# NTSB DCA20MA002: Saab 2000, N686PA, Unalaska, AK, October 18, 2019

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Class 1 · Major · Final report
- Date: October 17, 2019, 17:40 local (Oct 18, 2019, 02:40 UTC)
- Place: Unalaska, AK
- Coordinates: 53.898334, -166.54417
- Nearby events: https://openairdocs.org/map.md?lat=53.8983&lon=-166.5442&mi=10
- Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping)
- Defining event: [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300)
- Highest injury: Fatal
- Injuries: 1 fatal, 1 serious, 3 minor, 37 uninjured
- Status: Completed, report November 2, 2021
- Report: Board-adopted at Board Meeting, Board meeting November 2, 2021
- Investigation class: Class 1
- NTSB office: Major Investigations Division
- Parties: FAA AVP-100, Rolls-Royce
- Safety recommendations: Yes
- NTSB case key (mKey): 100437
- NTSB case page: https://www.ntsb.gov/investigations/Pages/DCA20MA002.aspx
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100437/pdf
- Board report AAR2105 (PDF): https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR2105.pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100437
- Page: https://openairdocs.org/ntsb/DCA20MA002

## Probable cause

The landing gear manufacturer’s incorrect wiring of the wheel speed transducer harnesses on the left main landing gear during overhaul. The incorrect wiring caused the antiskid system not to function as intended, resulting in the failure of the left outboard tire and a significant loss of the airplane’s braking ability, which led to the runway overrun. Contributing to the accident were (1) Saab’s design of the wheel speed transducer wire harnesses, which did not consider and protect against human error during maintenance; (2) the Federal Aviation Administration’s lack of consideration of the runway safety area dimensions at Unalaska Airport during the authorization process that allowed the Saab 2000 to operate at the airport; and (3) the flight crewmembers’ inappropriate decision, due to their plan continuation bias, to land on a runway with a reported tailwind that exceeded the airplane manufacturer’s limit. The safety margin was further reduced because of PenAir’s failure to correctly apply its company-designated pilot-in-command airport qualification policy, which allowed the accident captain to operate at one of the most challenging airports in PenAir’s route system with limited experience at the airport and in the Saab 2000 airplane.

## Findings

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

- [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Other (probable cause); cases with it: [Saab-Scania 2000, 1 case](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=7860200), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md)
- [Landing gear system: main landing gear](https://openairdocs.org/ntsb-findings/01023210): Aircraft › Aircraft systems · Incorrect service/maintenance (probable cause); cases with it: [Saab-Scania 2000, 1 case](https://openairdocs.org/ntsb-findings/01023210/cases.md?model=7860200), [All aircraft, 241 cases](https://openairdocs.org/ntsb-findings/01023210/cases.md)
- [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [Saab-Scania 2000, 1 case](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=7860200), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md)
- [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Saab-Scania 2000, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7860200), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md)
- [Wind: tailwind](https://openairdocs.org/ntsb-findings/03034015): Environmental issues › Conditions/weather/phenomena · Decision related to condition (probable cause); cases with it: [Saab-Scania 2000, 1 case](https://openairdocs.org/ntsb-findings/03034015/cases.md?model=7860200), [All aircraft, 594 cases](https://openairdocs.org/ntsb-findings/03034015/cases.md)
- [Design: equipment design](https://openairdocs.org/ntsb-findings/04011010): Organizational issues › Development · Manufacturer (probable cause); cases with it: [Saab-Scania 2000, 1 case](https://openairdocs.org/ntsb-findings/04011010/cases.md?model=7860200), [All aircraft, 35 cases](https://openairdocs.org/ntsb-findings/04011010/cases.md)
- [Landing gear system: land gear sys wiring](https://openairdocs.org/ntsb-findings/01023297): Aircraft › Aircraft systems · Design (probable cause); cases with it: [Saab-Scania 2000, 1 case](https://openairdocs.org/ntsb-findings/01023297/cases.md?model=7860200), [All aircraft, 9 cases](https://openairdocs.org/ntsb-findings/01023297/cases.md)
- [Policy/procedure](https://openairdocs.org/ntsb-findings/04021000): Organizational issues › Management · Operator (probable cause); cases with it: [Saab-Scania 2000, 1 case](https://openairdocs.org/ntsb-findings/04021000/cases.md?model=7860200), [All aircraft, 15 cases](https://openairdocs.org/ntsb-findings/04021000/cases.md)
- [Oversight: oversight of operation](https://openairdocs.org/ntsb-findings/04032015): Organizational issues › Support/oversight/monitoring · FAA/Regulator (probable cause); cases with it: [Saab-Scania 2000, 1 case](https://openairdocs.org/ntsb-findings/04032015/cases.md?model=7860200), [All aircraft, 61 cases](https://openairdocs.org/ntsb-findings/04032015/cases.md)
- [Airport facilities/design](https://openairdocs.org/ntsb-findings/03017000): Environmental issues › Operating environment · Decision related to condition (probable cause); cases with it: [Saab-Scania 2000, 1 case](https://openairdocs.org/ntsb-findings/03017000/cases.md?model=7860200), [All aircraft, 52 cases](https://openairdocs.org/ntsb-findings/03017000/cases.md)

## Sequence of events

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

- [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300) (defining event); cases with it: [Saab-Scania 2000, 1 case](https://openairdocs.org/ntsb-events/300/sequence.md?model=7860200), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md)

## Factual narrative

On October 17, 2019, about 1740 Alaska daylight time, PenAir flight 3296, a Saab 2000, N686PA, overran the runway while landing at the Thomas Madsen Airport (PADU), Unalaska, Alaska. The airplane passed through the airport perimeter fence, crossed a road, and came to rest on shoreline rocks. Of the 42 passengers and crewmembers on board, 1 passenger was fatally injured, and several other passengers sustained serious or minor injuries. The airplane received substantial damage. The regularly scheduled domestic passenger flight was operating under the provisions of 14 Code of Federal Regulations Part 121 from Ted Stevens International Airport (KANC), Anchorage, Alaska, to PADU.

## Aircraft

- Registration: [N686PA](https://openairdocs.org/deregistered/N686PA-2020-08-20), registration cancelled 2020-08-20, S/N 2000-017, built 1995 (OpenAirDocs)
- Reported make and model: Saab 2000 (No Series)
- Registry model: [Saab-Scania 2000](https://openairdocs.org/model/saab-scania-2000) (registry code 7860200) (OpenAirDocs)
- Registry engine: [Allison AE2100SER](https://openairdocs.org/engine/allison-ae2100ser) (registry code 03027, turbo-prop) (OpenAirDocs)
- Category: Airplane
- Serial number: 2000-017
- Year built: 1995
- Airframe hours: 12617
- Engines: Rolls-Royce AE2001A 3738 horsepower turbo prop; Rolls-Royce AE2001A 3738 horsepower turbo prop
- Damage: Substantial damage
- Flight: Part 121
- Operator: Peninsula AviationServices Inc.,, doing business as PenAir
- Registered owner: Wells Fargo Trust Co Na Trustee
- Airworthiness certificate: Standard, Transport
- Last inspection: Continuous airworthiness, October 16, 2019
- Departed: ANC, Anchorage, AK
- Destination: PADU, Unalaska, AK
- Flight plan: IFR
- Airport: PADU, Unalaska, runway 13, 4,500 × 100 ft, asphalt
- Equipment: Data recorder, Electronic multifunction display, Auto-pilot, Electronic primary flight display

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 56; injuries: none; airline transport, commercial; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; seat: left; restraint: 4-point; toxicology performed; flight hours: 14,630 total, 134 in this make and model, 11,679 as pilot in command
- Co-pilot; age 39; injuries: none; airline transport, commercial; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; seat: right; restraint: 4-point; toxicology performed; flight hours: 1,446 total, 147 in this make and model
- Cabin crew; injuries: none; seat: rear

## Weather

- Conditions: Visual (VMC), Day
- Lowest ceiling: 3,900 ft broken
- Temperature: 43 °F, dew point 36 °F
- Altimeter: 29.52 inHg

## 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 20191017015849A](https://openairdocs.org/incident/20191017015849A), Oct 17, 2019: Saab-Scania 2000, Unalaska, AK, Substantial damage, 1 fatal. Penair flight 3296 was flying from panc to padu and the flight crew initiated a go-around on their first approach due to being unstable. On their second…

## Docket (40 files)

The files NTSB released with the investigation on December 16, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100437. 784 MB in all.

- Weather study (item 1, PDF, 14 pages, 572 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9095837&FileExtension=pdf&FileName=WX_DCA20MA002_Study-Rel.pdf
- Attachment 1 to the weather study (item 2, PDF, 4 pages, 14 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9095910&FileExtension=pdf&FileName=WX_DCA20MA002_Attachment_1-Rel.pdf
- Attachment 2 to the weather study (item 3, PDF, 8 pages, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9097093&FileExtension=pdf&FileName=WX_DCA20MA002_Attachment_2_redacted-Rel.pdf
- Powerplants group chairman's factual report (item 4, PDF, 21 pages, 28 photos, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11568184&FileExtension=pdf&FileName=PenAir%20Saab%202000%20DUT%20PP%20factual%20final%20201104-Rel.pdf
- Maintenance records (item 5, PDF, 16 pages, 387 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11655402&FileExtension=pdf&FileName=Maintenance%20Factual%20Report-Rel.pdf
- Operational factors/human performance factual report (item 6, PDF, 41 pages, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11707349&FileExtension=pdf&FileName=DCA20MA002%20OPS-HP%20FACTUAL%20REPORT%20-Rel.pdf
- Errata 1 to operational factors/human performance factual report (item 7, PDF, 2 pages, 166 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11922567&FileExtension=pdf&FileName=DCA20MA002%20OPS-HP%20FACTUAL%20REPORT%20Errata%201-Rel.pdf
- Operational factors/human performance factual report attachment 1 (item 8, PDF, 3 pages, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11679445&FileExtension=pdf&FileName=Attachment%201%20Record%20of%20Conversation%20with%20Passenger%20Witness-Rel.pdf
- Operational factors/human performance factual report attachment 2 (item 9, PDF, 1,317 pages, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11679455&FileExtension=pdf&FileName=Attachment%202%20Company%20Interviews-redacted-Rel.pdf
- Operational factors/human performance factual report attachment 3 (item 10, PDF, 235 pages, 481 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11679497&FileExtension=pdf&FileName=Attachment%203%20FAA%20Interviews-redacted-Rel.pdf
- Operational factors/human performance factual report attachment 4 (item 11, PDF, 17 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11679852&FileExtension=pdf&FileName=Attachment%204%20Flight%203296%20load%20manifest,%20flight%20plan,%20disptach%20release_Redacted-Rel.pdf
- Operational factors/human performance factual report attachment 5 (item 12, PDF, 3 pages, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11680238&FileExtension=pdf&FileName=Attachment%205%20DUT%20Wind%20Chart-Rel.pdf
- Operational factors/human performance factual report attachment 6 (item 13, PDF, 6 pages, 210 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11680258&FileExtension=pdf&FileName=Attachment%206%20PenAir%20SAAB%202000%20Performance%20Binder%20excerpt%20(unfactored%20landing%20distance)-Rel.pdf
- Operational factors/human performance factual report attachment 7 (item 14, PDF, 2 pages, 235 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11680617&FileExtension=pdf&FileName=Attachment%207%20Captain%27s%20Designated%20PIC%20Airport%20Qualification%20form_Redacted-Rel.pdf
- Operational factors/human performance factual report attachment 8 (item 15, PDF, 13 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11681355&FileExtension=pdf&FileName=Attachment%208%20Crew%20flight%20time%20and%20duty%20logs_Redacted-Rel.pdf
- Operational factors/human performance factual report attachment 9 (item 16, PDF, 6 pages, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11681872&FileExtension=pdf&FileName=Attachment%209%20Crew%20Operating%20Experience%20(OE)%20records_Redacted-Rel.pdf
- Operational factors/human performance factual report attachment 10 (item 17, PDF, 7 pages, 188 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11681784&FileExtension=pdf&FileName=Attachment%2010%20PenAir%20Airport%20Analysis%20Manual%20excerpt-Rel.pdf
- Operational factors/human performance factual report attachment 11 (item 18, PDF, 13 pages, 547 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11681004&FileExtension=pdf&FileName=Attachment%2011%20PenAir%20SAAB%202000%20Aircraft%20Performance%20presentation%20excerpt-Rel.pdf
- Operational factors/human performance factual report attachment 12 (item 19, PDF, 3 pages, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11682053&FileExtension=pdf&FileName=Attachment%2012%20PADU%20RNAV(GPS)%20(Special)%20Instrument%20Procedure%20Charts-Rel.pdf
- Operational factors/human performance factual report attachment 13 (item 20, PDF, 28 pages, 757 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11682793&FileExtension=pdf&FileName=Attachment%2013%20PenAir%20Corporate%20Administration%20Manual%20excerpt-Rel.pdf
- Operational factors/human performance factual report attachment 14 (item 21, PDF, 2 pages, 828 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11683117&FileExtension=pdf&FileName=Attachment%2014%20PenAir%20TOLD%20data%20form-Rel.pdf
- Operational factors/human performance factual report attachment 15 (item 22, PDF, 3 pages, 197 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11683187&FileExtension=pdf&FileName=Attachment%2015%20Record%20of%20DUT%20Weather%20Office%20visit-Rel.pdf
- Operational factors/human performance factual report attachment 16 (item 23, PDF, 2 pages, 369 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11682811&FileExtension=pdf&FileName=Attachment%2016%20Flight%203296%20Flight%20Risk%20Assessment%20form_Redacted-Rel.pdf
- Survival factors 6 - specialists' factual report (item 24, PDF, 23 pages, 4.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11703293&FileExtension=pdf&FileName=UnalsakaFactualFINALDOCKET-Rel.pdf
- Survival factors 6 - attachment 1 - injury chart (item 25, PDF, 1 page, 123 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11706064&FileExtension=pdf&FileName=Attachment%201%20-%20Injury%20Chart-Rel.pdf
- Systems and structures factual report (item 26, PDF, 100 pages, 14.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11707339&FileExtension=pdf&FileName=DCA20MA002%20Systems%20and%20Structures%20Factual-Rel.pdf
- Survival factors 6 - attachment 2 - security camera footage #1 (item 27, MP4, 227 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11707096&FileExtension=mp4&FileName=OPH_Front_Door_20191017.174002-Rel.mp4
- Survival factors 6 - attachment 3 - security camera footage #2 (item 28, MP4, 227 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11708837&FileExtension=mp4&FileName=OPH_Fuel_Tank_20191017.174001-Rel.mp4
- Pilot/operator aircraft accident report, NTSB form 6120.1 (item 29, PDF, 11 pages, 4.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11710230&FileExtension=pdf&FileName=DCA20MA002%20-%20NTSB%206120_Redacted-Rel.pdf
- Cockpit voice recorder - group chairman's factual report (item 30, PDF, 72 pages, 982 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11709875&FileExtension=pdf&FileName=DCA20MA002%20CVR%20-%20Release-Rel.pdf
- Flight data recorder specialist's factual report (item 31, PDF, 21 pages, 4.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11711488&FileExtension=pdf&FileName=Flight%20Data%20Recorder%20Specialist%27s%20Factual%20Report-Rel.pdf
- Flight data recorder specialist's factual report - attachment 1 (item 32, CSV, 84.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11710859&FileExtension=csv&FileName=Flight%20Data%20Recorder%20Specialist%27s%20Factual%20Report%20-%20Attachment%201-Rel.csv
- Flight data recorder specialist's factual report - attachment 2 (item 33, CSV, 8.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11710815&FileExtension=csv&FileName=Flight%20Data%20Recorder%20Specialist%27s%20Factual%20Report%20-%20Attachment%202-Rel.csv
- Flight data recorder specialist's factual report - attachment 3 (item 34, CSV, 13.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11711117&FileExtension=csv&FileName=Flight%20Data%20Recorder%20Specialist%27s%20Factual%20Report%20-%20Attachment%203-Rel.csv
- Flight data recorder specialist's factual report - attachment 4 (item 35, CSV, 15.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11711388&FileExtension=csv&FileName=Flight%20Data%20Recorder%20Specialist%27s%20Factual%20Report%20-%20Attachment%204-Rel.csv
- Aircraft performance crash site factual (text) (item 36, PDF, 13 pages, 9.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11713006&FileExtension=pdf&FileName=DCA20MA002_Aircraft_Performance_Crash_Site_Factual_TEXT_FINAL-Rel.pdf
- Aircraft performance crash site factual (attachments) (item 37, PDF, 1,725 pages, 135 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11712599&FileExtension=pdf&FileName=DCA20MA002_Aircraft_Performance_Crash_Site_Factual_ATTACHMENTS_FINAL-Rel.pdf
- Aircraft performance group study (attachments) (item 38, PDF, 36 pages, 7.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11713198&FileExtension=pdf&FileName=DCA20MA002_Aircraft_Performance_Study_PenAir_Saab_2000_Landing_Overrun_ATTACHMENTS_FINAL-Rel.pdf
- Aircraft performance group study (text) (item 39, PDF, 27 pages, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11715822&FileExtension=pdf&FileName=DCA20MA002_Aircraft_Performance_Group_Study_PenAir_Saab_2000_Landing_Overrun_FINAL_TEXT-Rel.pdf
- Board meeting staff presentation (item 40, PDF, 53 pages, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12880823&FileExtension=pdf&FileName=DCA20MA002_Presentations_fordistribution-Rel.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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