ASN Wikibase Occurrence # 319317

This record has been locked for editing.
Date: | Thursday 17 October 2019 |
Time: | 17:40 |
Type: | Saab 2000 |
Owner/operator: | PenAir - Peninsula Airways |
Registration: | N686PA |
MSN: | 2000-017 |
Year of manufacture: | 1995 |
Total airframe hrs: | 12617 hours |
Engine model: | Allison AE2100A |
Fatalities: | Fatalities: 1 / Occupants: 42 |
Aircraft damage: | Substantial |
Category: | Accident |
Location: | Unalaska-Tom Madsen Airport, AK (DUT) -
United States of America
|
Phase: | Landing |
Nature: | Passenger - Scheduled |
Departure airport: | Anchorage-Ted Stevens International Airport, AK (ANC/PANC) |
Destination airport: | Unalaska-Tom Madsen Airport, AK (DUT/PADU) |
Investigating agency: | NTSB |
Confidence Rating: | Accident investigation report completed and information captured |
Narrative:A Saab 2000, registered N686PA, was substantially damaged when it experienced a runway excursion after landing on runway 13 at Unalaska Airport, Alaska.
The aircraft departed Anchorage, Alaska, USA at 15:15 hours local time, bound for Unalaska. As the flight descended towards Unalaska, it was cleared for the RNAV runway 13 approach. During the descent and approach the wind changed from 210 degrees at 8 knots, gusting to 14 knots, to 180 degrees at 7 knots. During the approach, the winds were reported as 270 degrees at 10 knots.
A go-around was executed as the aircraft was not stabilized on the approach, The flight returned for a visual approach to runway 13. Winds increased and during the second approach the controller reported winds of 300 degrees at 24 knots.
At 17:40 the aircraft touched down about 1,000 feet down the 4,500 feet long runway and the captain initiated reverse thrust and normal wheel-braking. The captain stated that he went to maximum braking around the 80 knot call. The flight crew reported that they attempted to steer the airplane to the right at the end of the runway to avoid going into the water.
The airplane then departed the runway and overrun area, traversed a section of grass, impacted a 3- to 4-ft high chain-linked perimeter fence with evidence of left engine propeller contact, crossed a ditch, impacted a large rock, and crossed a public roadway. The left wing or left engine propeller struck a 4 to 5 ft vertical signal post on the opposite shoulder of the road and the left propeller struck a 6 to 8-ft high yellow diamond shaped road sign. The left hand prop shattered, sending pieces into and through the fuselage. One propeller blade was found inside the fuselage.
Two people were critically injured. One passenger died of injuries the next day.
The the probable cause of this accident was the landing gear manufacturer's incorrect wiring of the wheel speed transducer harnesses on the left MLG 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 FAA's lack of consideration of the RSA dimensions at DUT 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 PIC 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.?
Sources:
KTUU thecordovatimes.com ADN NTSB update Accident investigation:
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| |
Investigating agency: | NTSB |
Report number: | DCA20MA002 |
Status: | Investigation completed |
Duration: | 2 years 1 month |
Download report: | Final report |
|
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Revision history:
Date/time | Contributor | Updates |
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