Bering Air C208B crash, preliminary report

[Robster]

The preliminary report has been released. . . see link to entire report at this website.

https://www.ntsb.gov/investigations/Pages/ANC25MA018.aspx

 

[wwillson]

It sounds like ice may have been the cause of the accident. Ice is to be highly respected in any aircraft.

 

[AZjeff]

Ice + overweight?

 

[wwillson]

Ice + overweight?

Overweight yes, but that wasn't the cause, but it absolutely contributed. He would have gotten away with the weight had he not picked up ice. When you operate outside of the envelope the problems often don't come on in a linear fashion.

 

[Robster]

If the TKS fluid reservoir was full, that would have been an additional 189 lbs of weight at takeoff. I'm still interested in the position of the switches for the TKS system. Also, the annunciator system will announce when TKS fluid is low--I don't know if that info is stored in memory.

The C208B (like most, if not all turbine-powered aircraft) has an inertial separator that should have been activated in any visible moisture, including icing conditions. If activated, that would have reduced available engine torque at a time when it would have been needed--another factor to consider.

Here's a link to a good video of how the C208 TKS anti-ice system works:

 

[AZjeff]

He would have gotten away with the weight had he not picked up ice.

Would he have been able to keep flying with ice if not overweight? Icing conditions aren't controllable, weight is. Is flying overweight SOP in that operating environment?

 

[wwillson]

Would he have been able to keep flying with ice if not overweight?

Likely at least for a while. More weight means higher angle of attack and when you add ice there is more flow separation. Adding ice to the equation is like throwing gasoline on a fire.

Is flying overweight SOP in that operating environment?

It shouldn't be.

 

[Robster]

I should note that I'm ASSuming that a pilot who's been flying in Alaska in the wintertime for 1000+ hours understands when to use the inertial separator and it's impact on performance. At the lowish altitudes he was flying at, lack of torque wouldn't be a problem, however, if he forgot to use the inertial separator in icing conditions it could cause a complete engine failure (intake icing). NOTE: A recent (forced) emergency landing by a C208B departing Dulles airport may have been caused by intake icing, although I haven't seen a conclusive report on that one yet.

The C208B is a capable airplane when flown within limitations and has an abundance of performance in reserve, but overweight with moderate icing conditions puts the pilot in uncharted territory performance-wise. These airplanes are flown by the package haulers every night in some bad weather conditions, particularly in the NE U.S.--we don't hear about many incidents with them. I doubt that they ever depart overweight.

 

[kschachn]

Weight and balance will get you every time.

 

[Astro14]

I should note that I'm ASSuming that a pilot who's been flying in Alaska in the wintertime for 1000+ hours understands when to use the inertial separator and it's impact on performance. At the lowish altitudes he was flying at, lack of torque wouldn't be a problem, however, if he forgot to use the inertial separator in icing conditions it could cause a complete engine failure (intake icing). NOTE: A recent (forced) emergency landing by a C208B departing Dulles airport may have been caused by intake icing, although I haven't seen a conclusive report on that one yet.

The C208B is a capable airplane when flown within limitations and has an abundance of performance in reserve, but overweight with moderate icing conditions puts the pilot in uncharted territory performance-wise. These airplanes are flown by the package haulers every night in some bad weather conditions, particularly in the NE U.S.--we don't hear about many incidents with them. I doubt that they ever depart overweight.

You assume too much.

Flying for 1,000 hours doesn’t mean that learning, or improvement, has taken place.

Some pilots make a shortcut in procedure, or ignore something, and it becomes ingrained in their ‘technique”. They keep repeating a mistake and that mistake becomes self-reinforcing. Because it worked, it must be OK.

Things like - taking off over weight, scud running, flying into icing.

But the shortcuts, the procedural violations, are not OK. They are dangerous, they are risky, and one day, like this day, they bite you.

Hard.

 

[Robster]

@Astro14, I don't disagree with any of that. I might add that at some part 135 and other for-hire operations safety-culture is diminished, if not absent altogether in the name of profit. Many of these operations hire young / low-time pilots who are desperate for flight time and are easy to manipulate by management to take chances that more experienced pilots would push back on. Of course, all that is an assumption too. Lacking evidence to the contrary, as spectators to the investigation that's about all we can do.

 

[Just a civilian pilot]

Not sure about the U.S but any flight ops MGT that pressures ( or is aware ) any pilot into doing unsafe things faces going to jail if an accident happens.

There is zero excuse to let anyone pressure you into doing things that are illegal ( taking off above max take off weight ).

I don't find its an experience thing as much as some people/pilots let people push them around and its a personality trait more than a lack of experience problem.

Even if the MEL ( ability to dispatch aircraft with certain things unserviceable ) says you can depart, its up to the Captain whether or not they want to take the plane and they need to make sure everyone is aware of that and stand their ground. It might be legal but it might not be a smart thing to do despite flights ops saying its safe.

Most well run operations know running a safe operation is cheaper in the long run and pay pilots to say no at times and support them.

In the past, the ability to stick up for yourself, push back and say no wasn't for the faint of heart, now flight operations will be held criminally responsible if they pressure any pilots.

I have flown for many mickey mouse operations but I never had a problem saying no, even when low experience.

I have hung up the phone with flight ops MGT before after I told them what I think.

 

[Just a civilian pilot]

Juan Browne: