In April, the National Transportation Safety Board released the public docket on its investigation into the Nov. 29, 2013 plane crash of a Hageland Aviation aircraft outside the Southwest Alaska village of St. Marys. The crash, which killed four people, and the resulting investigation, reveal troublesome lapses in operational oversight from both the company and the government agency tasked with regulating them.

The St. Marys docket release includes interviews with company personnel and management, survivors, first responders and Federal Aviation Administration personnel assigned to inspect and oversee the airline, as well as extensive analysis of the wreckage and weather around the time of the crash.

The material included in the release shows that the scope of the NTSB investigation has included not only the actions of the pilot involved in the accident, but also those who work on the ground in operational control at the company, and in air carrier surveillance and regulatory compliance with the FAA.

While a probable cause has not yet been determined for the St. Marys accident, that expanded scope is noteworthy -- especially in the wake of another probable cause report released in March on an earlier 2013 Hageland crash at the airstrip at the North Slope's Badami oil field. That report was unusual in that it blamed the crash not only on pilot error, but also on FAA oversight and company practices.

But the most frustrating aspect of the St. Marys accident is not found in the report.

The harsh truth of this Cessna 208 crash is that it was utterly unremarkable. It was very nearly indistinguishable from accidents of 30, 40 or even 50 years ago. Tragically, coupled with what took place in Badami, it serves as yet another reminder that for all our technological advances and use of fresh terms like "risk analysis" and "safety procedures," commercial aviation in Alaska has yet to leave behind its bush flying days.

There were several key elements in the NTSB report. First, an analysis of reported weather at Mountain Village -- one of the plane's two destinations on the day of the crash -- showed conditions that made the flight's successful arrival there questionable. The flight departed Bethel at 5:41 p.m. At 5:19 p.m. Mountain Village reported an overcast ceiling at 100 feet overcast with 8 miles visibility; at 6:09 p.m. the cloud ceiling was the same, but with only 2 miles visibility.

At St. Marys, conditions were not much better. At 5:36 p.m., the ceilings were at 400 feet and 1,800 feet broken, 2,400 feet overcast with a visibility of 7 miles. At 6:15 p.m. it had degraded to 300 overcast and 3 miles visibility.

These conditions require pilots to land under instrument flight rules (IFR) and there are instrument approaches at both airports. The conditions also placed the flight at a higher level of risk, according to Hageland Aviation's own operations manual.

However, in interviews with the NTSB, both the Bethel flight coordinators on the job that night said they made little note of the weather. They were aware of the instrument meteorological conditions but assumed as pilot Terry Hansen and the aircraft were both IFR capable, he would file an IFR flight plan.

Neither Kenny Miller, the Bethel flight coordinator tasked with operational control and release on the flight nor John Flynn, the other flight coordinator on duty who prepared the load manifest, spoke to the pilot about the weather prior to his departure. Miller told investigators he did not tell Hansen of the risk level assigned to his flight and, "He had no discussions with Terry about his flight."

As stated in the public docket, according to the Hageland General Operations Manual, flight coordinators are "required to consider the elements of risk and determine with the PIC the flight's risk assessment level and enter the risk level on the manifest before offering it to the PIC, and verbally confirm that the flight can safely begin."

Neither Miller nor Flynn knew why the flight departed 40 minutes late and both were unaware of Hansen's intentions -- or lack of intentions -- to file a flight plan.

Taking chances

According to the NTSB, Terry Hansen had 25,000 hours of flight time, was instrument rated and lived in St Marys. It's unlikely we'll ever know why he chose not to fly IFR that night.

The decision to take off under visual flight rules in spite of instrument meteorological conditions at his destinations is a familiar choice in Alaska aviation. There's even an unofficial term for it -- "taking a look," which implies the pilot will decide en route whether to continue VFR, turn back or request an IFR clearance, in this case from Anchorage Center, if needed.

Historically, the limitations of Alaska's weather reporting and the low number of airports with instrument approaches made "taking a look" a common aviation practice. Pilots departed with little real knowledge of the conditions they might encounter en route and adapted as necessary, lowering their flight safety standards as needed in order to complete a flight.

As Jean Potter recounted in her book "The Flying North," Pacific Alaska Airways in the 1930s suffered economically because of the conservative standards required by its parent company Pan American, where "a safety record was paramount." With Pacific Alaska soon dubbed the "Blue-Sky Outfit," Potter noted that "bush pilots were able to fly rings" around the carrier.

Decades later, long after Pacific Alaska was gone, little had changed for most Alaska carriers. In "Arctic Bush Pilot," Wien Air pilot James Anderson recounted a 1950s night flight from his Bettles base to the unlit airfield in Allakaket in snow, blustery winds and temperatures below zero. It was, he wrote, "a nasty night; even a daytime flight would have been questionable."

Anderson flew for 40 miles "through the snow and the wind a few hundred feet above the white, frozen Koyukuk River ... Someone, I never knew who, was waiting in the dark with a flashlight to show me where the end of the runway was."

His passenger was a pregnant woman in labor. Soon after this harrowing night, Anderson announced that Wien would no longer consider childbirth a medical emergency; families were just going to have to plan better to save him and other pilots from undertaking such dangerous flights.

Dozens of pilots died in bad weather on flights that should never have been attempted. One of the more famous was Harold Gillam, who crashed a twin-engine Lockheed Electra in 1943 near Annette Island after departing from Seattle on a day that, according to Potter, "all other flights north were canceled."

The survivors were found weeks later after one of them, Susan Baxter, had also died. Gillam was famous for flying in poor conditions through his career. In "The Flying North," Potter writes there were three kinds of weather in Alaska: "Pan American weather -- clear and unlimited;" good or bad weather in which "ordinary men would fly;" and the absolute worst, known as "Gillam weather."

But even after the crash no one wanted to believe it was Gillam's fault.

"None," writes Potter, "talking about his final accident, care to discuss the matter of recklessness."

FAA shortcomings

With a reported fleet of 56 aircraft and 1,200 weekly operations in Alaska, Hageland Aviation is by far the state's largest air carrier and, according to FAA databases, ranks as the largest scheduled Part 135 passenger air carrier operating of by fleet size in the country. But the FAA has struggled to address the demands this company places on their oversight capabilities.

In the post-accident investigation, the FAA's then-current principal operations inspector (POI) for Hageland, Danny Larson -- who has since retired -- detailed his struggle to stay on top of the airline. There are three investigators assigned to Hageland specializing in operations, maintenance and avionics. Prior to the crash, due to personnel changes, there had been six POIs in three years, most of them temporary and juggling dozens of other operators at the same time.

Larson was formally assigned to Hageland in September 2013. He told NTSB investigators that he was aware of numerous discrepancies between the idealized operation of the airline presented by its General Operations Manual and the actual procedures that were carried out on the ground but struggled to effect positive change. From the report:

When asked why the FAA continued to allow the company to operate, with all the documented...failures/violations of procedures and processes he (Larson) stated that he did not know what else he could have done. He felt they were doing all they could with current staffing levels, which he believed to be insufficient.

Larson's supervisor, Frontline Manager Dale Hansen, was more direct in his interview, saying:

...we've had numerous meetings...even with the ownership, with the HoTH Corporation that owns this company and Era Alaska [now Ravn Alaska]. You know, they gross $150 million a year, 17th biggest company in Alaska, you think they would try harder, you know. They're the biggest airline, I wish they were the best. But, you know, it's hard to push them. They have the bush pilot mentality that safety culture is -- we have to change that and we're trying our best to do it, it just takes time.

Hansen told investigators he had requested an increase in the regular staff assigned to Hageland but was hampered by FAA rules which assign inspectors based on the number of multi-engine/turbine aircraft in a fleet. Although Hageland had 56 total aircraft at the time of crash, most of them were single-engine, so the carrier did not meet the threshold allowing for increased assignment of safety inspectors.

When asked about this problematic approach to Alaska's air carriers, the FAA responded with a press release issued after the NTSB docket was made public last week. It stated that Hageland has three primary inspectors and two assistant inspectors and, "Since the beginning of Fiscal Year 2012, more than 40 ASIs (aviation safety inspectors) have performed hundreds of surveillance activities on Hageland encompassing thousands of hours."

However, as noted in an article last year, "surveillance activities" include ramp inspections where individual pilots are required to provide basic paperwork, ranging from proof of pilot's license and medical certificate, load manifest or aircraft documents. Multiple ramp checks can be completed within an hour, and each counts as a separate inspection.

The additional aviation safety inspectors are not assigned to the Hageland, but rather available occasionally to make spot inspections and because they work with numerous other operators around the state, they are likely unaware of the primary areas of concern with Hageland. Thus, without more specific information from the FAA, it is impossible to determine the true impact of the agency's surveillance figures when assessing Hageland's regulatory and safety compliance.

'More work to do'

In 2014, a new dispatch center was opened in Palmer to manage all Hageland Aviation flights. Licensed dispatchers are not required under Part 135 as they are for larger air carriers operating under Part 121, such as Hageland's sister companies, Era Aviation and Frontier Flying Service.

For those operators, dispatchers share responsibility for flight planning decisions with pilots and can be found at fault in an incident or accident. For carriers like Hageland, the dispatchers assist in flight planning and may carry responsibilities within the company, but never risk the loss of a license, and thus potentially a career, as pilots do.

At the Palmer center, all Hageland departures are now rated on a risk assessment scale and approved -- or not approved -- by a dispatcher. The pilots speak directly with the dispatchers about issues surrounding weather, equipment, load, etc. By having decisions originate in Palmer, the pilots and local personnel are now protected from any outside sources of pressure. The center should also prevent situations where a pilot departs without speaking to other company personnel as occurred in the St. Marys crash.

The Palmer center points to the high potential that changing attitudes and technology can bring to aviation safety.

"Operational control of both scheduled and on-demand Part 135 operators has long been a challenge here in Alaska," echoed NTSB Alaska Region Chief Clint Johnson in a recent phone call. "However, advances in technology like weather cameras, Spidertracks, satellite phones, and ADS-B are helping bridge that gap. Like anything else, we learn from our mistakes, and we've made some progress, but still have more work to do."

Looking forward

Hageland Aviation has a long and problematic safety history. According to the NTSB database, over the past two decades the company has been involved in 30 accidents and incidents, resulting in the deaths of 23 people. Since 2008, when Hageland formed a "family of airlines" with Frontier Flying Service -- and later, with Era Aviation -- that eventually came to be known as Ravn Alaska, there have been eight accidents involving Hageland aircraft.

History shows that in many ways, Hageland has operated no differently than dozens, if not hundreds, of other Alaska air carriers. The difference is that in the 21st century, it is increasingly difficult to excuse the multiple lapses -- lapses that caused an accident such as the one in Badami and are exposed in the St. Marys public docket.