Accident Saab 2000 N686PA, Thursday 17 October 2019
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Date:Thursday 17 October 2019
Time:17:40
Type:Silhouette image of generic SB20 model; specific model in this crash may look slightly different    
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
Other fatalities:0
Aircraft damage: Substantial, written off
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.?

METAR:

00:56 UTC / 16:56 local time:
PADU 180056Z 31011KT 10SM FEW034 BKN047 BKN060 07/01 A2950 RMK AO2 SLP995 T00720011

01:56 UTC / 17:56 local time:
PADU 180156Z 30021G27KT 5SM -RA BKN039 06/02 A2953 RMK AO2 PK WND 30027/0154 RAB41 SLP004 P0002 T00560017

02:56 UTC / 18:56 local time:
PADU 180256Z 25004KT 10SM BKN035 BKN044 BKN120 07/02 A2952 RMK AO2 RAE14 SLP002 ACSL NE P0002 60004 T00670017 53003

23:56 UTC / 14:56 local time:
PADU 172356Z 31006KT 10SM BKN036 BKN044 07/01 A2951 RMK AO2 RAB12E25 SLP999 P0000 60000 T00670011 10083 20056 53005

Accident investigation:
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Investigating agency: NTSB
Report number: DCA20MA002
Status: Investigation completed
Duration: 2 years 1 month
Download report: Final report

Sources:

KTUU
thecordovatimes.com
ADN
NTSB update

History of this aircraft

Other occurrences involving this aircraft

27 July 2014 N519JG Joe Gibbs Racing 0 Concord Regional Airport (KJQF), Concord, North Carolina unk

Location

Images:


photo (c) NTSB; Unalaska-Tom Madsen Airport, AK (DUT); 17 October 2019


photo (c) NTSB; Unalaska-Tom Madsen Airport, AK (DUT); 17 October 2019


photo (c) NTSB; Unalaska-Tom Madsen Airport, AK (DUT); 17 October 2019


photo (c) NTSB; Unalaska-Tom Madsen Airport, AK (DUT); 17 October 2019


photo (c) NTSB; Unalaska-Tom Madsen Airport, AK (DUT); 17 October 2019


photo (c) NTSB; Unalaska-Tom Madsen Airport, AK (DUT); 17 October 2019


photo (c) NTSB; Unalaska-Tom Madsen Airport, AK (DUT); 17 October 2019


photo (c) NTSB; Unalaska-Tom Madsen Airport, AK (DUT); October 2019


photo (c) NTSB; Unalaska-Tom Madsen Airport, AK (DUT); October 2019


photo (c) NTSB; Unalaska-Tom Madsen Airport, AK (DUT); 17 October 2019


photo (c) NTSB; Unalaska-Tom Madsen Airport, AK (DUT); 17 October 2019


photo (c) NTSB; Unalaska-Tom Madsen Airport, AK (DUT); 17 October 2019


photo (c) NTSB; October 2019

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