On February 6, 2025, about 1520 Alaska standard time, a Textron Aviation 208B airplane, N321BA, operated as Bering Air flight 445, was destroyed when it was involved in an accident near Nome, Alaska. The pilot and nine passengers died. The airplane was operated under Title 14 Code of Federal Regulations (CFR) Part 135 as a scheduled charter flight.
The accident pilot was scheduled to fly a three-leg roundtrip on the day of the accident, originating at Nome Airport (PAOM). The accident occurred during the third leg of the trip on the return flight to PAOM. The pilot departed on this last leg about 1437. He used the autopilot for most of the final flight.
The Bering Air dispatcher who reviewed the day’s weather with the pilot before the first flight leg stated that the pilot was aware of the weather and conditions for the time and route of the accident flight based on the information available at the time and had no concerns. However, about 38 minutes after departing on the last leg, the flight encountered severe icing conditions, including supercooled large droplets (SLD). The airplane had a functioning Tecalemit-Kilfrost-Sheepbridge Stokes (TKS) ice protection system, which the pilot used during the flight’s encounter with icing conditions.
About 1512, PAOM closed both of its runways for deicing, which was expected to take 10 to 15 minutes. The radar controller informed the pilot of the closure and suggested that he could “slow down a little bit” to prevent arriving before the runway was reopened. The pilot reduced engine power, and the airplane’s airspeed decreased from about 160 kts to about 110 kts; the pilot then increased engine power, and the airspeed increased to about 126 kts. About 1519, the airspeed again began to decrease, down to about 99 kts, which activated the airplane’s low airspeed awareness (LAA) system. As designed, activation of the LAA system resulted in the autopilot disengaging.
At 1519:46, the airplane’s descent rate was about 2,000 feet per minute (fpm); data from the airplane’s onboard avionics indicate that the airplane’s pitch attitude reached its maximum value of about 10º to12º nose up (consistent with an elevator input by the pilot) at an airspeed of 89 kts about this time. Its descent rate then decreased to 1,400 fpm over 3 seconds. Over the next 8 to 9 seconds, the airplane’s airspeed decreased to about 70 kts at an altitude of about 3,100 ft mean sea level (msl).
At 1520:07, the radar controller instructed the pilot to climb and maintain 4,000 ft msl. The controller attempted to contact the pilot again 7 seconds later but received no response. The final automatic dependent surveillance–broadcast position data point was recorded at 1520:09 when the airplane was at an altitude of 1,325 ft msl. It impacted pack ice about 12 miles offshore of Norton Sound and about 32 miles east of PAOM.
We determined that the probable cause of this accident was the pilot’s inadequate airspeed management due to workload and degraded situation awareness and his improper inputs leading up to and during the aerodynamic stall, which increased the airplane’s angle of attack. Also causal was operation of the airplane above maximum gross weight, which reduced the airplane’s stall margin.
Contributing to the accident were the operator’s inadequate safety management, which allowed the routine operation of flights that exceeded weight limitations, and the Federal Aviation Administration’s inadequate oversight of the operator, which failed to identify and address the routine operation of overweight flights.
As a result of this investigation, the National Transportation Safety Board makes the following new safety recommendation.
To the Federal Aviation Administration:
- Require all 14
Code of Federal Regulations Part 135 and 91K operators, except single-pilot and single-pilot-in-command operators, to incorporate upset prevention and recovery training, whether in a simulator or an aircraft, and related checklists and procedures into their training programs. (A-26-64)
- Develop explicit surveillance criteria for 14
Code of Federal Regulations Part 135 and 91K operators that are experiencing rapid growth, increased complexity of operations, accidents and/or incidents, or other changes that warrant increased oversight, including verifying that inspector staffing is adequate to accomplish the enhanced surveillance resulting from the new criteria, and increasing staffing for those certificates with insufficient staffing levels. (A-26-65)
Previously Issued Recommendations Reiterated in This Report
The National Transportation Safety Board reiterates the following safety recommendations.
To the Federal Aviation Administration:
- Require all 14 Code of Federal Regulations (CFR) Part 135 operators, except single-pilot and single-pilot-in-command (PIC) operators, to use certificated dispatchers who hold joint responsibility with the PIC for the safety and operational control of flights and whose responsibilities include preflight planning; flight dispatch, release, and cancellation decisions; and flight monitoring, consistent with the requirements for 14 CFR Part 121 domestic and flag operations. (A-24-17)
- Require all 14 Code of Federal Regulations Part 135 operators to install flight data recording devices capable of supporting a flight data monitoring program. (A-16-34)After the action in Safety Recommendation A-16-34 is completed, require all 14 Code of Federal Regulations Part 135 operators to establish a structured flight data monitoring program that reviews all available data sources to identify deviations from established norms and procedures and other potential safety issues. (A-16-35)
- Expand the applicability of the load manifest and recordkeeping requirements of Title 14 Code of Federal Regulations (CFR) 135.63(c) to include 14 CFR Part 135 single-engine aircraft operations. (A-24-18)
- Require the installation of a crash-resistant flight recorder system on all newly manufactured turbine-powered, nonexperimental, nonrestricted-category aircraft that are not equipped with a flight data recorder and a cockpit voice recorder and are operating under 14 Code of Federal Regulations Parts 91, 121, or 135. The crash-resistant flight recorder system should record cockpit audio and images with a view of the cockpit environment to include as much of the outside view as possible, and parametric data per aircraft and system installation, all as specified in Technical Standard Order C197, “Information Collection and Monitoring Systems.” (A-13-12)
- Require all existing turbine-powered, nonexperimental, nonrestricted-category aircraft that are not equipped with a flight data or cockpit voice recorder and are operating under 14 Code of Federal Regulations Parts 91, 121, or 135 to be retrofitted with a crash-resistant flight recorder system. The crash-resistant flight recorder system should record cockpit audio and images with a view of the cockpit environment to include as much of the outside view as possible, and parametric data per aircraft and system installation, all as specified in Technical Standard Order C197, “Information Collection and Monitoring Systems.” (A-13-13)