Crew and Controller Faulted in Fatal CFIT Accident

 - August 18, 2014, 11:10 AM

The crew of a Beech 1900C and the handling controller were both responsible for a controlled flight into terrain (CFIT) accident, according to the NTSB’s recently released final report. The twin turboprop was on an IFR Part 135 cargo flight in IMC on March 8, 2013, and was 10 miles east of Aleknagik, Alaska, when the accident happened. Both pilots were killed.

As the aircraft neared the airport, the controller cleared the crew to fly directly to the initial approach fix (IAF), stating, “Maintain at or above 2,000” until established on a published segment of the approach. The pilots repeated the clearance as “maintain 2,000” until established and began descending.

At 2,200 feet, the crew requested a holding pattern and the controller cleared them to hold “as published.” However, as published, the holding pattern altitude at the IAF is 4,300 feet. The aircraft hit terrain in a wings-level attitude on the outbound leg at 2,200 feet.

The NTSB determined the accident was caused by the “crew’s failure to maintain terrain clearance, which resulted in CFIT.” Contributing to the accident were the “controller’s ambiguous clearance, resulting in the airplane’s premature descent, his failure to address the pilot’s incorrect readback of the assigned altitudes and not issuing terrain-based safety alerts.” Investigators also noted the airplane had equipment that should have provided visual and aural terrain warnings.