# NTSB ANC98FA091: Swearingen SA-26AT, N501FS, St. George, AK, July 7, 1998 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: July 7, 1998, 15:47 local (23:47 UTC) - Place: St. George, AK - Coordinates: 56.569969, -169.629577 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=56.5700&lon=-169.6296&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report March 30, 2000 - Report: Approved by Office Director - NTSB office: Alaska Regional Office - NTSB case key (mKey): 43058 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC98FA091 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/43058/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=43058 - Page: https://openairdocs.org/ntsb/ANC98FA091 ## Probable cause The pilot-in-command's failure to adequately monitor the instrument approach and the co-pilot's failure to intercept and maintain the proper NDB bearing on the approach. Contributing factors were the pilot-in-command's obstructed view of the NDB indicator and his overconfidence in his personal ability, the terrain (cliffs), low ceiling, and the flight crew's disregard of the minimum descent altitude. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, approach - iaf to faf/outer marker (ifr) - flight/nav instruments,radio magnetic indicator - obstructed (contributing factor) - monitoring - inadequate, pilot in command (cause) - overconfidence in personal ability, pilot in command (contributing factor) - terrain condition - cliff (contributing factor) - proper alignment - not obtained/maintained, copilot/second pilot (cause) - weather condition - low ceiling (contributing factor) - minimum descent altitude - disregarded, flightcrew (contributing factor) ## Analysis The flight departed Anchorage, Alaska, and was en route to Saint George, Alaska, to pick up passengers for a return flight to Anchorage. The pilot-in-command (PIC) was seated in the right seat, and the copilot was seated in the left seat. This was the copilot's third flight in this make and model airplane, and he was not qualified as a crewman in it under 14 CFR Part 135. There was no record of when the copilot last performed a nondirectional beacon (NDB) approach. The NDB indicator in the cockpit was on the left side of the left control column, partially blocked from the view of the PIC. The minimum altitude for the segment of the approach prior to the final approach fix (FAF) was 1,700 feet. The Minimum Descent Altitude (MDA) for the final segment of the approach was 880 feet. The reported ceiling was 100 feet overcast. The Air Route Traffic Control Center radar altitude readout for the airplane revealed that the airplane descended below 600 feet prior to reaching the FAF. The radar ground track revealed the airplane on course prior to the course reversal procedure turn on the published approach. The radar ground track showed that after the course reversal, the airplane continued through the published final approach course, and turned to parallel the inbound track three miles north of course. The radar plot terminates about the location of the 550 feet high cliffs where the airplane was located. Weather at the time of the accident was reported as 100 foot overcast. This location was 5.5 miles (DME) from the airport. A review of radar tapes from the day prior to the accident, show the same airplane and PIC tracking the published course outbound and inbound, and descending below the published approach minima to below 500 feet. This flight successfully landed at the airport. An interview with the copilot from the successful flight revealed that the PIC intentionally descended to 300 feet on the approach until he acquired visual contact with the ocean, then flew to the airport to land. An aircraft flying on the published inbound final approach course at 5.5 DME is over water, approximately three miles from the nearest terrain. ## Factual narrative HISTORY OF FLIGHT On July 7, 1998, about 1547 Alaska daylight time, a Swearingen SA-26AT Merlin-IIB airplane, N501FS, operated by F. S. Air Service, Inc., of Anchorage, Alaska, was destroyed when it impacted terrain about 5.5 miles west-northwest of the New Saint George Airport, Saint George, Alaska. The two occupants, both flight crewmembers, sustained fatal injuries. The pilot-in-command (PIC) was the president and owner of F. S. Air Service, Inc., and occupied the right pilot seat. The copilot was not qualified as a pilot-in-command of the SA-26AT, and occupied the left pilot seat. The flight was conducted under 14 CFR Part 91 as a positioning flight to pick up three passengers for an on-demand charter flight from Saint George. The flight departed Anchorage International Airport at 1240 under a VFR flight plan, and an IFR clearance was received approximately 100 nautical miles northeast of Saint George. Instrument meteorological conditions prevailed at Saint George at the time of the accident. The last recorded radio communication from the airplane was at 1527, when the flight was cleared by the Anchorage Air Route Traffic Control Center (ARTCC) to perform the NDB/DME-A instrument approach. A witness who was awaiting pickup by the accident airplane told the NTSB investigator-in-charge (IIC) that he was waiting at the airport and heard an airplane fly over the airport on a southwesterly course about 1545. He said that the airplane transmitted that it was F. S. Air beginning the approach. No other transmission was overheard. The witness stated that the ceiling was about 300 feet. About 1600, the flight was reported overdue, and a search was initiated. The wreckage was located about 1630 by fishing boats near the northwest end of the island. The main wreckage came to rest on a beach, at the bottom of an approximately 550 feet high cliff. The location was 5.5 nautical miles on a magnetic bearing of 285 degrees from the airport. Portions of the wreckage was consumed by a postcrash fire. Lightweight debris from the airplane was located on the top of the cliff. DAMAGE TO AIRCRAFT The airplane was destroyed by a combination of impact forces and postcrash fire. PERSONNEL INFORMATION Pilot-In-Command The PIC was seated in the right seat. He held an airline transport pilot certificate with ratings for multiengine airplanes, and a commercial pilot certificate with ratings for single-engine land and sea airplanes, and multiengine seaplanes. He held type ratings in the CASA-212 and Lear Jet. He was authorized to fly as pilot-in-command under 14 CFR Part 135 in SA-26AT, SA-227, LR-35, CASA-212, SC-7, BE-18T, and PA-31 airplanes. His most recent 14 CFR 135.293, 135.297, and 135.299 checks were completed on June 12, 1998, in a PA-31 airplane. This check was administered by a company check airman, and included an NDB approach. Records of flight time were not up to date on the PIC. The most recent records available indicated that he had accumulated over 13,000 hours of flight experience, with over 5,000 hours in multiengine airplanes, more than 1,000 hours in instrument conditions, and over 250 in the SA-26AT. Company records indicated that in the previous 30 days, the pilot had flown 56 hours, 46 in the SA-26AT. On the day prior to the accident (July 6), he had flown the same airplane to Saint George, and flown the NDB A approach in instrument conditions. During the flight on July 6, he was seated in the left seat of the SA-26AT. Copilot The copilot held an airline transport pilot certificate, with ratings for multiengine and single-engine land airplanes, and a commercial pilot certificate with ratings for single engine seaplanes. He had accumulated 3,989 total hours of flight experience at the time of the accident, of which about 900 were in multiengine airplanes, and 500 were in actual or simulated instrument conditions. In the previous 30 and 90 days, he had flown 41 and 66 hours for the company, respectively. He held a first class medical certificate, with the restriction that "Holder shall wear corrective lenses." He possessed a Statement Of Demonstrated Ability (SODA) for defective distant vision of 20/200, which was correctable to 20/20 with lenses. The copilot had accumulated 3 hours, 2 flights, 1 instrument approach, and 5 landings in the SA-26AT prior to the accident. In the previous 90 days he had performed 10 instrument approaches in company aircraft. No record was available to determine if any of these were non-precision or NDB type approaches. There was no record of the copilot having flown to Saint George previously. The copilot was a part-time employee of the company. He had received salaried pay and completed monthly flight and duty time records as a pilot for F. S. Air Service, Inc., since April of 1998. On his FAA medical certificate application, FAA Form 8600-8, dated April 16, 1998, he lists his occupation as "Part Time Pilot" and his employer as "F.S. Air." He completed initial company training as a pilot on April 17, 1998, and successfully completed 135.293 checkrides as a second-in-command on the Lear-35 and SA-227. He had not completed a check as second-in-command for the SA-26AT. The 135.293 check flight report for the SA-227 on June 5, 1998, indicated that the copilot performed an ILS precision approach. There were no records that he performed an NDB or ADF nonprecision approach on either check flight. AIRCRAFT INFORMATION The airplane had accumulated 7,804 hours in service. It was maintained under an Approved Aircraft Inspection Program (AAIP), and 10 hours had been flown since the previous inspection. The navigation equipment included VOR/DME receivers, an NDB/ADF receiver, a radio altimeter, and a Global Positioning System (GPS). The GPS was not integrated to provide flight guidance information to the pilot's heading indicator, flight director, or autopilot. Each pilot position had standard flight instruments, Radio Magnetic Indicators (RMIs), and Distance Measuring Equipment (DME) displays. The GPS and radio altimeter display was visible from either pilot position. The fixed card NDB/ADF display was located on the lower left side of the left control column, visible to the left seat pilot, but partially obstructed from the view of the right seat pilot. METEOROLOGICAL INFORMATION The weather reporting for the New Saint George Airport was provided by an Automated Surface Observing System (ASOS). There is no official weather observer on the island. The ASOS information is available from the FAA Flight Service Stations, via aircraft radio, or telephone. Between 1053 and the time of the accident, 10 observations were recorded. The ceilings for all ten of these observations varied between 100 feet and 300 feet, with visibility ranging from 1/4 mile to 10 miles. The weather reported at 1453 ADT was a measured ceiling of 100 feet overcast, with 2 1/2 miles visibility in fog, temperature and dew point both at 46 degrees Fahrenheit, and winds from 210 degrees at 11 knots. The weather reported at 1553 was a ceiling of 1,000 feet broken, 1,400 feet overcast, visibility of 10 miles. The temperature was 47 degrees Fahrenheit, dew point was 46 degrees Fahrenheit, and winds of 200 degrees at 7 knots. A U. S. Fish and Wildlife biologist who arrived at the top of the cliff about 2000, told the NTSB IIC that the prevailing winds were southwest at 10 miles per hour, which created an updraft along the cliffs. AIDS TO NAVIGATION Navigation to the airport is provided by a nondirectional beacon (NDB) and a DME transmitter, located at the south end of the runway. The outbound course to be followed on the NDB/DME-A approach is 245 degrees magnetic after crossing the NDB. After performing a course reversal turn south of the outbound course, the inbound course to be flown is 065 degrees magnetic. The minimum altitudes specified for the appro ## Aircraft - Registration: [N501FS](https://openairdocs.org/deregistered/N501FS-1998-08-21), registration cancelled 1998-08-21, S/N T26146 (OpenAirDocs) - Reported make and model: Swearingen SA-26AT - Registry model: [Swearingen SA-26AT](https://openairdocs.org/model/swearingen-sa-26at) (registry code 8780112) (OpenAirDocs) - Category: Airplane - Serial number: T26-146 - Airframe hours: 7799 - Engines: Garrett TP-331-1-151G 665 horsepower turbo prop - Damage: Destroyed - Fire: On-Ground - Flight: Positioning, Part 91 - Operator: F. S. Air Service, Inc., doing business as F.S. Air - Registered owner: F. S. Air Service, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, July 5, 1998, 10 hours before - Departed: ANC, ANCHORAGE, AK - Destination: PBV - Flight plan: VFR/IFR - Airport: PBV, New St. George ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; commercial, airline transport; airplane ratings: single-engine sea, multi-engine sea, multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: right; toxicology performed; flight hours: 13,000 total, 250 in this make and model, 12,500 as pilot in command, 150 in the last 90 days, 56 in the last 30 days, 6 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Day - Wind: 210° at 11 knots - Visibility: 2.5 statute miles - Lowest ceiling: 100 ft overcast - Temperature: 46 °F, dew point 46 °F - Altimeter: 29.00 inHg - Observed at: PBV, 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 (OpenAirDocs). - [Accident 19980707015999A](https://openairdocs.org/incident/19980707015999A), Jul 7, 1998: Swrngn SA26AT, St George, AK, Destroyed, 2 fatal. (.4) The flight departed anchorage, Alaska, and was en route to saint George, Alaska, to pick up passengers for a return flight to anchorage. The… ## Other investigations on N501FS (1) 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. - [NTSB ANC96LA084](https://openairdocs.org/ntsb/ANC96LA084), Jun 5, 1996: Swearingen SA-26 (N501FS), Galena, AK, substantial damage. Probable cause: the pilot's selection of an unsuitable landing site. Factors associated with the accident were the soft and uneven airstrip conditions. ## Docket (27 files) The files NTSB released with the investigation on March 26, 1999, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=43058. 6.6 MB in all. - Supplement C - Wreckage Documentation (item 1, .PDF, 459 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40101968&FileExtension=.PDF&FileName=Supplement%20C%20-%20Wreckage%20Documentation-Master.PDF - Supplement D - Cockpit Documentation (item 2, .PDF, 505 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40101969&FileExtension=.PDF&FileName=Supplement%20D%20-%20Cockpit%20Documentation-Master.PDF - Supplement E - Second Pilot Infornation (item 3, .PDF, 146 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469952&FileExtension=.PDF&FileName=Supplement%20E%20-%20Second%20Pilot%20Infornation-Master.PDF - Supplement K (Seat 1) - Occupant, Survival and Injury Information (item 4, .PDF, 419 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40101971&FileExtension=.PDF&FileName=Supplement%20K%20(Seat%201)%20-%20Occupant,%20Survival%20and%20Injury%20Information-Master.PDF - Supplement K (Seat 2) - Occupant, Survival and Injury Information (item 5, .PDF, 432 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40101972&FileExtension=.PDF&FileName=Supplement%20K%20(Seat%202)%20-%20Occupant,%20Survival%20and%20Injury%20Information-Master.PDF - Supplement S - Aircraft Occupant and Injured Ground Personnel (item 6, .PDF, 70 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40101973&FileExtension=.PDF&FileName=Supplement%20S%20-%20Aircraft%20Occupant%20and%20Injured%20Ground%20Personnel-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 7, .PDF, 375 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469953&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Passenger Statements (item 8, .PDF, 143 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469954&FileExtension=.PDF&FileName=Passenger%20Statements-Master.PDF - Maps or Charts of Accident Area, Wreckage Diagrams (item 9, .PDF, 213 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40101976&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20Wreckage%20Diagrams-Master.PDF - Weather Reports and Records (item 10, .PDF, 170 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40101977&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Transcript of Radio Communications (item 11, .PDF, 289 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469955&FileExtension=.PDF&FileName=Transcript%20of%20Radio%20Communications-Master.PDF - Damage Sketches (item 12, .PDF, 194 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40101979&FileExtension=.PDF&FileName=Damage%20Sketches-Master.PDF - Approach Chart (item 13, .PDF, 213 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40101980&FileExtension=.PDF&FileName=Approach%20Chart-Master.PDF - Overlay of Radar Track (item 14, .PDF, 536 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40101981&FileExtension=.PDF&FileName=Overlay%20of%20Radar%20Track-Master.PDF - EARTS Plots July 7, 1998 (4 pages) (item 15, .PDF, 545 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40101982&FileExtension=.PDF&FileName=EARTS%20Plots%20July%207,%201998%20(4%20pages)-Master.PDF - EARTS from July 6, 1998 (item 16, .PDF, 395 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40101983&FileExtension=.PDF&FileName=EARTS%20from%20July%206,%201998-Master.PDF - After Accident Flight Inspection Report (item 17, .PDF, 234 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469956&FileExtension=.PDF&FileName=After%20Accident%20Flight%20Inspection%20Report-Master.PDF - Navigation Indicator Layout (item 18, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40101985&FileExtension=.PDF&FileName=Navigation%20Indicator%20Layout-Master.PDF - Training Manual (item 19, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40101986&FileExtension=.PDF&FileName=Training%20Manual-Master.PDF - Co-pilot Check Flights No NDB Approaches (item 20, .PDF, 202 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469957&FileExtension=.PDF&FileName=Co-pilot%20Check%20Flights%20No%20NDB%20Approaches-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 21, .PDF, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469958&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 22, .PDF, 108 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469959&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Toxicological Report (item 23, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469960&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Photo 1. Overhead View of Accident Site. Note debris on top of cliff, scarrring on cliff face, and main wreckage at bottom of cliff. (item 24, .PDF, 174 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40101991&FileExtension=.PDF&FileName=Photo%201.%20%20Overhead%20View%20of%20Accident%20Site.%20%20Note%20debris%20on%20top%20of%20cliff,%20scarrring%20on%20cliff%20face,%20and%20main%20wreckage%20at%20bottom%20of%20cliff.-Master.PDF - Photo 2. Empennage Exhibiting Postcrach Fire Damage. (No Negative) (item 25, .PDF, 163 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40101992&FileExtension=.PDF&FileName=Photo%202.%20%20Empennage%20Exhibiting%20Postcrach%20Fire%20Damage.%20%20(No%20Negative)-Master.PDF - Photo 3. Empennage With Scratches Oriented From Right To Left, Fore To Aft. (item 26, .PDF, 231 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40101993&FileExtension=.PDF&FileName=Photo%203.%20%20Empennage%20With%20Scratches%20Oriented%20From%20Right%20To%20Left,%20Fore%20To%20Aft.-Master.PDF - Photo 4. Photo of Cockpit of N501FS Before Accident. Note location of RMI with ADF/NDB Indicator is below and left of the left side control column. View of this indicator is blocked from right seat by control column. (No (item 27, .PDF, 124 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40101994&FileExtension=.PDF&FileName=Photo%204.%20%20Photo%20of%20Cockpit%20of%20N501FS%20Before%20Accident.%20%20Note%20location%20of%20RMI%20with%20ADF%2FNDB%20Indicator%20is%20below%20and%20left%20of%20the%20left%20side%20control%20column.%20%20View%20of%20this%20indicator%20is%20blocked%20from%20right%20seat%20by%20control%20column.%20%20(No%20-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.