Wilfred Ryan, president of Arctic Transportation Services, did what few others in the Alaska aviation world would have done. Ryan made a presentation at the recent Alaska Air Carriers Association convention - in front of officials from the Federal Aviation Administration, insurance brokers, attorneys and his competition - about a recent crash of one of his company's aircraft.

Ryan told how the company culture had allowed for errors that led to two aircraft crashes inside of four months.

"This was not only embarrassing, but it had an immediate impact on business," said Ryan. "Suddenly we find ourselves without two of our workhorse aircraft."

Ryan offered the presentation, called "Using adversity for positive results," on March 6, at the Captain Cook Hotel.

Fortunately, both crashes resulted in only slight injuries to the flight crews, though one essentially destroyed a $1.7 million cargo aircraft in Toksook Bay on Nov.1, and the other landed short of the runway on Valentines Day Feb. 14 at Kotzebue.

ATS is an all-cargo operation that launches flights from rural hubs to deliver building materials, fuel oil and supplies to Alaska villages. The company grew out of a small operation started by the Ryan family from Unalakleet in the 1950s.

Ryan's presentation included graphics from Google Earth that showed the flight track of a fateful flight that eventually went down in the tundra. The plane, on final approach went down in a right turn while making an approach to land at the Nelson Island village on Etolin Strait.

Ryan relayed the errors of the flight crew, who had experienced an in-flight emergency that eventually lead to the downing of the aircraft.

"The co-pilot was flying the turbo-twin-engine aircraft, adjusted the propeller pitch controls. One engine did not develop the same power as the other, the aircraft then started a right turn at minimum operation speed for one engine," Ryan said. "The pilot took over and failed to keep the aircraft flying above the minimum airspeed on one engine. The aircraft continued in a turn, stalled and crashed into the tundra."

The explanation for the aircraft going down sounded complete, but Ryan added further detail. Points were determined during a process called a "taproot drilldown."

The taproot process is a two-day, 16-hour class that has been used by the Medallion Foundation and promoted by the FAA for the past five years.

"This is a systematic and repeatable process that is used to get to the real cause of an accident," said Dennis Ward, executive director of the nonprofit Medallion Foundation. "It is a written step-by-step repeatable process that will give five different people working the same facts the same answer … with consistency."

Ward, who was one of two Medallion Foundation taproot-trained evaluators, worked with Ryan to determine the cause of the accident.

"The lever for the propeller engine and pitch control had come detached from the control quadrant," said Ryan. "While trying to determine how to solve the engine lever problem, the pilots failed to keep up the air speed and the aircraft stalled. "

Ward said Ryan's presentation was a huge step in raising the bar for aviation safety in Alaska.

"This also could very well save his company, as far as working with FAA is concerned," said Ward.

Ryan further explained that as a result of the taproot process, evaluators had determined that a culture change was necessary to both the pilot group and the mechanical side of ATS's procedures.

"We determined that we need to better train our crews on emergency procedures, and we have also implemented a new 50-hour check of the linkage and control modules on the Casa aircraft," said Ryan.

Before the taproot analysis, ATS mechanics had been using the routine 100-hour maintenance check on these control parts.

"This shows that the company is being more proactive about safety, making an effort so that it might not happen to them again," said Ward. "What Wilfred did was raise the safety bar higher. This will set a new standard, and is a first for the air carrier group."

Ryan reflected on the aircraft accidents and added the effects to ATS's business.

"Everything came to a halt at ATS, not only to determine the cause of this, but it affected our deliver because of the loss of lift, but it also lessons our clients confidence in the company, attracts legal problems and has an adverse affect on potential investors," said Ryan. "We want this to stop, and we don't ever want anymore planes or our people affected by a poor safety culture."

Rob Stapleton can be reached at

rob.stapleton@alaskajournal.com.