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Accidents · NTSB ANC17MA001 · Final report

Cessna 208B accident near Togiak, Alaska, October 2, 2016

On October 2, 2016 at about 7:57 pm local time, a 1995 Cessna 208B, registered N208SD, was destroyed in an accident during enroute (cruise) near Togiak, Alaska (Togiak airport). It was flown under charter and air-taxi rules (Part 135). 3 people were killed. The weather was visual conditions (good weather).

The NTSB's probable cause their words, unchanged

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.

Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.

What the record shows

Date
October 2, 2016 · about 7:57 pm local time
Place
Togiak, Alaska · Togiak · map
Type
Accident
Injuries
3 people were killed.
Weather
visual conditions (good weather)
Aircraft
Cessna 208B, built 1995 · all 208Bs on the register
Registration
N208SD · no longer on the register · serial 208B0491
Damage
Destroyed
Flight
Flight · charter and air-taxi rules (Part 135)

The NTSB's narrative final · quoted from the NTSB record

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 complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.

The factual record from the NTSB's investigation tables, in plain English

What happened, in order

  1. VFR encounter with IMC during enroute (cruise) defining event
  2. Controlled flight into terrain or object (CFIT) during enroute (cruise)

The NTSB's findings

  • cause Personnel issues › Action/decision › Info processing/decision › Decision making/judgment › Flight crew
  • cause Personnel issues › Action/decision › Action › Lack of action › Flight crew
  • cause Aircraft › Aircraft oper/perf/capability › Performance/control parameters › Altitude › Not attained/maintained
  • cause Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip › Below VFR minima › Decision related to condition
  • cause Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip › Below VFR minima › Response/compensation
  • cause Environmental issues › Physical environment › Terrain › Mountainous/hilly terrain › Response/compensation
  • cause Environmental issues › Physical environment › Terrain › Mountainous/hilly terrain › Contributed to outcome
  • factor Organizational issues › Management › Policy/procedure › Adequacy of policy/proc › Operator
  • factor Organizational issues › Support/oversight/monitoring › Training › CRM/MRM training › Operator
  • factor Organizational issues › Support/oversight/monitoring › Training › CRM/MRM training › FAA/Regulator
  • factor 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

Pilot

  • Certificate: flight instructor, commercial pilot
  • Ratings: multi-engine land; single-engine land; instructor: airplane multi-engine; instructor: airplane single-engine; instructor: instrument airplane; instrument: airplane
  • Flight time: 6,481 hours in all; 781 in this make and model; 271 in the last 90 days; 102 in the last 30 days; 6,181 as pilot in command
  • Last flight review: July 7, 2016
  • Medical certificate: Class 2 (without waivers/limitations)
  • Seat: left
  • Injury: fatal

Co-pilot

  • Certificate: commercial pilot
  • Ratings: single-engine land; instrument: airplane
  • Flight time: 273 hours in all; 84 in this make and model; 84 in the last 90 days; 83 in the last 30 days; 139 as pilot in command
  • Last flight review: September 3, 2016
  • Medical certificate: Class 2
  • Seat: rgt
  • Injury: fatal

Passenger

  • Seat: unk
  • Injury: fatal

The aircraft

  • Airframe total time: 20,562.1 hours
  • Last inspection: approved inspection programme, September 15, 2016
  • Maximum gross weight: 7,449 lb
  • Seats: 4
  • Landing gear: fixed
  • Engine: P&W PT6-114A (turboprop); 1,165 hours total
  • Operator: Hageland Aviation Services INC

The flight

  • Departed from: PAQH Quinhagak AK
  • Destination: PATG Togiak AK
  • A second pilot was aboard

Weather at the time

  • Light: daylight
  • Visibility: 7 statute miles
  • Sky: overcast at 4,700 ft; scat at 3,900 ft
  • Temperature: 45°F (7°C), dew point 43°F (6°C)
  • Altimeter: 29.87 inHg

Injuries

FatalSeriousMinorNone
Flight crew2
Passengers1

Documents from the investigation the NTSB's docket: the evidence folder behind the report

81 documents, released by the NTSB on August 17, 2017. View them here, or download them; the NTSB redacts some personal details before release, and this site shows the NTSB's own titles rather than its file names.

#DocumentWhat it is
1 1A Order of Hearing PDF, 2 pages View Download
2 1B Notice of Designation of Chairman of Board of Inquiry PDF, 2 pages View Download
3 1C Designation of Hearing Officer PDF, 2 pages View Download
4 1D Designation of Parties to the Hearing PDF, 2 pages View Download
5 1E Notice of Hearing PDF, 2 pages View Download
6 1F Statement of Purpose PDF, 3 pages View Download
7 Exhibit 1I - Safety Recommendations A-14-22 and A-14-23 PDF, 8 pages View Download
8 Exhibit 1J- Honeywell Kgp 560 Flight Manual Supplement PDF, 20 pages View Download
9 Exhibit 2A- Operational Factors Factual Report PDF, 33 pages View Download
10 Exhibit 2B - Operational Factors Attachment 1 - Interview Transcripts PDF, 354 pages View Download
11 Exhibit 2C - Operational Factors Attachment 2 - Interview Summaries PDF, 31 pages View Download
12 Exhibit 2D - Operational Factors Attachment 3 - Hageland Gom Excerpt - Weight and Balance-manifests PDF, 4 pages View Download
13 Exhibit 2E - Operational Factors Attachment 4- Hageland Flight 3153 Occ Flight Manifest PDF, 3 pages View Download
14 Exhibit 2F - Operational Factors Attachment 5 - Hageland Gom Excerpt - Safe Flight Categories Form PDF, 3 pages View Download
15 Exhibit 2G - Operational Factors Attachment 6 - Hageland Gom Excerpt - Risk Assessment Process PDF, 5 pages View Download
16 Exhibit 2H - Operational Factors Attachment 7 - Hageland Otm Excerpt - Cfit-a Training Module PDF, 3 pages View Download
17 Exhibit 2I - Operational Factors Attachment 8 - University of Alaska Simulator Evaluation PDF, 11 pages View Download
18 Exhibit 2J - Operational Factors Attachment 9 - Hageland Otm Excerpt - CRM Training Module PDF, 3 pages View Download
19 Exhibit 2K - Operational Factors Attachment 10 - Hageland Otm Excerpt - Oca Training PDF, 4 pages View Download
20 Exhibit 2L - Operational Factors Attachment 11 - Hageland Cfit-a Program Audit and Review (2015 & 2016) PDF, 8 pages View Download
21 Exhibit 2M - Operational Factors Attachment 12 - Hageland - FAA 7-POINT CFIT Mitigation Plan PDF, 3 pages View Download
22 Exhibit 2N - Operational Factors Attachment 13 - Faa-medallion Foundation Contract (Ota) PDF, 18 pages View Download
23 Exhibit 2O - Operational Factors Attachment 14 - FAA Hageland Audit Results PDF, 49 pages View Download
24 Exhibit 2P - Operational Factors Attachment 15 - FAA Cfit-a Letter to Operators PDF, 5 pages View Download
25 Exhibit 2Q - Operational Factors Attachment 16 - Medallion Foundation CFIT Avoidance Star Program Design and Process Measurement Audit Points PDF, 22 pages View Download
26 Exhibit 2R - Operational Factors Attachment 17 - Medallion Foundation Operational Control Star Program Design and Process Measurement Audit Points PDF, 21 pages View Download
27 Exhibit 2S - Operational Factors Attachment 18 - Hageland Operations Specifications A008, B050 PDF, 20 pages View Download
28 Exhibit 2T - Operational Factors Attachment 19 -hageland Flight 3153 Flight Log PDF, 3 pages View Download
29 Operational Factors Attachment 20 - Operational Factors and Human Performance Specialist's Visit to Honeywell Aerospace PDF, 4 pages View Download
30 Operational Factors Factual Report Errata PDF, 7 pages View Download
31 Exhibit 5A- Meteorology Factual Report PDF, 39 pages View Download
32 Exhibit 6A - FAA Order 8000.373 FAA Compliance Philosophy PDF, 3 pages View Download
33 Exhibit 6B - FAA Safety Briefing Excerpts PDF, 13 pages View Download
34 Exhibit 6C - Costello Letter PDF, 3 pages View Download
35 Exhibit 6D - May 2017 FAA Audit of Medallion Foundation PDF, 3 pages View Download
36 Exhibit 6E - April 2016 FAA Audit of Medallion Foundation PDF, 3 pages View Download
37 Exhibit 14A - Human Performance Factual Report PDF, 18 pages View Download
38 Exhibit 14B - Human Performance Attachment 1 - Interview Summaries PDF, 68 pages View Download
39 Exhibit 14C - Human Performance Attachment 2 - Interview Transcripts PDF, 226 pages View Download
40 Exhibit 14D - Human Performance Attachment 3 - Hageland Cfit-a Training Manual Excerpts PDF, 13 pages View Download
41 Exhibit 14E - Human Performance Attachment 4 - Fsf CFIT Aid Excerpts PDF, 40 pages View Download
42 Exhibit 14F - Human Performance Attachment 5 - Hageland Otm Excerpts PDF, 10 pages View Download
43 Exhibit 14G - Human Performance Attachment 6 - Hageland Gom Excerpts PDF, 15 pages View Download
44 Exhibit 14H - Human Performance Attachment 7 - Faa-hageland Post Accident Agreement PDF, 3 pages View Download
45 Exhibit 14I - Human Performance Attachment 8 - Medallion Foundation Shield Program Documents PDF, 72 pages View Download
46 Exhibit 14J - Human Performance Attachment 9 - FAA CFIT Letter PDF, 5 pages View Download
47 Exhibit 14K - Human Performance Attachment 10 - FAA 2017 Alaskan Aviator's Safety Handbook PDF, 69 pages View Download
48 Exhibit 14L - Human Performance Attachment 11 - Honeywell Kgp 560/860 Pilot’s Guide PDF, 39 pages View Download
49 Exhibit 14M - Human Performance Attachment 12 - FAA Advisory Circular 25-23 PDF, 36 pages View Download
50 Exhibit 14N - Human Performance Attachment 13 - Hageland Safety Manual Excerpts PDF, 19 pages View Download
51 Human Performance Factual - Addendum 1 PDF, 4 pages View Download
52 Human Performance Factual - Errata 1 PDF, 7 pages View Download
53 Electronic Device Specialist Report PDF, 6 pages View Download
54 Pilot/operator Aircraft Accident Report, NTSB Form 6120.1 PDF, 9 pages View Download
55 EGPWS Examination Report PDF, 4 pages View Download
56 PIC Toxicological Report PDF, 1 page View Download
57 SIC Toxicological Report PDF, 1 page View Download
58 Photos PDF, 3 pages View Download
59 Iic Presentation PDF, 20 pages View Download
60 Panel 1-1 Hageland (Cfit-a Presentation) PDF, 9 pages View Download
61 Panel 1-2 Honeywell (EGPWS Presentation) PDF, 12 pages View Download
62 Panel 1-3 FAA (Alaska Flight Services Information Area Group Presentation) PDF, 15 pages View Download
63 Panel 2-1 Hageland (Operational Control Presentation) PDF, 9 pages View Download
64 Panel 3-1 Hageland (Safety Initatives and Programs Presentation) PDF, 4 pages View Download
65 Panel 3-2 FAA (Reducing Aviation Accidents in Alaska Presentation) PDF, 17 pages View Download
66 Panel 3-3 Medallion Foundation (Improving Aviation Safety in Alaska Presentation) PDF, 11 pages View Download
67 Exhibit 1H- Witness Biographies PDF, 5 pages View Download
68 Transcript - Public Hearing Day 1 (08/17/17) PDF, 259 pages View Download
69 Computed Tomography Specialist's Factual Report PDF, 30 pages View Download
70 Medical Factual Report PDF, 4 pages View Download
71 Hageland Party Submissions PDF, 66 pages View Download
72 Medallion Hearing Party Submission PDF, 57 pages View Download
73 FAA Submission PDF, 26 pages View Download
74 Statement of Party Representatives to NTSB Investigation PDF, 4 pages View Download
75 Aircraft Time Life Report PDF, 40 pages View Download
76 Flight Track Data PDF, 14 pages View Download
77 ADS-B Deferral PDF, 1 page View Download
78 22 Feb Hageland Mitigation Plan Update PDF, 3 pages View Download
79 Training Records PDF, 29 pages View Download
80 Hageland General Operations Manual Excerpts PDF, 5 pages View Download
81 Aircraft Accident Report AAR-18-02 PDF, 91 pages View Download

The same docket at the NTSB · documents without a copy here are fetched from the NTSB when you open them.

Everything on this page comes from the NTSB's public records. The narrative, probable cause and findings are the NTSB's own words; the coded tables behind the report are written out in plain English, with pilots' ages, home towns and medical details left out. The documents and photographs are the NTSB's docket, shown as the NTSB released them. This site's own text never names anyone involved. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.