# NTSB ANC99FA028: Beech 1900C, N31240, Saint Mary'S, AK, February 12, 1999 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Field investigation · Final report - Date: February 11, 1999, 23:45 local (Feb 12, 1999, 03:45 UTC) - Place: Saint Mary'S, AK - Coordinates: 62.06023, -163.290786 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=62.0602&lon=-163.2908&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report June 21, 2000 - Report: Approved by Office Director - NTSB office: Alaska Regional Office - NTSB case key (mKey): 45798 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC99FA028 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/45798/pdf - Page: https://openairdocs.org/ntsb/ANC99FA028 ## Probable cause The pilot's descent below the minimum descent altitude on the instrument approach. Factors were pilot fatigue resulting from the pilot's rest period being interrupted by scheduling discussions and the night weather conditions of low ceilings and whiteout. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, approach - faf/outer marker to threshold (ifr) - weather condition - low ceiling (contributing factor) - weather condition - whiteout (contributing factor) - light condition - night (contributing factor) - minimum descent altitude - exceeded, pilot in command - fatigue(flight and ground schedule), pilot in command (contributing factor) ## Analysis The airline transport pilot was cleared for the localizer approach. The airplane impacted the ground 3.2 nautical miles from the runway threshold. The minimum descent altitude (MDA) for the approach was 560 feet msl, which is 263 feet above touchdown. Night, instrument meteorological conditions prevailed at the time of the accident. The surrounding terrain was flat, snow-covered, and featureless. The reported weather was 200 feet overcast, 1 1/2 miles visibility in snow, and winds of 12 knots, gusting to 32 knots. The pilot reported he was established on the final approach course, descending to the MDA, and then woke up in the snow. He said he did not remember any problems with the airplane. No preaccident mechanical anomalies were discovered with the airplane during the investigation. The airport has high intensity runway lights, sequenced flashing lead-in lights, and visual approach slope indicator lights. All airport lights and navigation aids were functioning. The airplane was not equipped with an autopilot. Captains have the option of requesting a copilot, but, the captain's pay is reduced by a portion equal to one-half the copilot's pay. The pilot had returned from the previous nights trip at 0725. He had three rest periods, four hours, two hours, and five hours 15 minutes, since his previous nights flight. Each rest period was interrupted by contact with the company. The company indicated that it is the pilot's responsibility to tell the company if duty times are being exceeded. 14 CFR 135.267 states, in part: '(d) Each assignment ... must provide for at least 10 consecutive hours of rest during the 24 hours that precedes the planned completion of the assignment.' ## Factual narrative HISTORY OF FLIGHT On February 11, 1999, at 2345 Alaska standard time, a Beech 1900C airplane, N31240, was destroyed when it collided with terrain 3.2 nautical miles north of the Saint Mary's Airport, Saint Mary's, Alaska. The solo airline transport pilot sustained serious injuries. The on-demand cargo flight was operated under 14 CFR Part 135 by Alaska Central Express, Inc., of Anchorage, Alaska, from Anchorage to Saint Mary's. The flight departed Anchorage at 2145. Night instrument meteorological conditions prevailed at the time of the accident, and an instrument flight rules (IFR) flight plan was filed. The flight was cleared for the LOC/DME 16 instrument approach at 2325. The last radar contact with the airplane was at 2340. The radar controller observed the airplane about 10 miles north of the airport, executing the procedure turn for the approach. The flight was reported overdue at 2355. An emergency locator transmitter (ELT) signal was received by satellite about 0100. The wreckage and pilot were located about 0400 by searchers on snow machines. The airplane had broken into three sections, and both pilot seats were found about 200 feet from the cockpit. The airplane came to rest about 1/4 mile east of the localizer course centerline, about the same elevation as the airport. The pilot told the NTSB investigator-in-charge (IIC) during an interview on February 16, and wrote in his NTSB Pilot / Operator report, that he did not recall any discrepancies with the airplane. He said that he was established on the final approach course, inside the final approach fix, and then woke up face down in the snow. PERSONNEL INFORMATION The pilot holds an airline transport pilot certificate for multi-engine airplanes. He holds airplane type ratings in the Beech 1900, and the Boeing 747. His most recent first class medical certificate was issued on December 30, 1998, with no restrictions. The pilot had accrued 12,187 hours of total flight experience at the time of the accident; 1,587 hours were in the Beech 1900C. In the previous 30 and 90 days, he had flown 91, and 206 hours, respectively. All flights were in the Beech 1900C. In the previous 30 days, the pilot had flown all flights without a copilot. A review of the pilot's flight records revealed he had accrued 96.8 hours in the accident airplane since it was put into revenue service with the company. The pilot was hired by the company in March 1997. He completed initial training on March 10, 1997. He completed pilot training, to include a type rating in the Beech 1900, at Flight Safety International, LaGuardia Airport, New York, on May 19, 1997. On May 29, 1997, the pilot was administered a second-in-command, 14 CFR 135.293 and 135.299 proficiency and line check by a company check airman. He was assigned and flew as a second-in-command until he was administered a 14 CFR 135.297 instrument proficiency check on July 31, 1997. At that time, he was assigned as a pilot-in-command in the Beech 1900C. The pilot's most recent flight check was in the Beech 1900C, on September 27, 1998, and met the requirements of 14 CFR 135.293, 297, and 299. The flight check was conducted by a company check airman. According to company records, the pilot had flown to Saint Mary's on five occasions prior to the accident flight. On all of these flights, the airport was reporting weather greater than 1000 feet ceilings and visibility greater than 3 miles. The first three were with a two pilot crew. The last two were single pilot. Flight and Duty Time The pilot was based, and lived, in Fairbanks. He normally flew his trips from there. The pilot flew as a pilot-in-command the night prior to the accident. According to company flight records, the pilot completed his flights at 0604 on February 11. According to the company mail records, he completed unloading the mail at 0725 on February 11, in Fairbanks. The company scheduler / flight follower from Anchorage, contacted the cargo supervisor in Fairbanks about 1130, and asked him to send the pilot to Anchorage on the company's flight leaving Fairbanks at 1425, so he could fly the accident flight. According to the cargo supervisor, he responded that he would not call the pilot because he had just got in and was tired. About 1130, the pilot was called at home by the company scheduler / flight follower from Anchorage, and asked if he would fly the accident flight to Saint Mary's. At 1330 the pilot arrived at the company's base in Fairbanks. The cargo supervisor told an FAA inspector that when the accident pilot arrived for the flight to Anchorage he looked "awfully tired." The flight to Anchorage arrived at 1519. According to the pilot, he went to his brother's home and slept. At 2045, he returned to the company base in Anchorage to begin preparation for the accident flight. When questioned by an FAA inspector about assigning the pilot to the accident flight, both the Director of Operations, and the Anchorage crew scheduler / flight follower replied that they don't assign extra flights. Rather, the company offers them to pilots. The PIC, and the crew scheduler, share responsibility to tell the company if the pilot is exceeding flight or duty times. The Director of Operations also stated that he did not consider the jumpseat flight an assignment, but rather, the same as an airline pilot commuting from his home to an assigned domicile. According to the FAA inspector, he was told by the Fairbanks cargo supervisor that the accident pilot stated "if you turn down flights, you will not be called for flights in the future." The Director of Operations wrote to the NTSB IIC that when company officials asked both the pilot, and cargo supervisor if they had said this, they both denied having made such a statement. The NTSB IIC discussed the pilot's assignment to the flight with the Director of Operations on June 28. The Director of Operations told the IIC that the company did not contact the pilot. He provided copies of the company telephone records which showed no calls from the Anchorage scheduler's number to the pilot's home. Three telephone calls were placed to the Fairbanks freight company number; at 0707, at 1104, and at 1433. He further provided a record showing a call placed from the pilot's home, to the Anchorage scheduler's "1-800" number at 1253. The Director of Operations stated that the pilot called the company asking for a flight, because he wanted the extra flight time. He indicated that there were crews available in Anchorage to fly the accident flight, but the accident pilot was allowed to take the flight because he asked for it. He further said that jumpseating to Anchorage was the pilot's choice. The NTSB IIC attempted between June 29, and July 14, to hold a telephone interview with the pilot to clarify how he was assigned to the accident flight. The IIC was unable to reach the pilot, or the pilot's brother, who told the IIC he was acting as the pilot's legal representative and requested that any interview be conducted from the brother's law offices in Fairbanks. Telephone calls by the NTSB IIC were not returned, and a series of written questions was sent to the pilot via certified mail. The questions were received by the pilot on July 16. No response to these questions was received by the IIC as of August 30, 1999. In the 24 hours prior to the accident, the pilot had flown 5 hours 54 minutes, and been on duty for 12 hours 30 minutes. During this 24 hours, he had three interrupted rest periods. One of four hours, between 0730 and 1130. Two hours rest from 1130 to 1330, after which he traveled via jumpseat on a company airplane to Anchorage. He then had another rest period of five hours 10 minutes, after which he arrived at the company base in Anchorage for the accident flight. AIRCRAFT INFORMATION The airplane was a Beech 1900C, and was used in an all carg ## Aircraft - Registration: [N31240](https://openairdocs.org/deregistered/N31240-2000-07-14), registration cancelled 2000-07-14, S/N UC-28 (OpenAirDocs) - Reported make and model: Beech 1900C - Registry model: [Beech 1900C](https://openairdocs.org/model/beech-1900c) (registry code 1154161) (OpenAirDocs) - Category: Airplane - Serial number: UC-28 - Airframe hours: 19588 - Engines: P&W PT6A-65B 1100 horsepower turbo prop - Damage: Substantial damage - Flight: Part 135 - Operator: Alaska Central Express, Inc., doing business as Ace - Registered owner: Raytheon Aircraft Credit Corp. - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, February 1, 1999, 132 hours before - Departed: ANC, ANCHORAGE, AK - Destination: KSM - Flight plan: IFR - Airport: KSM, Saint Mary'S, runway 16, 6,003 × 150 ft, gravel ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 45; airline transport, commercial, flight engineer; airplane ratings: single-engine sea, single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; flight hours: 12,326 total, 1,587 in this make and model, 266 in the last 90 days, 91 in the last 30 days, 7 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 150° at 14 knots, gusting 27 - Visibility: 2 statute miles - Lowest ceiling: 200 ft overcast - Temperature: 5 °F, dew point 3 °F - Altimeter: 29.00 inHg - Observed at: KSM, 4 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 19990211009069A](https://openairdocs.org/incident/19990211009069A), Feb 11, 1999: Beech 1900C, St Marys, AK, Substantial damage. (.19) On February 11, 1999, at 2345 Alaska standard time, a Beech 1900C, N31240, was destroyed when it collided with terrain 4.1 nautical miles north of the… 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.