NTSB CAROL · Event
Event ANC17MA001
Aircraft involved
Probable cause & findings
The flight crew's decision to continue the visual flight rules flight into deteriorating visibility and their failure to perform an immediate escape maneuver after entry into instrument meteorological conditions, which resulted in controlled flight into terrain (CFIT). Contributing to the accident were (1) Hageland's allowance of routine use of the terrain inhibit switch for inhibiting the terrain awareness and warning system alerts and inadequate guidance for uninhibiting the alerts, which reduced the margin of safety, particularly in deteriorating visibility; (2) Hageland's inadequate crew resource management (CRM) training; (3) the Federal Aviation Administration's failure to ensure that Hageland's approved CRM training contained all the required elements of Title 14 Code of Federal Regulations 135.330; and (4) Hageland's CFIT avoidance ground training, which was not tailored to the company's operations and did not address current CFIT-avoidance technologies.
Factual narrative
The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-18/02. On October 2, 2016, about 1157 Alaska daylight time, Ravn Connect flight 3153, a turbine-powered Cessna 208B Grand Caravan airplane, N208SD, collided with steep, mountainous terrain about 10 nautical miles northwest of Togiak Airport (PATG), Togiak, Alaska. The two commercial pilots and the passenger were killed, and the airplane was destroyed. The scheduled commuter flight was operated under visual flight rules by Hageland Aviation Services, Inc., Anchorage, Alaska, under the provisions of Title 14 Code of Federal Regulations Part 135. Visual meteorological conditions prevailed at PATG (which had the closest weather observing station to the accident site), but a second company flight crew (whose flight departed about 2 minutes after the accident airplane and initially followed a similar route) reported that they observed unexpected fog, changing clouds, and the potential for rain along the accident route. Company flight-following procedures were in effect. The flight departed Quinhagak Airport, Quinhagak, Alaska, about 1133 and was en route to PATG. The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-18/02. On October 2, 2016, about 1157 Alaska daylight time, Ravn Connect flight 3153, a turbine-powered Cessna 208B Grand Caravan airplane, N208SD, collided with steep, mountainous terrain about 10 nautical miles northwest of Togiak Airport (PATG), Togiak, Alaska. The two commercial pilots and the passenger were killed, and the airplane was destroyed. The scheduled commuter flight was operated under visual flight rules by Hageland Aviation Services, Inc., Anchorage, Alaska, under the provisions of Title 14 Code of Federal Regulations Part 135. Visual meteorological conditions prevailed at PATG (which had the closest weather observing station to the accident site), but a second company flight crew (whose flight departed about 2 minutes after the accident airplane and initially followed a similar route) reported that they observed unexpected fog, changing clouds, and the potential for rain along the accident route. Company flight-following procedures were in effect. The flight departed Quinhagak Airport, Quinhagak, Alaska, about 1133 and was en route to PATG. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).
- C Personnel issues-Action/decision-Info processing/decision-Decision making/judgment-Flight crew
- C Personnel issues-Action/decision-Action-Lack of action-Flight crew
- C Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Altitude-Not attained/maintained
- C Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-Below VFR minima-Decision related to condition
- C Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-Below VFR minima-Response/compensation
- C Environmental issues-Physical environment-Terrain-Mountainous/hilly terrain-Response/compensation
- C Environmental issues-Physical environment-Terrain-Mountainous/hilly terrain-Contributed to outcome
- F Organizational issues-Management-Policy/procedure-Adequacy of policy/proc-Operator
- F Organizational issues-Support/oversight/monitoring-Training-CRM/MRM training-Operator
- F Organizational issues-Support/oversight/monitoring-Training-CRM/MRM training-FAA/Regulator
- F Organizational issues-Support/oversight/monitoring-Training-(general)-Operator
- — Aircraft-Aircraft systems-Navigation system-Ground proximity system-Not used/operated
- — Aircraft-Aircraft systems-Navigation system-Ground proximity system-Related operating info
- — Aircraft-Aircraft systems-Navigation system-Ground proximity system-Capability exceeded
- — Aircraft-Aircraft systems-Navigation system-Ground proximity system-Design
- — Environmental issues-Operating environment-Communication system-VHF/HF radio-Not specified
- — Environmental issues-Operating environment-Meteorological services-Meteo equip coverage/avail-Not specified
- — Organizational issues-Support/oversight/monitoring-Safety programs-(general)-FAA/Regulator
- — Organizational issues-Support/oversight/monitoring-Safety programs-(general)-Other institution/organization
- — Aircraft-Aircraft systems-Indicating/recording systems-Data recorders (flight/maint)-Not installed/available
Verbatim from NTSB's published report. Source file
NTSB_2016_ANC17MA001.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (controlled flight into terrain, cfit, crm). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- Flight Safety Foundation 2023 · FSF / AeroSafety World
Controlled Flight Into Terrain (CFIT) — A 2023 Industry Refresh
Foundation 2023 CFIT data refresh — three decades after the original CFIT Task Force eliminated >95% of air-carrier CFIT, the GA + Part 135 communities still account for most CFIT fatalities.
- NASA NTRS 2019 · Technical Publication (TP)
Flight Simulator Evaluation of Synthetic Vision Display Concepts to Prevent Controlled Flight Into Terrain (CFIT)
In commercial aviation, over 30-percent of all fatal accidents worldwide are categorized as Controlled Flight Into Terrain (CFIT) accidents, where a fully functioning airplane is inadvertently flown i…
- NASA NTRS 2019 · Other
Preliminary Effect of Synthetic Vision Systems Displays to Reduce Low-Visibility Loss of Control and Controlled Flight Into Terrain Accidents
An experimental investigation was conducted to study the effectiveness of Synthetic Vision Systems (SVS) flight displays as a means of eliminating Low Visibility Loss of Control (LVLOC) and Controlled…
- NASA NTRS 2019 · Technical Memorandum (TM)
Rating the Relevance of QUORUM-Selected ASRS Incident Narratives to a "Controlled Flight into Terrain" Accident
An exploratory study was conducted to identify commercial aviation incidents that are relevant to a "controlled flight into terrain" (CFIT) accident using a NASA-developed text processing method.
- NASA NTRS 2018 · Preprint (Draft being sent to journal)
CFIT Prevention Using Synthetic Vision
In commercial aviation, over 30-percent of all fatal accidents worldwide are categorized as Controlled Flight Into Terrain (CFIT) accidents where a fully functioning airplane is inadvertently flown in…
- Embry-Riddle Scholarly Commons 2001 · Journal article (JAAER)
Controlled Flight into Terrain: How the Airlines and the Federal Aviation Administration are Addressing the Problem
Controlled Flight into Terrain (CFIT) is not a new problem. It has been around since the beginning of manned flight. A CFIT accident occurs when an airworthy aircraft, under the control of a pilot, is…
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