Series of Errors Led to Fatal 2019 Airplane Crash in Alaska

The airliner headed from Anchorage to a small Alaska island didn’t stand a chance.

A maintenance error had severely impaired the PenAir plane’s brakes, the pilot wasn’t qualified to land at the airport, the plane model shouldn’t have been allowed to fly there and winds were too strong to land.

The U.S. National Transportation Safety Board on Tuesday concluded the problem with the brakes was the primary reason the plane skidded off the runway two years ago with 42 people on board, leading to the first airline fatality in the U.S. since 2018. But investigators also raised numerous questions about the troubling series of events leading to the death of one passenger and serious injury to another when a propeller broke off and pierced the fuselage.

Safety investigators said the pilots’ decision to land in prohibited winds was “intentional,” faulted the airline’s lack of internal safety systems and called the U.S. Federal Aviation Administration’s oversight of the now-defunct airline “inadequate.”

The accident prompted the NTSB to raise safety concerns about aircraft manufacturers similar to those from the recent investigations into two fatal crashes on the Boeing Co. 737 Max that killed 346 people.

Like Boeing, the maker of the plane in the Alaska crash, Saab AB, didn’t have an advanced internal safety program that might have highlighted risks in the plane’s design, the NTSB found. It was difficult to detect the maintenance error and no procedures existed to test for it, NTSB investigators said.

Saab didn’t immediately respond to an email seeking comment on the NTSB findings.

U.S. regulators planned to create a mandate for such safety programs as early as 2018, but it was quietly shelved during the Trump administration. The FAA is drafting a new proposed regulation on the issue, but it hasn’t been released yet.

PenAir Flight 3296, which was operating under contract with Alaska Airlines Inc. arrived at Dutch Harbor’s Unalaska Airport in the Aleutian Islands on Oct. 17, 2019, according to NTSB records.

After touching down with a strong tailwind, the Saab 2000 turboprop plane slid off the runway and airport grounds, coming to rest on a rock berm protecting the airport from an adjacent harbor. The impact tore a propeller blade loose and it sliced into the side of the plane, killing a 38-year-old man in his seat. A second passenger was seriously injured.

Just over a minute before touchdown, one of the pilots seemed to acknowledge the difficult environment they faced.

“Oh God,” the copilot said after being told by an airport weather observer’s radio call that the rapidly shifting winds were blowing almost 28 miles (45 kilometers) per hour from nearly directly at their rear, according to a transcript of cockpit conversations.

Landing with a tail wind increases speed on the ground, requiring a longer stopping distance and stressing the brakes. Saab’s flight manual said landings shouldn’t occur with tail winds over 17 miles per hour.

But after a brief discussion, the pilots continued toward the runway. “Alright,” the captain said. “Last try.”

What they didn’t realize was the plane had a hidden malfunction that had lay dormant for more than two years after the landing gear was overhauled by Saab. Crossed wires meant that when pilots jammed on the brake pedals, the anti-skid system would hamper the brakes instead of helping to stop, according to preliminary NTSB findings.

One of the four main tires that had full braking burst after skidding down the runway, further limiting the ability to stop, according to investigators.

“I’m sliding,” the captain said as he attempted to slow the plane.

PenAir’s parent, Ravn Air Group, ceased operations in 2020 and attempts to reach officials at the company weren’t successful.

There’s rarely a single cause for an aircraft accident and the PenAir case illustrates that.

Saab’s design of the plane’s wheels made it relatively easy to miswire the brakes and there was no procedure to test for such a problem, the NTSB said.

Because it can be challenging to fly into Dutch Harbor, PenAir required that captains operating there had at least 100 hours commanding its aircraft. The captain on the accident flight had less than 16 hours, according to the NTSB.

Additionally, the Saab 2000 aircraft shouldn’t have been allowed to fly to the airport, according to FAA guidelines. That model required longer safety areas at the end of the runway, according to NTSB documents.

An FAA inspector told investigators he couldn’t recall approving the operation and PenAir told NTSB its records were lost in a ransomware hacker attack two months after the accident.

As part of the investigation, NTSB issued 10 recommendations. It called on FAA to improve safety at planemakers and assess whether other aircraft might be susceptible to similar brake failures. The NTSB also urged Saab to redesign the wiring in its brakes.