# NTSB ANC95FA016: Cessna 402C, N1238K, Elim, AK, December 10, 1994 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 10, 1994, 19:00 local (23:00 UTC) - Place: Elim, AK - Coordinates: 64.630256, -162.339675 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=64.6303&lon=-162.3397&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 5 fatal - Status: Completed, report October 16, 1995 - Report: Approved by Office Director - NTSB office: Alaska Regional Office - NTSB case key (mKey): 2578 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC95FA016 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/2578/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=2578 - Page: https://openairdocs.org/ntsb/ANC95FA016 ## Probable cause VFR FLIGHT BY THE PILOT INTO INSTRUMENT METEOROLOGICAL CONDITIONS (IMC), AND HIS FAILURE TO MAINTAIN SUFFICIENT ALTITUDE OR CLEARANCE FROM MOUNTAINOUS TERRAIN. FACTORS RELATED TO THE ACCIDENT WERE: DARKNESS AND THE ADVERSE WEATHER CONDITIONS. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, cruise - light condition - dark night (contributing factor) - weather condition - low ceiling (contributing factor) - weather condition - snow (contributing factor) - vfr flight into imc - continued, pilot in command (cause) - In flight collision with terrain/water, cruise - terrain condition - mountainous/hilly - altitude/clearance - not maintained, pilot in command (cause) ## Analysis THE AIRPLANE WAS ON A FLIGHT AT NIGHT FROM NOME TO KOYUK, AK, WHEN IT CRASHED INTO A MOUNTAIN AT THE 2725 FOOT LEVEL. THE ACCIDENT SITE WAS DIRECTLY ON A COURSE LINE BETWEEN THE NOME AND KOYUK AIRPORTS. THE CEILING AT NOME WAS 3500 OVERCAST AT THE TIME OF DEPARTURE. ACCORDING TO RESCUE PERSONNEL, WEATHER AT THE ACCIDENT AREA WAS: INDEFINABLE CEILING AND POOR VISIBILITY WITH HEAVY SNOW AND BLOWING SNOW. THE PILOT HAD A HAND HELD GPS ON BOARD THAT HE HAD BARROWED FROM ANOTHER PILOT. BUT THE DATABASE COULD NOT BE RETRIEVED FROM THE GPS. ACCORDING TO THE OWNER OF THE GPS, HE AND THE ACCIDENT PILOT PROGRAMMED DIFFERENT WAYPOINTS. THE PILOT DID NOT FILE A VFR OR AN IFR FLIGHT PLAN WITH THE FAA. ## Factual narrative HISTORY OF FLIGHT On December 10, 1994, at 1900 Alaska standard time, a retractable gear, wheel equipped Cessna 402C, N1238K, registered to and operated by Ryan Air Service of Anchorage, Alaska, crashed into a mountain located approximately 12 miles northwest of Elim, Alaska. The scheduled air taxi flight, operating under 14 CFR Part 135 as Ryan Air Flight 2402, departed Nome, Alaska, on a route that would have taken the flight to Koyuk, Shaktoolik, and a return to Nome. The flight did not reach the first destination. A Federal Aviation Administration (FAA) flight plan was not filed but a company flight plan was in effect. Instrument meteorological conditions prevailed at the accident site. The airline transport certificated pilot and the four passengers were fatally injured and the airplane was destroyed by impact forces. INJURIES TO PERSONS The pilot and the four passengers received fatal injuries. All were ejected from the airplane. DAMAGE TO AIRCRAFT ` All the major components of the airplane were located at the wreckage site or along the wreckage path. The airplane fuselage was the largest piece and was resting upside down. The forward section, the nose and cockpit area, were curled rearward into the cabin of the airplane. The empennage remained attached to the fuselage. The vertical fin and rudder were resting on the ground and had numerous bends and dents. The horizontal stabilizer and elevators remained attached in their proximate correct locations and they were dented. The left wing was attached to the fuselage only by control cables and was right side up. It was positioned in front of the main wreckage with the wing root near the nose of the airplane. The left engine had separated from the engine nacelle and was resting on the ground in front of the airplane approximately 25 feet up hill. The right wing root and engine nacelle remained attached to the fuselage and was inverted. The right engine separated from the engine nacelle but was connected by the engine control cables and electrical wiring harnesses. The outboard portion of the right wing was separated and located to the left and along the wreckage path. Both propellers were separated from the engines and were located 205 feet from the wreckage along the wreckage path. The main landing gear remained attached to their proximate correct locations and were both retracted. The nose gear and surrounding structure was separated and the nose gear was extended but not locked down. PERSONNEL INFORMATION PILOT The 51 year old pilot was the holder of an airline transport pilot certificate with type ratings in the DC-3, the EMB-110, and DH-4 airplanes. He held commercial privileges for airplane single engine land and sea. According to company records, the pilot had satisfactorily completed his 14 CFR Part 135.298 a and b checkride earlier that day. The records show the pilot was current and qualified to operate the airplane for this particular flight. OPERATIONS AGENT According to the Nome station manager, the company operations agents are hired to monitor the flight's progress and to accomplish the paperwork task. He stated they do not have a formal training program for the operations agents. Their primary duties are to answer the telephones, collect and distribute tickets, coordinate with passengers, assist pilots in obtaining weather information from other village operations agents, weigh baggage, and assist the pilot in making a weather decision. The station manager stated that the operations agent at any of the villages, including Nome, has the full authority to stop any flight if they believe it to be unsafe for any reason. Examination of the company's policy and procedures showed no formal procedure. The station manager stated that if any pilot were to go against what the operations agent decided or attempted to intimidate the operations agent, the pilot would be fired immediately. The operations agents are not required by regulations to have a dispatcher's license nor a pilot certificate. STATION MANAGER The Nome station manager is responsible for all the daily operations of the company at the Nome facility. He is a certificated private pilot. He does have an airframe and powerplant mechanic's certificate and functioned primarily as a mechanic until he was promoted to station manager. There is no formal company training program for station managers. He stated that he was not in the facility for the launching of the accident flight, Ryan Air Flight 2402. He said the operations agent is normally "responsible" to be present for the departure and arrival. He stated that the operations agents will leave the office during the flight to accomplish other tasks and will usually return before the flight. CHIEF PILOT The chief pilot for the company is not based in Nome. His primary duty station is Anchorage. He travels to the outlying facilities to monitor and perform necessary training and checkrides. He was not at the Nome station on the day of the accident. AIRCRAFT INFORMATION N1238K, a Cessna 402C airplane, had a total of 10,722 hours accrued on the airframe. The airplane was operating on an approved inspection program and had operated 34 hours since its last inspection. An FAA Principal Avionics Inspector examined the maintenance records for N1238K and found that the original Cessna directional gyro, slaving accessory, flux detector, and navigation indicator was removed and replaced with King compass system which consisted of a horizontal situation indicator, remote directional gyro, autopilot adapter, VOR/LOC converter, and a flux detector. The inspector also found that the pilot's altimeter was removed and a encoding altimeter was installed. According to the records, a FAA Form 337, major repair and alteration was completed and signed by an airframe and powerplant mechanic who also holds and Inspection Authorization. According to 14 CFR Part 91.411, it states, in part, "that no person may operate an airplane in controlled airspace under IFR (instrument flight rules) unless within the preceding 24 calendar months, each static pressure system, each altimeter instrument, and each automatic pressure altitude reporting system has been tested and inspected and found to comply with appendix E of part 43 of this chapter." It further states, "except for the use of the system drain and alternate static pressure valves, following any opening and closing of the static pressure system, that the system has been tested and inspected and found to comply with paragraph (a), appendices E and F, part 43 of this chapter.... The tests required by paragraph (a) of this section must be conducted by the manufacturer of the airplane or a certificated repair station...." METEOROLOGICAL INFORMATION At the time of the accident the destination village of Koyuk did not have a weather observation facility. The nearest weather reporting facility to the accident site is Nome, Alaska, located 76.5 miles on the 238 degree magnetic bearing from the accident site. The reported observation at Nome, taken at 1752 was measured 3500 broken, 4300 overcast, visibility 7 miles with light snow, temperature 26 degrees fahrenheit, dewpoint 19 degrees fahrenheit, wind from 050 degrees at 19 knots, altimeter setting 29.34 inches of mercury. According to the station manager, the pilot should have been looking for a minimum ceiling of 500 feet above the ground and 2 miles of visibility at his destination before launching. The weather source used at Koyuk was the village agent who was not a trained weather observer. He stated the village agents have been looking at the weather for years and he felt they were able to determine a 500 foot ceiling and a 2 mile visibility. Accordi ## Aircraft - Registration: [N1238K](https://openairdocs.org/deregistered/N1238K-2000-10-03), registration cancelled 2000-10-03, S/N 402C1019 (OpenAirDocs) - Reported make and model: CESSNA 402C - Registry model: [Cessna 402C](https://openairdocs.org/model/cessna-402c) (registry code 207590R) (OpenAirDocs) - Category: Airplane - Serial number: 402C1019 - Airframe hours: 10722 - Engines: CONTINENTAL TSIO-520-VB 325 horsepower reciprocating - Damage: Destroyed - Flight: Part 135 - Registered owner: Ryan Air Service - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, December 2, 1994, 34 hours before - Departed: OME, NOME, AK - Destination: KKA, KOYUK, AK - Flight plan: VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 51; airline transport; airplane ratings: single-engine sea, multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 15,804 total, 828 in this make and model, 15,004 as pilot in command, 164 in the last 90 days, 97 in the last 30 days, 5 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 50° at 19 knots - Temperature: 27 °F, dew point 19 °F - Altimeter: 29.00 inHg - Observed at: OME, 77 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 19941210041249A](https://openairdocs.org/incident/19941210041249A), Dec 10, 1994: Cessna 402C, Eim, AK, Destroyed, 5 fatal. En route VFR at night flew into side of a mountain. Snow and blowing snow in area. GPS used for navigation. ## Docket (19 files) The files NTSB released with the investigation on August 27, 1995, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=2578. 2.3 MB in all. - Supplement A - Wreckage Documentation (item 1, .PDF, 157 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40026847&FileExtension=.PDF&FileName=Supplement%20A%20-%20Wreckage%20Documentation-Master.PDF - Supplement B - Cockpit Documentation (item 2, .PDF, 214 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40026848&FileExtension=.PDF&FileName=Supplement%20B%20-%20Cockpit%20Documentation-Master.PDF - Supplement I - Crash Kinematics (item 3, .PDF, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40026849&FileExtension=.PDF&FileName=Supplement%20I%20-%20Crash%20Kinematics-Master.PDF - Supplement S - Aircraft Occupant and Injured Ground Personnel (item 4, .PDF, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40026850&FileExtension=.PDF&FileName=Supplement%20S%20-%20Aircraft%20Occupant%20and%20Injured%20Ground%20Personnel-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 5, .PDF, 380 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478335&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - FAA Inspector's Statement (item 6, .PDF, 212 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478336&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Statement-Master.PDF - Map of Accident Site (item 7, .PDF, 183 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40026853&FileExtension=.PDF&FileName=Map%20of%20Accident%20Site-Master.PDF - Weather Reports and Records (item 8, .PDF, 170 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40026854&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - FAA Personnel Statement (item 9, .PDF, 26 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478337&FileExtension=.PDF&FileName=FAA%20Personnel%20Statement-Master.PDF - FAA GPS Statement (item 10, .PDF, 155 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478338&FileExtension=.PDF&FileName=FAA%20GPS%20Statement-Master.PDF - Ryan Air Manifest (item 11, .PDF, 267 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40026857&FileExtension=.PDF&FileName=Ryan%20Air%20Manifest-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 12, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478339&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Photo 1. This photo was taken the evening of the accident. View is across main wreckage looking back toward the airplane's flight path. The Alaska State Troopers retain the negative to this photograph. (item 13, .PDF, 27 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40026859&FileExtension=.PDF&FileName=Photo%201.%20%20This%20photo%20was%20taken%20the%20evening%20of%20the%20accident.%20%20View%20is%20across%20main%20wreckage%20looking%20back%20toward%20the%20airplane%27s%20flight%20path.%20%20The%20Alaska%20State%20Troopers%20retain%20the%20negative%20to%20this%20photograph.-Master.PDF - Photo 2. This photo was taken in May from near the same point as the previous picture. (item 14, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40026860&FileExtension=.PDF&FileName=Photo%202.%20%20This%20photo%20was%20taken%20in%20May%20from%20near%20the%20same%20point%20as%20the%20previous%20picture.-Master.PDF - Photo 3. View of the airplane wreckage looking toward the intended direction of flight. (item 15, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40026861&FileExtension=.PDF&FileName=Photo%203.%20%20View%20of%20the%20airplane%20wreckage%20looking%20toward%20the%20intended%20direction%20of%20flight.-Master.PDF - Photo 4. View from the observed initial impact point looking along the wreckage path. (item 16, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40026862&FileExtension=.PDF&FileName=Photo%204.%20%20View%20from%20the%20observed%20initial%20impact%20point%20looking%20along%20the%20wreckage%20path.-Master.PDF - Photo 5. Photo of left side. (item 17, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40026863&FileExtension=.PDF&FileName=Photo%205.%20%20Photo%20of%20left%20side.-Master.PDF - Photo 6. View of the bottom of the airplane. (item 18, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40026864&FileExtension=.PDF&FileName=Photo%206.%20%20View%20of%20the%20bottom%20of%20the%20airplane.-Master.PDF - Photo 7. Photo of the Garmin 55 GPS located at the accident site. (item 19, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40026865&FileExtension=.PDF&FileName=Photo%207.%20%20Photo%20of%20the%20Garmin%2055%20GPS%20located%20at%20the%20accident%20site.-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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.