Alaskan Double-Cross: The crash of PenAir flight 3296

On the 17th of October 2019, a PenAir commuter plane overran the runway in Unalaska, Alaska, narrowly escaping a plunge into the icy waters of Dutch Harbor. But disaster, unfortunately, was not avoided, as the left propeller disintegrated and sent a loose blade slicing through the cabin, killing a passenger and injuring several others.

For experienced investigators, human error would have been the prime suspect, as it is in most runway overrun accidents. But when the NTSB sat down with the pilot, he delivered a bombshell: as the Saab 2000 hurtled down the runway, he stepped on the brakes, and nothing happened! An examination of the plane’s braking system revealed that he was telling the truth. In fact, someone had wired the anti-skid system backwards, a massive error that caused flight 3296 to lose almost all braking power right when it was needed most — during a dangerous landing in a tailwind that exceeded the manufacturer’s limit. Following the trail of evidence deeper, the NTSB found that the airline’s dysfunctional management had created an environment in which 42 passengers and crew could be dispatched aboard a plane with a fatal flaw, to an airport where neither the plane nor the pilot should have been allowed to land.

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Since the dawn of commercial aviation, Alaska has been one of the most challenging and lucrative airline markets. Hundreds of isolated communities, cut off by vast distances and a lack of roads, rely on air travel for their very survival. The hardy pilots who choose to fly to these scattered villages must contend with terrible weather, poor infrastructure, and dramatic topography, giving Alaska a reputation as a final frontier for aviation safety, a place where, it seems, no one is more than one or two degrees of separation from someone who died in a plane crash. But by the late 2010s, the danger had largely been consigned to small private and charter flights, while the scheduled airlines extended fatality-free runs from years into decades.

One of the airlines providing scheduled services on the Alaskan frontier was Peninsula Airways, a regional carrier founded in 1955 to serve the isolated communities of the Alaskan Peninsula and the Aleutian Islands. For much of its history, the airline was owned by the Seybert family, whose members were well-known and well-liked throughout the region. But, starting in 2012, the airline made an ambitious foray into the Lower 48 which turned out to be a financial disaster. Attempts to create regional hubs in Boston, Denver, and Portland, Oregon failed to generate much revenue, and by 2017 the airline had fallen into significant debt. That year the Seyberts were forced to declare bankruptcy, and PenAir was sold to the owners of its competitor Ravn Alaska. By the second half of 2019, the new owners were busy merging the two airlines in a move that would herald the end of the PenAir brand after 64 years in service.

On the 17th of October that year, with the merger already well underway, a PenAir aircraft and crew prepared for a regularly scheduled flight from Anchorage to Unalaska, a town of about 4,000 people in the eastern Aleutian Islands. Unalaska is home to Dutch Harbor, the most productive fishing port in America, an institution which so dominates the town’s identity that locals are more likely to say that they’re “going to Dutch Harbor” (or just “Dutch”) than to Unalaska.

Flight 3296 to Unalaska would be operated by a Swedish-made Saab 2000, a midsized twin turboprop with room for about 50 passengers. Today it would carry 39, including an entire high school swim team and their chaperones. Three crewmembers brought the total to 42, including the two pilots, Captain Paul Wells and First Officer Justin Lunn. The 56-year-old Captain Wells had over 14,000 hours of experience flying in Alaska, but he had only recently been hired by PenAir and was new to the Saab 2000, with only 131 hours on the type, and the 39-year-old First Officer Lunn had about the same number.

In Anchorage at around 14:00, while inspecting the plane for its 15:10 flight to Unalaska, First Officer Lunn noticed that the outboard tire on the left main landing gear had developed a bald spot. Whipping out his phone, he took a photo and returned to the cockpit to show it to Captain Wells, who examined the damage and compared it to the company limits on tire wear depth. According to PenAir guidelines, the tire was okay to fly as long as it “wasn’t showing cord,” and since the bald spot appeared to be confined to the tread, he concluded that they could proceed with the flight.

Sometime later, the dispatcher briefed the pilots about the weather conditions in Unalaska. A storm was moving in that day, with winds at 15 to 25 knots out of the west, broken clouds, and periodic light rain forecast for the airport. According to PenAir rules, a captain with less than 300 hours on the aircraft type could only be dispatched if the forecast wind plus half the gust margin added up to 20 knots or less, and if the forecast was close to this value then the pilot and the dispatcher needed to explicitly agree that it was safe to fly. But while the wind at Unalaska that day was right at the edge of the acceptable value, Captain Wells and the dispatcher agreed to conduct the flight without any apparent hesitation.

Flight 3296 departed Anchorage at 15:23 and proceeded to the southwest, expecting to arrive in Unalaska in about two hours. While in cruise, the crew considered their options for landing. Unalaska Airport is located on Amaknak Island, a small island in Dutch Harbor which is connected by a bridge to the mainland and includes much of the town’s industrial and fishing infrastructure. The airport presents a challenge for flight crews no matter which runway they use — runway 13 from the northwest, or runway 31 from the southeast — because of its orientation relative to nearby mountains, which force planes to come in at an angle over the bay before turning to line up with the runway very late in the approach. At Unalaska Airport, pilots refer to the runway 13 and runway 31 approaches as the “front door” and “back door” respectively, with the “front door” approach considered the easier of the two due to the greater distance between the runway threshold and the mountains. On flight 3296, Captain Wells decided early in the flight that he wanted to perform the front door approach to runway 13, with which he was more familiar, even though weather reports indicated that this would probably result in a tailwind component on landing.

At that time the wind was reported to be about eight knots out of the southwest, not a significant concern for an approach to runway 13. But as the flight continued, the wind swung around to the northwest and increased in strength, as the forecast predicted. “Yeah it’s changed, the weather’s updated,” Captain Wells said at about 16:57. “Three zero, uh, three one zero at one one.”

“M’kay,” said First Officer Lunn.

“Starting to favor the back door a little more,” Wells continued. That was an understatement: at that moment the wind would be directly at their backs at 11 knots if they took the front door approach to runway 13, a major liability on a short runway like Unalaska. But the pilots seemed to have committed themselves to the idea that they would stick with the front door and take the back door if they needed to — without clearly articulating what would constitute “need.”

At 17:06, the airport weather observer reported that the wind had swung back to the southwest at six knots with gusts to 14. “Direct crosswind… yeah, it’s pretty much a direct crosswind,” Wells said. “We had that the other day too, I did that with [name redacted]… we’re like a half mile final when she says ‘out of two four zero at two five…’ I went, ‘the fuck you want me to do about it now?’”

Nine minutes later, having been cleared for the approach to runway 13, Captain Wells said, “And just like the other day, if there’s any major changes in wind then we’ll just — ”

“We’ll switch,” Lunn finished for him.

But the thought was soon put out of mind, as the weather observer now reported wind directly out of the south at eight knots, clearly favoring runway 13. It seemed like their bet on the front door approach had paid off.

As they were coming in to land on runway 13, everything seemed normal: the runway was in sight and they had lined up successfully. But as the plane neared 300 feet, the pilots observed that they were straying from the recommended speed and trajectory. “Whaddaya think?” Wells asked.

“Go around,” said First Officer Lunn.

“Going around,” said Wells, pushing the throttles to go-around power to abandon the approach.

“Dutch Harbor traffic, Peninsula 3296 going around, we’re going to come back for a visual,” Lunn said over the radio.

“Yeah, we’re gonna go out here and do a one-eighty and come back in,” Wells said, apparently suggesting that they were going to turn around and try runway 31.

But one minute later, First Officer Lunn said on the radio “We’re at twelve hundred coming back around for one… uh, the visual one three.”

Captain Wells corrected him, saying, “Three one, three one.”

“Three one?” Lunn asked, sounding confused.

“Back door?” said Wells.

“I thought we were doing one three,” said Lunn.

“Oh, okay, sure, we’ll try again,” Wells said. He had apparently wanted to try runway 31, but he gave in without a fight to his first officer’s suggestion that they use runway 13 again. Flight 3296 circled around and lined up for runway 13 for the second time.

At 500 feet, Lunn asked, “You okay with this?”

“Eh… I was thinking about going the other way,” said Wells. But he didn’t press the point, and the plane kept descending.

At 17:38, less than two minutes from landing, Wells ordered Lunn to get one last wind check.

“Right now, midfield winds at three zero zero at twenty four,” the weather observer replied.

Indeed, the wind had swung back to the northwest, almost directly behind them and way faster than the safe tailwind landing limit. “Oh god,” Lunn said, apparently taken by surprise.

“Ah shit,” said Wells.

“Damn,” said Lunn. “Do you wanna back out, do it again?”

“Uh…”

“I think — ”

“Keep talking to weather,” Wells decided.

“Alright, we’ll try it again,” Lunn said.

“Alright, last try,” Wells agreed.

According to the manufacturer, the Saab 2000 should not be landed with a tailwind greater than 15 knots. Landing with a 24-knot tailwind should have been completely out of the question. And yet, for some reason, the pilots continued the approach, somehow convinced that they could still safely land on runway 13.

By the time flight 3296 actually arrived over the runway threshold, the tailwind was around 15 knots. Landing with such a tailwind is risky because an airplane in flight must maintain a certain speed relative to the surrounding air. If the wind is blowing from behind the plane, maintaining a safe speed relative to the air results in a higher speed relative to the ground. As a result, by the time flight 3296 planted its wheels on the runway, it was traveling at a ground speed of 142 knots, much faster than normal.

Having touched down 1,100 feet (335m) down the runway, the crew had approximately 2,800 feet (850m) left to bring their speeding plane to a stop. Even with the tailwind, they should have made it, albeit without much margin for error. But there is always an element of the unknown, the collection of what-if scenarios that sometimes don’t seem worth thinking about. Indeed, when he decided to land on runway 13, Captain Wells assumed that he would have functional brakes — not at all an unreasonable assumption, but one which would prove to be tragically wrong.

In 2017, the main landing gear from this airplane was sent to the manufacturer, UK-based Héroux-Devtek, for a scheduled overhaul. The overhaul included maintenance and inspection of the anti-skid system, one of the most critical components involved in bringing the plane to a stop. If a wheel begins to skid during landing, the brakes on that wheel — which work by bleeding off rotational energy — will become ineffective. To prevent this from happening, the anti-skid system constantly compares the speed of each wheel to the speed of the airplane, and if it detects a significant difference, it will relax the applied brake pressure until the wheel starts spinning again. However, reducing brake pressure to a single wheel would cause asymmetric drag, negatively affecting the airplane’s directional stability; therefore, the system will reduce pressure either to both inboard wheels or both outboard wheels, but never to only one wheel at a time.

On the Saab 2000, the anti-skid system receives data from a wheel speed transducer on each of the four main landing gear wheels. The signals from the transducers are sent to the anti-skid control unit via wires which run up the landing gear struts and into the fuselage. During the overhaul at Héroux-Devtek, these wires were removed for inspection and then put back into place. At the top, where the wire harnesses pass through a fuselage bulkhead, different attachment point designs ensure that the wires for the inboard and outboard wheels can only be connected to the correct input channels on the anti-skid control unit. However, at the bottom, where the wires connect to the wheel speed transducers, there was no such distinction, and it was possible to attach the inboard wire to the outboard wheel, and vice versa. To make matters worse, the nomenclature used to describe the two wire harnesses was confusing and inconsistent, and the parts were not labelled in such a way as to clearly indicate which wire should attach to which transducer. And on top of that, the setup was not symmetrical: the same model of wire was used on the right wheel on both gears, and a different model on the left, rather than one model for the outboard wheels and another for the inboard wheels.

Therefore, if a mechanic did not understand this asymmetry and did not read the directions correctly, there was nothing to prevent them from attaching the wire harnesses to the wrong wheel speed transducers. In fact, this is exactly what happened during the overhaul: after rewiring the right main landing gear correctly, the mechanic apparently attached the left main landing gear outboard wheel speed transducer to the inboard anti-skid channel, and the inboard transducer to the outboard channel.

Following the incorrect installation, the anti-skid system passed every test, because none of the prescribed tests could detect that the system had been wired backwards. The plane was returned to PenAir without anyone realizing that Héroux-Devtek had introduced a potentially fatal weak point into the braking system.

This hidden danger went undetected for years in large part due to PenAir’s bankruptcy. Following the overhaul in 2017, the airplane sat unused for two years as PenAir and Ravn Alaska management worked out the fate of the troubled airline. The plane finally entered service in the summer of 2019, flying its first passengers for PenAir on June 26th. It was only a matter of time before some unfortunate crew discovered the horrifying consequences of the manufacturer’s colossal maintenance mistake.

As PenAir flight 3296 touched down on the runway at Unalaska, the first couple seconds seemed normal. First Officer Lunn pulled the engines into reverse while Captain Wells applied the brakes, and the pilots felt the aircraft begin to decelerate. But at that moment, the bald spot on the outboard left main landing gear wheel caught on the asphalt, and the wheel began to skid.

Because the outboard left wheel speed transducer had been wired to the inboard anti-skid channel, the anti-skid control unit thought that it was the inboard left wheel which was skidding. The unit therefore sent a command to reduce brake pressure to both inboard wheels. For obvious reasons this failed to stop the skid, so the system kept reducing brake pressure all the way to zero. The left outboard wheel burst, several anti-skid fault messages appeared in the cockpit, and the master caution alarm started blaring. Captain Wells hammered on the brakes, but the plane refused to decelerate normally — with the left outboard wheel in a skid and brake pressure removed from both inboard wheels, the plane had lost 75% of its braking power.

“Brakes!” First Officer Lunn exclaimed.

“I got ’em all the way!” said Wells.

“On behalf of PenAir and Alaska Airlines, we’d like to welcome you to Dutch Harbor,” the flight attendant said cheerfully over the public address system.

“Hang on!” Wells said. “I’m sliding!”

Both pilots let loose a flurry of expletives as the plane continued past the end of the runway and onto the paved overrun area. The helplessness they must have felt can only be imagined, as their most powerful tool to stop the plane refused to respond.

Seeing the end of the paved surface fast approaching, Captain Wells steered to the right, aiming for a nearby road in an attempt to stay away from the water. The plane plowed over a chain link fence, bounced through a ditch, struck a signal post and a road sign, then tipped over the edge of the breakwater, coming to rest with its nose just brushing up against the cold, gray surface of Dutch Harbor.

At the moment the plane went over the edge, the left main landing gear collapsed and the still-spinning left propeller struck the stones of the breakwater, instantly shearing the propeller from its mountings and sending blades flying in all directions. One blade was catapulted harmlessly into the bay, but two more launched themselves directly into the side of the passenger cabin, slicing through the wall with explosive force. Debris burst out into the aisle as one of the blades demolished seat 4A, mortally wounding 38-year-old passenger David Oltman. Within a split second it was over, as the blade came to rest in row five, jammed vertically between the footwell and the overhead bins, just inches from passengers’ legs.

In the cockpit, the left engine fire alarm sounded, and Captain Wells quickly pulled the fire extinguisher before ordering an evacuation. Picking up the radio, Wells broadcast a distress call: “Dutch Harbor, PenAir 3296, we’re off the runway…”

“Just get out!” someone yelled.

In the cabin, one of the panicked high school students shouted “fire,” but the group’s chaperone shouted back that there was none, possibly preventing a stampede. As passengers poured out of the rear exits and onto the breakwater, others pulled David Oltman into the aisle and attempted to render first aid. Bystanders rushed to help, as did the airport’s single fire truck, which arrived on the scene two minutes after the crash. Within nine minutes, a doctor boarded the plane, and after fourteen minutes Oltman was airlifted to hospital, where surgeons fought to save his life. Unfortunately, there was little they could do, and he soon died of his injuries — becoming just the second fatality due to an accident on an American passenger flight in the past decade. Another nine passengers were injured, one of them seriously, including several who hurt themselves during the evacuation and at least one who was struck by debris.

Considering the rarity of such an accident, the National Transportation Safety Board quickly launched a major investigation. Although the NTSB was committed to examining all possibilities, early media speculation about the accident mostly focused on the actions of the crew. Why had they decided to land? Was it even possible to stop the plane on the runway given the conditions? One passenger, who was himself a pilot with 20 years’ experience, said he asked the captain why he had landed at all, to which Wells allegedly replied that the computer (probably his iPad) said it would be okay.

But when the investigators sat down to interview him, Captain Wells claimed that when he attempted to brake, the plane didn’t slow down. The runway was dry; hydroplaning was out of the question. Something had to be mechanically wrong with the airplane — and when they examined the landing gear, they found the problem. It was such a simple error, with such catastrophic consequences: crossing the wheel speed transducer wires was easy to do, all but impossible to detect, and unlikely to cause trouble until the moment the system was most needed. Indeed, calculations showed that had the anti-skid system worked as designed, flight 3296 would have been able to stop on the runway despite the damage to the outboard left wheel.

The NTSB found records of three previous minor runway overrun incidents on other aircraft types due to crossed anti-skid wiring. However, Saab was completely unaware of the problem or its potential consequences. Although the company had conducted a risk analysis of the anti-skid system, which included possible maintenance errors, the analysis was mostly focused on physical failures, and nobody considered what would happen if a mechanic simply attached the wires the wrong way around.

As a result of this discovery, Saab clarified its maintenance manuals, removing inconsistent terminology and warning that the wires could be swapped accidentally. The European Union Aviation Safety Agency (EASA) issued an airworthiness directive mandating inspections of the anti-skid system wiring on all Saab 2000 airplanes, and Saab introduced a new post-maintenance test which would “instantly” flag any swapped wires. However, no significant design changes were implemented, in large part due to the fact that the Saab 2000 had been out of production for more than 20 years and only 45 were left in service.

But the faulty anti-skid system was only half of the puzzle. Calculations also showed that had the pilots landed into the wind, they would have been able to stop on the runway even with the 75% loss of braking power. And yet the cockpit voice recording revealed a shocking blunder: despite learning from the weather observer that there was a 24-knot tailwind on runway 13, the pilots continued their approach to this runway. Why would a pair of experienced pilots make such an obviously dangerous decision? Both pilots indicated that they knew the tailwind landing limit for the Saab 2000 was 15 knots, but they also said that they didn’t think they were afoul of the limit. How could this be?

By following their conversation throughout the second half of the flight, it was possible to see how the pilots built up an expectation that they would be landing on runway 13, despite the weather forecast prior to their departure indicating that winds would favor runway 31. Based on his statements, it seemed that Captain Wells was considering landing on runway 31 after the first failed approach, but First Officer Lunn quickly roped him back into another attempt on runway 13, apparently without eliciting any protest. Investigators felt that Wells displayed poor crew resource management when he let the First Officer make a critical operational decision without any discussion, and criticized him for a “lack of flight deck leadership.”

A number of external factors may have contributed to Captain Wells’ belated decision to try to land on runway 13 a second time. At several points during the flight, the weather observer reported wind speeds under 10 knots out of the south or southwest, giving them a manageable crosswind on landing. This could have helped the pilots settle into a plan to perform the slightly simpler and more familiar approach to runway 13. Then, during their second approach to this runway, the weather observer suddenly informed them that conditions had changed completely. The pilots reacted with shock to the news, and they clearly considered circling around to the opposite runway. But in the end they kept going, as though their train of thought was stuck on a track that led straight down to runway 13. Psychologists call this “plan continuation bias”: the reluctance to abandon a plan as it draws closer to completion, despite mounting evidence that a new plan is needed.

The power of plan continuation bias was such that the pilots were unable to assimilate this dire new wind information, subconsciously writing it off as acceptable or manageable because of the greater importance placed on following through with a plan that was nearing completion. Certainly, if you asked either pilot whether it’s a good idea to land with a reported 24-knot tailwind, they would say it is not. And yet in moments of stress, the capacity of the human mind to make catastrophic errors of judgment is much greater than we sometimes imagine.

However, it turned out that this error could have been prevented — if not by the pilots, then by the airline.

Due to its difficult approaches, PenAir required captains to undergo a special training course before they could land at Unalaska Airport. In order to be eligible for the course, a captain needed 300 hours on the aircraft type; or at least 100 hours, a recommendation from a check airman, and a letter of approval from the chief pilot. But Captain Wells met none of these requirements when he was cleared to fly to Dutch Harbor. In fact, PenAir’s Chief Pilot Crystal Branchaud waived these requirements for Wells when he had only 20 hours on the Saab 2000, in clear violation of company procedures. It turned out that the bankruptcy and merger with Ravn Alaska had caused a damaging exodus of experienced pilots, which in turn put pressure on PenAir management to fast-track new hires into the special airport training programs. Wells was one of these pilots, and in June 2019 he was sent to the special airport training with almost no experience on his aircraft and only limited previous experience flying to Unalaska.

Chief Pilot Branchaud told the NTSB after the crash that she did not know a pilot needed 100 hours and a recommendation letter from a check airman for the 300-hour minimum to be waived, even though this was stated on the waiver form. Furthermore, other senior PenAir pilots said that the waiver was only meant for captains who had very extensive experience at the airport under previous employers, not as a loophole for management to qualify new pilots more quickly. Because of the shortage of pilots who could fly to the special airports — at the time that Wells was approved, only four or five PenAir captains were authorized to fly to Unalaska — PenAir and Ravn management had introduced a plan to reduce the requirement from 300 hours to 100 hours in all cases. The new rules hadn’t even been officially drawn up, let alone approved by the FAA or formally implemented, and yet Branchaud was acting like they were already in place.

Not everyone at PenAir was happy with this decision. Many pilots thought the move would be dangerous, and one check airman even resigned from his post in protest, only for Branchaud to threaten him with extra work and a pay cut. And that wasn’t the only area where the behavior of company management raised eyebrows at the NTSB. One PenAir captain told investigators that she once rejected a flight because the weather conditions were too close to the legal margins and she thought the flight was too risky. Instead of congratulating her for her attention to safety, she was called to a “counselling session” by Chief Pilot Branchaud and Ravn Alaska Senior Vice President of Flight Operations Deke Abbott. Branchaud allegedly called her decision “unprofessional and immature” and told her that with “a legal airplane, legal weather, and legal crew, it was [her] job” to conduct the flight. Abbott piled on, telling her that he “didn’t trust [her] decision-making from the left seat” and that he “didn’t think [she] deserved to be on the flight line anymore.”

News of the incident spread like wildfire among PenAir pilots and contributed to a significant souring of relations between pilots and management. The trust which had been built up over 60 years under the Seybert family rapidly disappeared, to the point that many pilots reported feeling uncomfortable voicing safety concerns or exercising caution beyond legal requirements. After the accident, Captain Wells expressed no particular reservations about safety at PenAir, but everyone at the airline knew what would have happened if he had expressed any doubt about flying to Unalaska in bad weather with his limited Saab 2000 experience.

In the investigators’ opinion, sending a captain with so little experience on the aircraft to conduct a challenging approach to Unalaska with forecast winds close to the allowable maximum was a recipe for disaster. Furthermore, Wells acknowledged that the Saab 2000 was faster and harder to handle than the de Havilland Canada DHC-8 which he had flown for most of his career. Therefore, if he had had more experience with the risks of landing a faster, larger airplane on the short runway at Unalaska, Wells might have made different decisions that day. Looking back over the sequence of events which put flight 3296 onto that runway, it seems clear that a better company culture would have ensured that the crew was never in that situation in the first place.

The NTSB also found that the decision to fly the Saab 2000 to Unalaska was a risky one from the beginning. In order to determine recommended safety margins, airplanes are divided into various weight and speed classes. The runway end safety areas at Unalaska Airport were designed to comply with the recommended margins for the Saab 340B, which had a weight class of BII and required a 300-foot (91m) clear area at the end of each runway. However, the Saab 2000 was part of the larger and faster CIII weight class, which came with a recommended clear area of 1,000 feet (300m). Unalaska Airport did not come close to meeting this recommendation, and the lack of adequate room to stop the Saab 2000 in the event of an emergency‚ such as a brake failure, should have given the Federal Aviation Administration pause. But when the FAA approved PenAir’s Saab 2000 service to Unalaska, the recommended size of the runway end safety area was not one of the criteria under consideration, nor was it standard practice to include it. The NTSB rightly questioned what the recommendations were for, if the FAA wasn’t considering them.

As a result of the NTSB’s findings, Ravn Alaska lost a lucrative code sharing agreement with Alaska Airlines, sending the company into a financial tailspin. Already burdened by $90 million in unpaid bills, Ravn Alaska entered the Covid-19 pandemic with no ability to weather the severe drop in passenger numbers. In 2020, Ravn Alaska and PenAir permanently ceased operations due to bankruptcy. Although Ravn publicly blamed its troubles on the pandemic, articles published in the Anchorage Daily News have suggested that the financial fallout from the airline’s safety problems was the real reason it was unable to stay afloat, citing the fact that no other major regional airlines in Alaska went bankrupt.

The air operator certificates for Ravn Alaska and PenAir were subsequently purchased by a commuter airline based in California, which resurrected the Ravn brand name and resumed services to Unalaska in early 2021. But travelers can rest assured that the airline is under completely new management, and the only vestige of the old, troubled carrier is the name.

The crash of PenAir flight 3296 is a stark reminder for airlines that in the modern American aviation industry, the death of even a single passenger due to a poor safety culture can result in the collapse of the company. There was a time when a lower level of safety in Alaska was accepted, but the fate of Ravn Alaska shows that that era is over.

The crash also conveys important lessons about risk. Safety margins are sometimes large enough to render abstract the dangers they are designed to mitigate, but that doesn’t change the fact that the dangers are real. The tailwind limits and landing distance requirements for the Saab 2000 were sufficiently conservative that the pilots could in theory have landed on runway 13 with a massive tailwind and faced no adverse consequences, even though the legal limits were exceeded. But if someone had suggested that they would also lose all braking power on three out of four wheels, the possibility would have been dismissed with a laugh. After all, what are the chances of that?

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Admiral Cloudberg

Admiral Cloudberg

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Analyzer of plane crashes and author of upcoming book (eventually™). Contact me via @Admiral_Cloudberg on Reddit or by email at kylanddempsey@gmail.com.