, and then ran to call for help.

The flight crew regained consciousness while lying on the ramp, and then walked to the freight building. Medical personnel provided care, to include 100 percent oxygen. The flight crew were flown to a hospital in Anchorage where they were released the following day. The crewmembers had no memory of events from the time they stopped the airplane on the ramp, until they woke-up on the airport ramp. The first officer reported that as the captain was taxiing back to the airport ramp, he felt the effects of the gas release, and both crewmembers opened the cockpit windows. Once stopped, he got up to open the forward door, but collapsed at the door.

The director of operations indicated that the airplane initially departed Sheldon Point, Alaska, with an intermediate stop in Aniak for fuel and cargo, before continuing to Anchorage. At Sheldon Point, the crew loaded several large metal cylinders designed to hold compressed gas. Several of the cylinders were empty, but several were full of carbon dioxide. The cylinders have a screw type valve, and a threaded metal safety cap, which is used to protect the valve. Several cylinders were placed in metal racks along the left and right sides of the airplane's cargo compartment. Several others were placed on the floor.

On December 18, a Federal Aviation Administration (FAA) inspector, Anchorage Flight Standards District Office (FSDO), inspected the airplane in Aniak. He reported that the cargo compartment had two tank racks containing five bottles each, standing vertically along each side of the airplane. Two of the cylinders in the left side rack did not have any safety caps installed. Three of the cylinders in the right side rack also did not have any safety caps installed. The caps were found on the floor of the airplane. The inspector found that the middle tank of the three in the right side rack, had a partially open valve. The interior of the airplane had a large amount of frost. The open tank valve was about 1/2 turn open, and was positioned against the interior side-wall of the cargo compartment.

The FAA inspector also indicated that nine carbon dioxide tanks were lying on the floor of the cargo area. They were braced by chocks, but were not strapped down. The crew oxygen masks were not utilized, and the crew oxygen supply tank was full.

An FAA Hazardous Materials Division inspector reported that the cylinders of carbon dioxide are considered hazardous material because they are a pressurized gas in excess of 40 psi. The inspector also indicated that the shipper has a responsibility to properly identify and declare hazardous materials that they are shipping, the carrier has a responsibility to properly train airplane crewmembers to identify and accept hazardous materials, and the flight crew has a responsibility to properly secure hazardous materials during transport.

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.

Hazardous materials leak/spillTakeoff - roll/run
Procedure inadequateOther personFactor
Loading of cargo - improperFlightcrewCause
Inadequate trainingCompany/operator managementFactor
Miscellaneous/otherStanding - engine(s) not operating
Incapacitation(loss of consciousness)Flightcrew
Oxygen system,crew - not activated

Aircraft

Registration
N111AX
Reported as
Beech 1900
Category
Airplane
Serial number
UC-81
Airframe hours
48,506
Engine
Pratt & Whitney Canada PT6A-65B, 1,100 horsepower, turbo prop
Damage
No damage
Flight
Part 135
Registered owner
Alaska Central Express
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · December 1, 2007 · 96 hours before
Departed
PANI · Aniak, AK
Destination
PANC · Anchorage, AK
Flight plan
IFR
Airport
PANI · Aniak

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
41
Injuries
None
Certificates
Airline transport, Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
September 1, 2007
Seat
Left
Flight hours
19,100 total · 8,000 in this make and model
Role
Co-pilot
Age
30
Injuries
Minor
Certificates
Airline transport, Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
July 1, 2007
Seat
Rear
Flight hours
4,700 total · 600 in this make and model · 280 as pilot in command

Weather

Conditions
Visual (VMC) · Night/dark
Visibility
10 statute miles
Lowest ceiling
None
Temperature
-6 °F

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 N111AX · 2

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