ANC93FA050

NTSB accident investigation · Cessna 207 · Nome, AK · April 3, 1993

Accident · FatalField investigationFinal report
Date
April 3, 1993, 10:11 local (14:11 UTC)
Place
Nome, AK
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N6467HCessna 207
Weather
Instrument (IMC) · Day
Status
Completed · report November 1, 1994
Report
Approved by Office Director
NTSB office
Alaska Regional Office
FAA report
19930403007809A
Case key
2296

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 initiated VFR flight into instrument meteorological and whiteout conditions. Factors which contributed to the accident were: inadequate supervision of the pilot by the company, inadequate oversight by the federal aviation administration, the pilot's self-induced pressure to conduct the flight, and the existing weather conditions and snow covered terrain.

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 collision with terrain/waterCruise - normal
Weather condition - low ceilingFactor
Weather condition - snowFactor
Weather condition - obscurationFactor
Weather condition - whiteoutFactor
Vfr flight into imc - initiatedPilot in commandCause
Self-induced pressurePilot in commandFactor
Supervision - inadequateCompany/operator managementFactor
Inadequate surveillance of operationFaa(organization)Factor
Terrain condition - snow coveredFactor

Analysis

Pireps provided to the pilot by fss prior to takeoff indicated that fog & low visibility had been encountered on the pilot's route to the east, forcing airplanes to return to Nome. In addition, as the flight taxied for takeoff, the pilot was told '... VFR is not recommended to the east...' The airplane impacted flat snow covered terrain in a steep left wing down attitude aprx 4 mi east of the departure end of the runway. The area was a treeless, snow covered flat coastal plain bordered by a sea frozen with white ice. The pilot had returned to work 4/1 after a 30-DAY suspension following a takeoff accident, and was assigned only to Cessna 207 'VFR only' airplanes. The poi did not discuss the earlier accident or the pilot with the operator's management.

Factual narrative

History of flight

Note: All times indicated in Alaska standard time except transcripts of air traffic control communications found in "meteorological information" and attached FSS transcripts.

On April 3, 1993, at approximately 1011 Alaska standard time, a wheel-equipped Cessna 207 airplane, N6467H, operating as Ryan Air Services flight 403 under 14 CFR Part 135 as a scheduled air carrier, collided with the ground one mile east of the Nome, Alaska, VOR station. The airplane departed Nome airport at 1006 on a VFR flight plan filed by the pilot in command. The Nome Control Zone was visual meteorological conditions (VMC) at the time of departure. At 1009 a special weather report was issued indicating the Nome Control Zone was instrument meteorological conditions (IMC) and this information was transmitted to Ryan 403. The airline transport certificated pilot and a passenger received fatal injuries. The airplane was destroyed.

Pilot weather reports (PIREPS) provided to the accident pilot by the Flight Service Station (FSS) prior to takeoff indicated visual meteorological conditions prevailed at the flight's destination, but that fog and low visibility had been encountered on the route to the east, forcing airplanes to return to Nome. Additionally, the FSS cautioned prior to takeoff, that VFR was "not recommended, but then said, ". . . you already have em [sic] pilot reports to the east but appreciate some new ones it looks like it is improving a little bit." The pilot acknowledged the transmission, and took off on runway 9 and was seen to depart "straight out to the east."

The impact marks indicated that the red colored Cessna was in a left steep turn from east to north at the time of impact with the snow covered tundra.

The visual flight path of the accident airplane took it along the beach line of the Bering Sea which was frozen with white ice. A treeless, snow covered flat coastal plane bordered the sea. A beach road leading to Council (Nome-Council Road) was also snow covered and only usable by snow machines. One mile west of the crash site, a line of approximately 18 cabins formed a string of visible objects on the beach. Beyond those cabins, a single cabin with a sled and a string of sled dogs were the only dark colored objects seen by investigators in the afternoon on the day following the accident.

This camp is known locally as "Farley's Camp." The crash site was located approximately 1500 yards beyond Farley's Camp. (See photograph attachment 4.)

ATC specialists at the Nome FSS told investigators that shortly after the 1006 takeoff of Ryan flight 403, a weather report from the National Weather Service was issued in the form of an electronic print-out at the Nome FSS. This report (see attachment) indicated that the Nome Control Zone was below visual meteorological conditions. At 1009, the FSS advised the Ryan Air pilot that the control zone was IFR conditions. The pilot acknowledged the weather advisory and reported "clear to the east." (Indicating to the Nome flight service specialist that his aircraft was beyond the boundary of the Nome Control Zone in his direction of flight). See transcript of communications with Ryan flight 403.

Evidence found at the scene indicated the airplane to have impacted on flat snow covered terrain in a steep left wing down attitude on a heading approximately 010 degrees magnetic. The cockpit instruments were substantially damaged, and will be described in the "wreckage and impact information." The pilot's attitude indicator was found to be at approximately left wing-down at 90 degrees angle of bank.

The crash location was within the control zone. The Nome Control Zone extends approximately seven miles beyond the VOR station to the east and the accident location was approximately 6 miles inside the control zone, an approximately 4 miles east of the departure end of the runway.

Injuries to persons

The pilot-in-command and a revenue passenger were the sole occupants and both received fatal injuries.

Damage to aircraft

The aircraft was destroyed by impact forces. There was no evidence of inflight separation or fire, either inflight or post- impact in nature.

Personnel information

Captain Andrew Kenneth Jukkala, Box 1866, Nome, Alaska Age 27, FAA Airline Transport Pilot (ATP) number 551551649

The pilot in command, Andrew Kenneth Jukkala, held an ATP in land multiengined airplanes, and a FAA Commercial Pilot's certificate (same number) rated in airplane single engine land. The rating includes an airplane instrument rating. The pilot had a FAA first class medical certificate, dated August 26, 1992, with no limitations or waivers indicated in record.

Records provided by the company indicated that the pilot had 3212.6 total flight hours as pilot and 1762.5 hours as pilot in the Cessna 207. Records also indicated that he had flown 134.8 hours in the past 90 days, 11.5 hours in the past 30 days and 7.4 hours in the past 24 hours. The investigation revealed that the pilot had approximately 13 hours off duty time since flight duty on the previous day. On the day of the accident he flew a one hour round trip from Nome to Teller and return, a distance of approximately 60 miles, arriving at 0932. (See attached aircraft flight log)

Records indicated that of the 134.8 hours flown in 90 days, all but approximately 16 were flown in the multiengined, IFR-approved airplane. The 11.5 hours of single engine flight time was accrued since returning to work, two days previously. Records indicate that the pilot flew 5.3 hours the previous day.

On an application for renewal of a 1992 FAA medical certificate, the pilot stated that he had 2900 hours of pilot flight time and had flown 500 hours in the previous 6 month period as a pilot for Ryan Air. The pilot's medical history, including those observations taken following the Cessna 402 accident in February 1993, did not indicate use of drugs or other than routine physician's visits.

The pilot was certificated by the Office of Aviation Services (OAS), U. S. Department of Agriculture, as a pilot qualified in the Cessna 207 for VFR single engine operations.

Passenger

Frederick C. Bradley, Box 39005, Elim, Alaska Age 42, store operator at Elim

The passenger was a ticketed revenue passenger originating in Nome with a destination of Elim, Alaska.

Aircraft information

N6467H was a 1979 Cessna 207A, serial number 207-00531, a high wing single engine, fixed tricycle wheeled airplane with a normal airworthiness certificate. It was powered by a Continental IO- 520F, 300 horsepower, fuel injected engine, serial number 280017- R. The airplane was equipped for instrument flight. Company records indicated that the airplane (airframe) had 11,854 hours on it at the time of the accident, and the last inspection was performed on March 31, 1993 under an Approved Aircraft Inspection Program (AAIP). Records indicated that it had flown 9.4 hours since the inspection.

Aircraft flight log records for the flight previously as well on 13 flights of the airplane on the previous day The Continental engine had 3100 hours on it since new, and 1411 hours since major overhaul. Like the airframe, records provided by the company indicated that the engine had been inspected 9.4 hours of flight time prior to the accident.

Meteorological information

The pilot in command filed a VFR flight plan with Nome FSS at 0953 and received the following Nome weather sequence observation: 600 foot scattered, 1500 foot broken, 20000 overcast and 4 miles visibility with light snow. The FSS specialist also advised the pilot that a (Cessna) "206 return around Came Nome because of fog, that was at um [sic] 8:45 and then Golovin at about 9:10 2000 (foot) scattered to broken, unrestricted (visibility).

Refer to FSS transcript attached 1852:48 to 1854:19 UTC (GMT) Alaska standard time of 1000 is equivalent to 1900 UT

Aircraft

Registration
N6467H
Reported as
Cessna 207
Category
Airplane
Serial number
20700531
Airframe hours
11,854
Engine
Continental IO-520-F, 300 horsepower, reciprocating
Damage
Destroyed
Flight
Part 135
Operator
Ryan Air Service, Inc
Registered owner
Ryan Air Service
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · March 31, 1993 · 9 hours before
Departed
OME
Destination
ELI · Elim, AK
Flight plan
Company VFR

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
27
Certificates
Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
3,213 total · 1,763 in this make and model · 3,102 as pilot in command · 135 in the last 90 days · 12 in the last 30 days · 7 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
70° at 13 knots
Visibility
0.25 statute miles
Lowest ceiling
500 ft broken
Temperature
28 °F, dew point 27 °F
Altimeter
29.00 inHg
Observed at
OME, 5 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.