On October 17, 2019, about 1740 Alaska daylight time, Peninsula Aviation Services Inc. d.b.a. PenAir flight 3296, a Saab 2000, N686PA, was landing at Unalaska Airport (DUT), Unalaska, Alaska, when the airplane overran the end of the runway, passed through the airport perimeter fence, crossed a road, and pitched down over shoreline rocks with its nosewheel in Dutch Harbor.
Two flight crew members, one flight attendant, and 39 passengers were aboard the airplane; one passenger sustained fatal injuries from an . The airplane was substantially damaged. The airplane was operating as a regularly scheduled Part 121 passenger flight. Visual meteorological conditions prevailed at the time of the accident. The flight had departed from Ted Stevens Anchorage International Airport at 1523.
The fatally injured passenger had been seated in seat 4A. He was struck and killed by a composite propeller blade which entered the cabin after separating during the accident, and was pronounced dead shortly after arrival at a local hospital. The Medical Examiner’s Office reported his cause of death to be “blunt impacts of head, trunk and extremities with multiple skeletal and visceral injuries.”
Captain’s flight times:
Total: 14,761 hrs
PIC: 11,811 hrs
SA-2000: 131 hrs
SA-2000 PIC: 131 hrs
First Officer’s flight times:
Total: 1,447 hrs
PIC: 1,370 hrs
SA-2000: 138 hrs
SA-2000 PIC: 0 hrs
The sole runway at DUT had a Runway Design Code of B-II. This meant it was built to accommodate aircraft whose Aircraft Approach Category (AAC), which is based on VREF, is B, and whose wingspan and tail height place it in Airplane Design Group (ADG) II.20
According to the standards contained in FAA Advisory Circular (AC) 150/5300-13A, Airport Design, the Saab 340 previously flown by PenAir into DUT had an AAC-ADG value of B-II. The Saab 2000 was a C-III airplane.
One runway design element specified in the AC is the length of the Runway Safety Area (RSA) beyond the end of the runway. For a runway with Design Code B-II this length should be 300 feet. For runways built to accommodate airplanes in the AAC-ADG category C-III, the length should be 1000 ft.
The AC states that any operation of an aircraft that exceeds design criteria of the airport may result in either an unsafe operation or a lesser safety margin unless air traffic control standard operating procedures are in place for those operations. The AC also states, “Aircraft operations cannot be prevented, regulated, or controlled simply because the airport or runway does not meet the design standards for a particular aircraft type.”
PenAir began operating the Saab 2000 into DUT in 2016. The investigation sought to learn if either the FAA or PenAir had awareness of the mis-match or made any safety accommodations performed any risk analysis, or considered any mitigations when planning for the operation of a C-III airplane to and from a B-II runway.
The FAA POI at the time of the Saab 2000’s authorization to operate into DUT was interviewed specifically concerning this topic. He said he had no memory of any consideration of this issue.
The FAA was asked to provide any records or documentation that dealt with their authorization for PenAir to operate the Saab 2000 into DUT. They responded with the completed version of a data collection tool (DCT) titled “Aircraft Performance Operating Limitations, Design Assessment, Operations”. According to the description contained in the DCT, its objective was to “Determine if the Certificate Holder will be able to; (1) Comply with regulations; (2) Operate Aircraft within the performance limitations of the Aircraft Flight Manual (AFM).” The DCT was completed in January of 2016. No mention was found in the DCT of consideration of Runway Design Code, AAC, or ADG when planning for operation into any airport.
PenAir stated that the individuals who would be able to answer questions about the initial authorization process for the Saab 2000 in 2015-2016 had since left the company due to the company’s 2017 bankruptcy and recent furloughs of company personnel caused by the Ravn bankruptcy in April of 2020. The company provided the names of the Director of Operations and the assistant Director of Operations in place at the time of the Saab 2000 authorization. Both had previously left PenAir. Both were contacted, and neither had any recollection of this issue being considered during the 2015-2016 Saab 2000 authorization process.
When asked to provide related records or documentation, PenAir stated that any files they may have had regarding the authorization of the Saab 2000 to operate into DUT were lost in a ransomware attack the company suffered in December of 2019.
But that’s really just the tip of the iceberg. See, particularly, the Operations and Survival Factors Factual Report for additional information, available at https://tiny.cc/penair3296.
0:00 Accident video
3:45 Accident photographs
7:17 CVR transcript excerpt
source
