# NTSB ANC17MA001: Cessna 208B, N208SD, Togiak, AK, October 2, 2016

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Class 1 · Major · Final report
- Date: October 2, 2016, 11:57 local (19:57 UTC)
- Place: Togiak, AK
- Coordinates: 59.165554, -160.653335
- Nearby events: https://openairdocs.org/map.md?lat=59.1656&lon=-160.6533&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Defining event: [Enroute-cruise: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401)
- Highest injury: Fatal
- Injuries: 3 fatal
- Status: Completed, report May 1, 2018
- Report: Board-adopted at Board Meeting
- Investigation class: Class 1
- NTSB office: Alaska Regional Office
- Parties: FAA, Honeywell Aerospace, Pratt & Whitney Canada, Hageland Aviation Services, Inc., Hageland Aviation, Hartzell Propellers
- Safety recommendations: Yes
- NTSB case key (mKey): 94121
- NTSB case page: https://www.ntsb.gov/investigations/Pages/ANC17MA001.aspx
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94121/pdf
- Board report AAR1802 (PDF): https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR1802.pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94121
- Page: https://openairdocs.org/ntsb/ANC17MA001

## Probable cause

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 CFIT avoidance ground training, which was not tailored to the company's operations and did not address current CFIT-avoidance technologies.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Flight crew (probable cause); cases with it: [Cessna 208B, 18 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2073701), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md)
- [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Flight crew (probable cause); cases with it: [Cessna 208B, 3 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=2073701), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md)
- [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 208B, 2 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=2073701), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md)
- [Ceiling/visibility/precip: below VFR minima](https://openairdocs.org/ntsb-findings/03035075): Environmental issues › Conditions/weather/phenomena · Decision related to condition (probable cause); cases with it: [Cessna 208B, 3 cases](https://openairdocs.org/ntsb-findings/03035075/cases.md?model=2073701), [All aircraft, 184 cases](https://openairdocs.org/ntsb-findings/03035075/cases.md)
- [Ceiling/visibility/precip: below VFR minima](https://openairdocs.org/ntsb-findings/03035075): Environmental issues › Conditions/weather/phenomena · Response/compensation (probable cause); cases with it: [Cessna 208B, 3 cases](https://openairdocs.org/ntsb-findings/03035075/cases.md?model=2073701), [All aircraft, 184 cases](https://openairdocs.org/ntsb-findings/03035075/cases.md)
- [Terrain: mountainous/hilly terrain](https://openairdocs.org/ntsb-findings/03021010): Environmental issues › Physical environment · Response/compensation (probable cause); cases with it: [Cessna 208B, 2 cases](https://openairdocs.org/ntsb-findings/03021010/cases.md?model=2073701), [All aircraft, 329 cases](https://openairdocs.org/ntsb-findings/03021010/cases.md)
- [Terrain: mountainous/hilly terrain](https://openairdocs.org/ntsb-findings/03021010): Environmental issues › Physical environment · Contributed to outcome (probable cause); cases with it: [Cessna 208B, 2 cases](https://openairdocs.org/ntsb-findings/03021010/cases.md?model=2073701), [All aircraft, 329 cases](https://openairdocs.org/ntsb-findings/03021010/cases.md)
- [Policy/procedure: adequacy of policy/proc](https://openairdocs.org/ntsb-findings/04021015): Organizational issues › Management · Operator (probable cause); cases with it: [Cessna 208B, 6 cases](https://openairdocs.org/ntsb-findings/04021015/cases.md?model=2073701), [All aircraft, 106 cases](https://openairdocs.org/ntsb-findings/04021015/cases.md)
- [Training: cRM/MRM training](https://openairdocs.org/ntsb-findings/04031025): Organizational issues › Support/oversight/monitoring · Operator (probable cause); cases with it: [Cessna 208B, 1 case](https://openairdocs.org/ntsb-findings/04031025/cases.md?model=2073701), [All aircraft, 2 cases](https://openairdocs.org/ntsb-findings/04031025/cases.md)
- [Training: cRM/MRM training](https://openairdocs.org/ntsb-findings/04031025): Organizational issues › Support/oversight/monitoring · FAA/Regulator (probable cause); cases with it: [Cessna 208B, 1 case](https://openairdocs.org/ntsb-findings/04031025/cases.md?model=2073701), [All aircraft, 2 cases](https://openairdocs.org/ntsb-findings/04031025/cases.md)
- [Training](https://openairdocs.org/ntsb-findings/04031000): Organizational issues › Support/oversight/monitoring · Operator (probable cause); cases with it: [Cessna 208B, 3 cases](https://openairdocs.org/ntsb-findings/04031000/cases.md?model=2073701), [All aircraft, 26 cases](https://openairdocs.org/ntsb-findings/04031000/cases.md)
- [Navigation system: ground proximity system](https://openairdocs.org/ntsb-findings/01023444): Aircraft › Aircraft systems · Not used/operated (probable cause); cases with it: [Cessna 208B, 1 case](https://openairdocs.org/ntsb-findings/01023444/cases.md?model=2073701), [All aircraft, 7 cases](https://openairdocs.org/ntsb-findings/01023444/cases.md)
- [Navigation system: ground proximity system](https://openairdocs.org/ntsb-findings/01023444): Aircraft › Aircraft systems · Related operating info (probable cause); cases with it: [Cessna 208B, 1 case](https://openairdocs.org/ntsb-findings/01023444/cases.md?model=2073701), [All aircraft, 7 cases](https://openairdocs.org/ntsb-findings/01023444/cases.md)
- [Navigation system: ground proximity system](https://openairdocs.org/ntsb-findings/01023444): Aircraft › Aircraft systems · Capability exceeded (probable cause); cases with it: [Cessna 208B, 1 case](https://openairdocs.org/ntsb-findings/01023444/cases.md?model=2073701), [All aircraft, 7 cases](https://openairdocs.org/ntsb-findings/01023444/cases.md)
- [Navigation system: ground proximity system](https://openairdocs.org/ntsb-findings/01023444): Aircraft › Aircraft systems · Design (probable cause); cases with it: [Cessna 208B, 1 case](https://openairdocs.org/ntsb-findings/01023444/cases.md?model=2073701), [All aircraft, 7 cases](https://openairdocs.org/ntsb-findings/01023444/cases.md)
- [Communication system: vHF/HF radio](https://openairdocs.org/ntsb-findings/03016010): Environmental issues › Operating environment · Not specified (probable cause); cases with it: [Cessna 208B, 1 case](https://openairdocs.org/ntsb-findings/03016010/cases.md?model=2073701), [All aircraft, 6 cases](https://openairdocs.org/ntsb-findings/03016010/cases.md)
- [Meteorological services: meteo equip coverage/avail](https://openairdocs.org/ntsb-findings/03013010): Environmental issues › Operating environment · Not specified (probable cause); cases with it: [Cessna 208B, 1 case](https://openairdocs.org/ntsb-findings/03013010/cases.md?model=2073701), [All aircraft, 3 cases](https://openairdocs.org/ntsb-findings/03013010/cases.md)
- [Safety programs](https://openairdocs.org/ntsb-findings/04035000): Organizational issues › Support/oversight/monitoring · FAA/Regulator (probable cause); cases with it: [Cessna 208B, 1 case](https://openairdocs.org/ntsb-findings/04035000/cases.md?model=2073701), [All aircraft, 7 cases](https://openairdocs.org/ntsb-findings/04035000/cases.md)
- [Safety programs](https://openairdocs.org/ntsb-findings/04035000): Organizational issues › Support/oversight/monitoring · Other institution/organization (probable cause); cases with it: [Cessna 208B, 1 case](https://openairdocs.org/ntsb-findings/04035000/cases.md?model=2073701), [All aircraft, 7 cases](https://openairdocs.org/ntsb-findings/04035000/cases.md)
- [Indicating/recording systems: data recorders (flight/maint)](https://openairdocs.org/ntsb-findings/01023130): Aircraft › Aircraft systems · Not installed/available (probable cause); cases with it: [Cessna 208B, 1 case](https://openairdocs.org/ntsb-findings/01023130/cases.md?model=2073701), [All aircraft, 17 cases](https://openairdocs.org/ntsb-findings/01023130/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Enroute-cruise: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401) (defining event); cases with it: [Cessna 208B, 4 cases](https://openairdocs.org/ntsb-events/401/sequence.md?model=2073701), [All aircraft, 392 cases](https://openairdocs.org/ntsb-events/401/sequence.md)
- [Enroute-cruise: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120); cases with it: [Cessna 208B, 7 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=2073701), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md)

## Analysis

The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-18/02. On October 2, 2016, about 1157 Alaska daylight time, Ravn Connect flight 3153, a turbine-powered Cessna 208B Grand Caravan airplane, N208SD, collided with steep, mountainous terrain about 10 nautical miles northwest of Togiak Airport (PATG), Togiak, Alaska. The two commercial pilots and the passenger were killed, and the airplane was destroyed. The scheduled commuter flight was operated under visual flight rules by Hageland Aviation Services, Inc., Anchorage, Alaska, under the provisions of Title 14 Code of Federal Regulations Part 135. Visual meteorological conditions prevailed at PATG (which had the closest weather observing station to the accident site), but a second company flight crew (whose flight departed about 2 minutes after the accident airplane and initially followed a similar route) reported that they observed unexpected fog, changing clouds, and the potential for rain along the accident route. Company flight-following procedures were in effect. The flight departed Quinhagak Airport, Quinhagak, Alaska, about 1133 and was en route to PATG.

## Factual narrative

The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-18/02. On October 2, 2016, about 1157 Alaska daylight time, Ravn Connect flight 3153, a turbine-powered Cessna 208B Grand Caravan airplane, N208SD, collided with steep, mountainous terrain about 10 nautical miles northwest of Togiak Airport (PATG), Togiak, Alaska. The two commercial pilots and the passenger were killed, and the airplane was destroyed. The scheduled commuter flight was operated under visual flight rules by Hageland Aviation Services, Inc., Anchorage, Alaska, under the provisions of Title 14 Code of Federal Regulations Part 135. Visual meteorological conditions prevailed at PATG (which had the closest weather observing station to the accident site), but a second company flight crew (whose flight departed about 2 minutes after the accident airplane and initially followed a similar route) reported that they observed unexpected fog, changing clouds, and the potential for rain along the accident route. Company flight-following procedures were in effect. The flight departed Quinhagak Airport, Quinhagak, Alaska, about 1133 and was en route to PATG.

## Aircraft

- Registration: [N208SD](https://openairdocs.org/deregistered/N208SD-2016-11-09), registration cancelled 2016-11-09, S/N 208B0491, built 1995 (OpenAirDocs)
- Reported make and model: CESSNA 208B
- Registry model: [Cessna 208B](https://openairdocs.org/model/cessna-208b) (registry code 2073701) (OpenAirDocs)
- Registry engine: [Pratt & Whitney PT6A series](https://openairdocs.org/engine/pratt-whitney-pt6a-series) (registry code 52032, turbo-prop) (OpenAirDocs)
- Category: Airplane
- Serial number: 208B0491
- Year built: 1995
- Airframe hours: 20562.1
- Engines: P&W PT6-114A 675 horsepower turbo prop
- Damage: Destroyed
- Flight: Part 135
- Operator: Hageland Aviation Services Inc, doing business as Ravn Connect
- Registered owner: Icecap LLC Trustee
- Airworthiness certificate: Standard, Normal
- Last inspection: AAIP, September 15, 2016
- Departed: PAQH, QUINHAGAK, AK
- Destination: PATG, TOGIAK, AK
- Flight plan: Company VFR
- Airport: PATG, Togiak
- Equipment: Electronic multifunction display, Auto-pilot, Satellite tracking device, Stall warning system, ADS-B

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 43; injuries: fatal; flight instructor, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review July 7, 2016; seat: left; toxicology performed; flight hours: 6,481 total, 781 in this make and model, 6,181 as pilot in command, 271 in the last 90 days, 102 in the last 30 days, 4 in the last 24 hours
- Co-pilot; age 29; injuries: fatal; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2; last flight review September 3, 2016; seat: right; toxicology performed; flight hours: 273 total, 84 in this make and model, 139 as pilot in command, 84 in the last 90 days, 83 in the last 30 days, 5 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: calm
- Visibility: 7 statute miles
- Lowest ceiling: 4,700 ft overcast
- Temperature: 45 °F, dew point 43 °F
- Altimeter: 29.87 inHg
- Observed at: PATG, 11 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 (OpenAirDocs).

- [Accident 20161002019779A](https://openairdocs.org/incident/20161002019779A), Oct 2, 2016: Cessna 208B, Togiak, AK, Destroyed, 3 fatal. A Cessna 208B N208SD departed quinhagak airport Alaska at 1133 local time on October 2, 2016 enroute for Togiak airport Alaska. A two pilot crew with on…

## Docket (81 files)

The files NTSB released with the investigation on August 17, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94121. 94.4 MB in all.

- 1A Order of Hearing (item 1, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454974&FileExtension=.PDF&FileName=1A%20Order%20of%20Hearing-Master.PDF
- 1B Notice of Designation of Chairman of Board of Inquiry (item 2, .PDF, 132 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454975&FileExtension=.PDF&FileName=1B%20Notice%20of%20Designation%20of%20Chairman%20of%20Board%20of%20Inquiry-Master.PDF
- 1C Designation of Hearing Officer (item 3, .PDF, 128 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454976&FileExtension=.PDF&FileName=1C%20Designation%20of%20Hearing%20Officer-Master.PDF
- 1D Designation of Parties to the Hearing (item 4, .PDF, 176 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454977&FileExtension=.PDF&FileName=1D%20Designation%20of%20Parties%20to%20the%20Hearing%20-Master.PDF
- 1E Notice of Hearing (item 5, .PDF, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454978&FileExtension=.PDF&FileName=1E%20Notice%20of%20Hearing-Master.PDF
- 1F Statement of Purpose (item 6, .PDF, 114 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454979&FileExtension=.PDF&FileName=1F%20Statement%20of%20Purpose-Master.PDF
- Exhibit 1I - Safety Recommendations A-14-22 and A-14-23 (item 7, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454980&FileExtension=.PDF&FileName=Exhibit%201I%20-%20Safety%20Recommendations%20A-14-22%20and%20A-14-23-Master.PDF
- Exhibit 1J- Honeywell KGP 560 Flight Manual Supplement (item 8, .PDF, 551 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454981&FileExtension=.PDF&FileName=Exhibit%201J-%20Honeywell%20KGP%20560%20Flight%20Manual%20Supplement-Master.PDF
- Exhibit 2A- Operational Factors Factual Report (item 9, .PDF, 1 photo, 578 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455301&FileExtension=.PDF&FileName=Exhibit%202A-%20Operational%20Factors%20Factual%20Report-Master.PDF
- Exhibit 2B - Operational Factors Attachment 1 - Interview Transcripts (item 10, .PDF, 8.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454983&FileExtension=.PDF&FileName=Exhibit%202B%20-%20Operational%20Factors%20Attachment%201%20-%20Interview%20Transcripts-Master.PDF
- Exhibit 2C - Operational Factors Attachment 2 - Interview Summaries (item 11, .PDF, 543 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454984&FileExtension=.PDF&FileName=Exhibit%202C%20-%20Operational%20Factors%20Attachment%202%20-%20Interview%20Summaries-Master.PDF
- Exhibit 2D - Operational Factors Attachment 3 - Hageland GOM Excerpt - Weight and Balance-Manifests (item 12, .PDF, 127 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454985&FileExtension=.PDF&FileName=Exhibit%202D%20-%20Operational%20Factors%20Attachment%203%20-%20Hageland%20GOM%20Excerpt%20-%20Weight%20and%20Balance-Manifests-Master.PDF
- Exhibit 2E - Operational Factors Attachment 4- Hageland Flight 3153 OCC Flight Manifest (item 13, .PDF, 332 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454986&FileExtension=.PDF&FileName=Exhibit%202E%20-%20Operational%20Factors%20Attachment%204-%20Hageland%20Flight%203153%20OCC%20Flight%20Manifest-Master.PDF
- Exhibit 2F - Operational Factors Attachment 5 - Hageland GOM Excerpt - Safe Flight Categories Form (item 14, .PDF, 249 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454987&FileExtension=.PDF&FileName=Exhibit%202F%20-%20Operational%20Factors%20Attachment%205%20-%20Hageland%20GOM%20Excerpt%20-%20Safe%20Flight%20Categories%20Form-Master.PDF
- Exhibit 2G - Operational Factors Attachment 6 - Hageland GOM Excerpt - Risk Assessment Process (item 15, .PDF, 108 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454988&FileExtension=.PDF&FileName=Exhibit%202G%20-%20Operational%20Factors%20Attachment%206%20-%20Hageland%20GOM%20Excerpt%20-%20Risk%20Assessment%20Process-Master.PDF
- Exhibit 2H - Operational Factors Attachment 7 - Hageland OTM Excerpt - CFIT-A Training Module (item 16, .PDF, 141 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454989&FileExtension=.PDF&FileName=Exhibit%202H%20-%20Operational%20Factors%20Attachment%207%20-%20Hageland%20OTM%20Excerpt%20-%20CFIT-A%20Training%20Module-Master.PDF
- Exhibit 2I - Operational Factors Attachment 8 - University of Alaska Simulator Evaluation (item 17, .PDF, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454990&FileExtension=.PDF&FileName=Exhibit%202I%20-%20Operational%20Factors%20Attachment%208%20-%20University%20of%20Alaska%20Simulator%20Evaluation-Master.PDF
- Exhibit 2J - Operational Factors Attachment 9 - Hageland OTM Excerpt - CRM Training Module (item 18, .PDF, 142 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454991&FileExtension=.PDF&FileName=Exhibit%202J%20-%20Operational%20Factors%20Attachment%209%20-%20Hageland%20OTM%20Excerpt%20-%20CRM%20Training%20Module-Master.PDF
- Exhibit 2K - Operational Factors Attachment 10 - Hageland OTM Excerpt - OCA Training (item 19, .PDF, 163 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454992&FileExtension=.PDF&FileName=Exhibit%202K%20-%20Operational%20Factors%20Attachment%2010%20-%20Hageland%20OTM%20Excerpt%20-%20OCA%20Training-Master.PDF
- Exhibit 2L - Operational Factors Attachment 11 - Hageland CFIT-A Program Audit and Review (2015 & 2016) (item 20, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455144&FileExtension=.PDF&FileName=Exhibit%202L%20-%20Operational%20Factors%20Attachment%2011%20-%20Hageland%20CFIT-A%20Program%20Audit%20and%20Review%20(2015%20%26%202016)-Master.PDF
- Exhibit 2M - Operational Factors Attachment 12 - Hageland - FAA 7-Point CFIT Mitigation Plan (item 21, .PDF, 325 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455145&FileExtension=.PDF&FileName=Exhibit%202M%20-%20Operational%20Factors%20Attachment%2012%20-%20Hageland%20-%20FAA%207-Point%20CFIT%20Mitigation%20Plan-Master.PDF
- Exhibit 2N - Operational Factors Attachment 13 - FAA-Medallion Foundation Contract (OTA) (item 22, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455148&FileExtension=.PDF&FileName=Exhibit%202N%20-%20Operational%20Factors%20Attachment%2013%20-%20FAA-Medallion%20Foundation%20Contract%20(OTA)-Master.PDF
- Exhibit 2O - Operational Factors Attachment 14 - FAA Hageland Audit Results (item 23, .PDF, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455321&FileExtension=.PDF&FileName=Exhibit%202O%20-%20Operational%20Factors%20Attachment%2014%20-%20FAA%20Hageland%20Audit%20Results-Master.PDF
- Exhibit 2P - Operational Factors Attachment 15 - FAA CFIT-A Letter to Operators (item 24, .PDF, 638 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455153&FileExtension=.PDF&FileName=Exhibit%202P%20-%20Operational%20Factors%20Attachment%2015%20-%20FAA%20CFIT-A%20Letter%20to%20Operators-Master.PDF
- Exhibit 2Q - Operational Factors Attachment 16 - Medallion Foundation CFIT Avoidance Star Program Design and Process Measurement Audit Points (item 25, .PDF, 703 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455157&FileExtension=.PDF&FileName=Exhibit%202Q%20-%20Operational%20Factors%20Attachment%2016%20-%20Medallion%20Foundation%20CFIT%20Avoidance%20Star%20Program%20Design%20and%20Process%20Measurement%20Audit%20Points-Master.PDF
- Exhibit 2R - Operational Factors Attachment 17 - Medallion Foundation Operational Control Star Program Design and Process Measurement Audit Points (item 26, .PDF, 543 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455158&FileExtension=.PDF&FileName=Exhibit%202R%20-%20Operational%20Factors%20Attachment%2017%20-%20Medallion%20Foundation%20Operational%20Control%20Star%20Program%20Design%20and%20Process%20Measurement%20Audit%20Points-Master.PDF
- Exhibit 2S - Operational Factors Attachment 18 - Hageland Operations Specifications A008, B050 (item 27, .PDF, 231 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455159&FileExtension=.PDF&FileName=Exhibit%202S%20-%20Operational%20Factors%20Attachment%2018%20-%20Hageland%20Operations%20Specifications%20A008,%20B050-Master.PDF
- Exhibit 2T - Operational Factors Attachment 19 -Hageland Flight 3153 Flight Log (item 28, .PDF, 121 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455160&FileExtension=.PDF&FileName=Exhibit%202T%20-%20Operational%20Factors%20Attachment%2019%20-Hageland%20Flight%203153%20Flight%20Log-Master.PDF
- Operational Factors Attachment 20 - Operational Factors and Human Performance Specialist's Visit to Honeywell Aerospace (item 29, .PDF, 71 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455322&FileExtension=.PDF&FileName=Operational%20Factors%20Attachment%2020%20-%20Operational%20Factors%20and%20Human%20Performance%20Specialist%27s%20Visit%20to%20Honeywell%20Aerospace-Master.PDF
- Operational Factors Factual Report Errata (item 30, .PDF, 453 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461572&FileExtension=.PDF&FileName=Operational%20Factors%20Factual%20Report%20Errata-Master.PDF
- Exhibit 5A- Meteorology Factual Report (item 31, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455161&FileExtension=.PDF&FileName=Exhibit%205A-%20Meteorology%20Factual%20Report-Master.PDF
- Exhibit 6A - FAA Order 8000.373 FAA Compliance Philosophy (item 32, .PDF, 162 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455302&FileExtension=.PDF&FileName=Exhibit%206A%20-%20FAA%20Order%208000.373%20FAA%20Compliance%20Philosophy-Master.PDF
- Exhibit 6B - FAA Safety Briefing Excerpts (item 33, .PDF, 3.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455303&FileExtension=.PDF&FileName=Exhibit%206B%20-%20FAA%20Safety%20Briefing%20Excerpts-Master.PDF
- Exhibit 6C - Costello Letter (item 34, .PDF, 190 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455304&FileExtension=.PDF&FileName=Exhibit%206C%20-%20Costello%20Letter-Master.PDF
- Exhibit 6D - May 2017 FAA Audit of Medallion Foundation (item 35, .PDF, 124 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455305&FileExtension=.PDF&FileName=Exhibit%206D%20-%20May%202017%20FAA%20Audit%20of%20Medallion%20Foundation-Master.PDF
- Exhibit 6E - April 2016 FAA Audit of Medallion Foundation (item 36, .PDF, 134 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455306&FileExtension=.PDF&FileName=Exhibit%206E%20-%20April%202016%20FAA%20Audit%20of%20Medallion%20Foundation-Master.PDF
- Exhibit 14A - Human Performance Factual Report (item 37, .PDF, 214 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455307&FileExtension=.PDF&FileName=Exhibit%2014A%20-%20Human%20Performance%20Factual%20Report-Master.PDF
- Exhibit 14B - Human Performance Attachment 1 - Interview Summaries (item 38, .PDF, 841 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455308&FileExtension=.PDF&FileName=Exhibit%2014B%20-%20Human%20Performance%20Attachment%201%20-%20Interview%20Summaries-Master.PDF
- Exhibit 14C - Human Performance Attachment 2 - Interview Transcripts (item 39, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455309&FileExtension=.PDF&FileName=Exhibit%2014C%20-%20Human%20Performance%20Attachment%202%20-%20Interview%20Transcripts-Master.PDF
- Exhibit 14D - Human Performance Attachment 3 - Hageland CFIT-A Training Manual Excerpts (item 40, .PDF, 569 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455164&FileExtension=.PDF&FileName=Exhibit%2014D%20-%20Human%20Performance%20Attachment%203%20-%20Hageland%20CFIT-A%20Training%20Manual%20Excerpts-Master.PDF
- Exhibit 14E - Human Performance Attachment 4 - FSF CFIT Aid Excerpts (item 41, .PDF, 406 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455165&FileExtension=.PDF&FileName=Exhibit%2014E%20-%20Human%20Performance%20Attachment%204%20-%20FSF%20CFIT%20Aid%20Excerpts-Master.PDF
- Exhibit 14F - Human Performance Attachment 5 - Hageland OTM Excerpts (item 42, .PDF, 611 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455166&FileExtension=.PDF&FileName=Exhibit%2014F%20-%20Human%20Performance%20Attachment%205%20-%20Hageland%20OTM%20Excerpts-Master.PDF
- Exhibit 14G - Human Performance Attachment 6 - Hageland GOM Excerpts (item 43, .PDF, 523 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455167&FileExtension=.PDF&FileName=Exhibit%2014G%20-%20Human%20Performance%20Attachment%206%20-%20Hageland%20GOM%20Excerpts-Master.PDF
- Exhibit 14H - Human Performance Attachment 7 - FAA-Hageland Post Accident Agreement (item 44, .PDF, 468 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455168&FileExtension=.PDF&FileName=Exhibit%2014H%20-%20Human%20Performance%20Attachment%207%20-%20FAA-Hageland%20Post%20Accident%20Agreement-Master.PDF
- Exhibit 14I - Human Performance Attachment 8 - Medallion Foundation Shield Program Documents (item 45, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455169&FileExtension=.PDF&FileName=Exhibit%2014I%20-%20Human%20Performance%20Attachment%208%20-%20Medallion%20Foundation%20Shield%20Program%20Documents-Master.PDF
- Exhibit 14J - Human Performance Attachment 9 - FAA CFIT Letter (item 46, .PDF, 811 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455170&FileExtension=.PDF&FileName=Exhibit%2014J%20-%20Human%20Performance%20Attachment%209%20-%20FAA%20CFIT%20Letter-Master.PDF
- Exhibit 14K - Human Performance Attachment 10 - FAA 2017 Alaskan Aviator's Safety Handbook (item 47, .PDF, 8.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455171&FileExtension=.PDF&FileName=Exhibit%2014K%20-%20Human%20Performance%20Attachment%2010%20-%20FAA%202017%20Alaskan%20Aviator%27s%20Safety%20Handbook-Master.PDF
- Exhibit 14L - Human Performance Attachment 11 - Honeywell KGP 560/860 Pilot’s Guide (item 48, .PDF, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455172&FileExtension=.PDF&FileName=Exhibit%2014L%20-%20Human%20Performance%20Attachment%2011%20-%20Honeywell%20KGP%20560%2F860%20Pilot%E2%80%99s%20Guide-Master.PDF
- Exhibit 14M - Human Performance Attachment 12 - FAA Advisory Circular 25-23 (item 49, .PDF, 374 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455173&FileExtension=.PDF&FileName=Exhibit%2014M%20-%20Human%20Performance%20Attachment%2012%20-%20FAA%20Advisory%20Circular%2025-23-Master.PDF
- Exhibit 14N - Human Performance Attachment 13 - Hageland Safety Manual Excerpts (item 50, .PDF, 537 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455174&FileExtension=.PDF&FileName=Exhibit%2014N%20-%20Human%20Performance%20Attachment%2013%20-%20Hageland%20Safety%20Manual%20Excerpts-Master.PDF
- Human Performance Factual - Addendum 1 (item 51, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461573&FileExtension=.PDF&FileName=Human%20Performance%20Factual%20-%20Addendum%201-Master.PDF
- Human Performance Factual - Errata 1 (item 52, .PDF, 438 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461574&FileExtension=.PDF&FileName=Human%20Performance%20Factual%20-%20Errata%201-Master.PDF
- Electronic Device Specialist Report (item 53, .PDF, 9 photos, 569 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455175&FileExtension=.PDF&FileName=Electronic%20Device%20Specialist%20Report-Master.PDF
- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 54, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455176&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF
- EGPWS Examination Report (item 55, .PDF, 3 photos, 343 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455310&FileExtension=.PDF&FileName=EGPWS%20Examination%20Report-Master.PDF
- PIC Toxicological Report (item 56, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455311&FileExtension=.PDF&FileName=PIC%20Toxicological%20Report-Master.PDF
- SIC Toxicological Report (item 57, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455312&FileExtension=.PDF&FileName=SIC%20Toxicological%20Report-Master.PDF
- Photos (item 58, .PDF, 3 photos, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455313&FileExtension=.PDF&FileName=Photos-Master.PDF
- IIC Presentation (item 59, .PDF, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455323&FileExtension=.PDF&FileName=IIC%20Presentation-Master.PDF
- Panel 1-1 Hageland (CFIT-A Presentation) (item 60, .PDF, 257 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455314&FileExtension=.PDF&FileName=Panel%201-1%20Hageland%20(CFIT-A%20Presentation)-Master.PDF
- Panel 1-2 Honeywell (EGPWS Presentation) (item 61, .PDF, 679 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455315&FileExtension=.PDF&FileName=Panel%201-2%20Honeywell%20(EGPWS%20Presentation)-Master.PDF
- Panel 1-3 FAA (Alaska Flight Services Information Area Group Presentation) (item 62, .PDF, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455316&FileExtension=.PDF&FileName=Panel%201-3%20FAA%20(Alaska%20Flight%20Services%20Information%20Area%20Group%20Presentation)-Master.PDF
- Panel 2-1 Hageland (Operational Control Presentation) (item 63, .PDF, 926 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455317&FileExtension=.PDF&FileName=Panel%202-1%20Hageland%20(Operational%20Control%20Presentation)-Master.PDF
- Panel 3-1 Hageland (Safety Initatives and Programs Presentation) (item 64, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455318&FileExtension=.PDF&FileName=Panel%203-1%20Hageland%20(Safety%20Initatives%20and%20Programs%20Presentation)-Master.PDF
- Panel 3-2 FAA (Reducing Aviation Accidents in Alaska Presentation) (item 65, .PDF, 998 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455319&FileExtension=.PDF&FileName=Panel%203-2%20FAA%20(Reducing%20Aviation%20Accidents%20in%20Alaska%20Presentation)-Master.PDF
- Panel 3-3 Medallion Foundation (Improving Aviation Safety in Alaska Presentation) (item 66, .PDF, 488 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455320&FileExtension=.PDF&FileName=Panel%203-3%20Medallion%20Foundation%20(Improving%20Aviation%20Safety%20in%20Alaska%20Presentation)-Master.PDF
- Exhibit 1H- Witness Biographies (item 67, .PDF, 196 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455431&FileExtension=.PDF&FileName=Exhibit%201H-%20Witness%20Biographies-Master.PDF
- Transcript - Public Hearing Day 1 (08/17/17) (item 68, .PDF, 380 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456575&FileExtension=.PDF&FileName=Transcript%20-%20Public%20Hearing%20Day%201%20(08%2F17%2F17)-Master.PDF
- Computed Tomography Specialist's Factual Report (item 69, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461575&FileExtension=.PDF&FileName=Computed%20Tomography%20Specialist%27s%20Factual%20Report-Master.PDF
- Medical Factual Report (item 70, .PDF, 512 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461576&FileExtension=.PDF&FileName=Medical%20Factual%20Report-Master.PDF
- Hageland Party Submissions (item 71, .PDF, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461577&FileExtension=.PDF&FileName=Hageland%20Party%20Submissions-Master.PDF
- Medallion Hearing Party Submission (item 72, .PDF, 12.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461578&FileExtension=.PDF&FileName=Medallion%20Hearing%20Party%20Submission-Master.PDF
- FAA Submission (item 73, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461579&FileExtension=.PDF&FileName=FAA%20Submission-Master.PDF
- Statement of Party Representatives to NTSB Investigation (item 74, .PDF, 329 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461580&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF
- Aircraft Time Life Report (item 75, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461581&FileExtension=.PDF&FileName=Aircraft%20Time%20Life%20Report-Master.PDF
- Flight Track Data (item 76, .PDF, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461582&FileExtension=.PDF&FileName=Flight%20Track%20Data-Master.PDF
- ADS-B Deferral (item 77, .PDF, 101 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461583&FileExtension=.PDF&FileName=ADS-B%20Deferral-Master.PDF
- 22 Feb Hageland Mitigation Plan Update (item 78, .PDF, 259 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461584&FileExtension=.PDF&FileName=22%20Feb%20Hageland%20Mitigation%20Plan%20Update-Master.PDF
- Training Records (item 79, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461585&FileExtension=.PDF&FileName=Training%20Records-Master.PDF
- Hageland General Operations Manual Excerpts (item 80, .PDF, 95 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461586&FileExtension=.PDF&FileName=Hageland%20General%20Operations%20Manual%20Excerpts-Master.PDF
- Aircraft Accident Report AAR-18-02 (item 81, .PDF, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40462644&FileExtension=.PDF&FileName=Aircraft%20Accident%20Report%20AAR-18-02-Master.PDF

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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