ANCHORAGE, Alaska — An Alaska commuter airline routinely failed to follow its own risk assessment plan in the days leading up to a crash that killed four people outside the village of St. Mary's, according to documents released Thursday by the National Transportation Safety Board.
The operations manual of Hageland Aviation called for flight coordinators to assess risk before allowing flights to begin, according to an NTSB report on operational factors in the crash. However, flight coordinators were undertrained and pilots regularly took off without consulting them, according to testimony collected by investigators.
Employees had a "bush pilot mentality," a Federal Aviation Administration manager told the NTSB. The report documents FAA frustrations with Hageland, the largest commuter operation in Alaska, and the agency made repeated requests for additional inspectors for oversight of Hageland.
The documents are part of the record that will precede a final determination of the cause of the fatal crash, said Clint Johnson, head of the NTSB Alaska office.
The company has made "monumental" upgrades, Johnson said, including an operations control center that reviews flights for risks.
"That's definitely a step in the right direction," he said.
Hageland, Frontier Flying Service and Era Aviation were under the corporate umbrella of HoTH Inc., now doing business as Ravn Alaska, Ravn Connect and Corvus Airlines.
The Nov. 29, 2013, crash killed pilot Terry Hansen, 68, passengers Rose Polty, 57, Richard Polty, 65, and 5-month-old Wyatt Coffee.
The airplane left Bethel for Mountain Village and began icing up when it ran into thick, cold fog. The pilot tried diverting to St. Mary's, overflew the village and crashed on a ridge 4 miles away. Six passengers survived.
Initial stages of the investigation, and other fatal or near-fatal incidents involving the companies, prompted the NTSB in May to issue an "urgent safety recommendation" that the FAA review of the businesses operating under HoTH Inc. to check for regulatory compliance and operational safety.
The latest documents showed the company could not produce records of training for the flight coordinators, who were supposed to judge conditions before releasing flights.
A July 2013 FAA safety inspection in Nome, for example, found that a manager and four ticket agents shared flight coordinator duties.
"They had not received any formal training, and were attempting to manage customer service, flight manifests, flight coordination and other duties at the same time," an inspector noted.
Dale Hansen, an FAA manager who oversaw inspectors, told the NTSB that Hageland was making 1,200 flights per week with 56 aircraft. The FAA had three inspectors for the operation.
Most of the time, he told the NTSB, pilots did not have a conversation with flight coordinators about weather and other risks on the days they flew.
"They just came in and did their own weather report and left or whatever," Hansen said. "So getting that to change was a major problem."
The company made changes after the St. Mary's crash, Hansen said.
Hageland marketing manager Charlotte Sieggreen in a statement said the company looks forward to the final report regarding the crash and will continue with the FAA and the NTSB to improve operations. The release date for the final report isn't known.