DEHAVILLAND DHC-3 near Ketchikan, AK — 2015-06-25
- Date
- 2015-06-25
- Location
- Ketchikan, AK, USA
- Aircraft
- DEHAVILLAND DHC-3
- Registration
- N270PA
- Category
- Airplane
- Highest injury
- Fatal
- Fatalities
- 9
Probable cause
(1) the pilot's decision to continue visual flight into an area of instrument meteorological conditions, which resulted in his geographic disorientation and controlled flight into terrain; and (2) Promech's company culture, which tacitly endorsed flying in hazardous weather and failed to manage the risks associated with the competitive pressures affecting Ketchikan-area air tour operators; its lack of a formal safety program; and its inadequate operational control of flight releases.
NTSB narrative
The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-17/02. On June 25, 2015, about 1215 Alaska daylight time, a single-engine, turbine-powered, float-equipped de Havilland DHC-3 (Otter) airplane, N270PA, collided with mountainous, tree-covered terrain about 24 miles east-northeast of Ketchikan, Alaska. The commercial pilot and eight passengers sustained fatal injuries, and the airplane was destroyed. The airplane was owned by Pantechnicon Aviation, of Minden, Nevada, and operated by Promech Air, Inc., of Ketchikan. The flight was conducted under the provisions of 14 Code of Federal Regulations Part 135 as an on-demand sightseeing flight; a company visual flight rules flight plan (by which the company performed its own flight-following) was in effect. Marginal visual flight rules conditions were reported in the area at the time of the accident. The flight departed about 1207 from Rudyerd Bay about 44 miles east-northeast of Ketchikan and was en route to the operator's base at the Ketchikan Harbor Seaplane Base, Ketchikan.
NTSB coding
Evidence available
- Video
- FDR / data
- ADS-B / radar
- Photos
- 59 docket documents
Docket documentsshowing 50 of 59
- Cockpit Displays – Recorded Flight Data - Attachment 1 (IDU 36519 AC.DAT File)fdr
- Cockpit Displays – Recorded Flight Data - Attachment 2 (IDU 34790 AC.DAT File)fdr
- Cockpit Displays – Recorded Flight Data - Attachment 3 (IDU 36519 SETTINGS.DAT File)fdr
- Cockpit Displays – Recorded Flight Data - Attachment 4 (IDU 34790 AC.DAT File)fdr
- Cockpit Displays – Recorded Flight Data - Attachment 5 (Tabular Data)fdr
- Cockpit Displays – Recorded Flight Data - Specialist's Factual Reportfdr
- Cockpit Displays – Recorded Flight Data Replay - Specialist's Study Reportfdr
- Cockpit Displays – Recorded Flight Data Replay - Specialist's Study Report - Attachment 1 (Quicktime Movie)fdr
- Cockpit Displays – Recorded Flight Data – Addendum 1fdr
- Cockpit Displays – Recorded Flight Data – Addendum 1 - Attachment 1 (Tabular Data)fdr
- Evidence Control Formform
- Evidence Control Form - Returnform
- Operations & Human Performance Factual - Attachment 01 - Interview Summariesform
- Operations & Human Performance Factual - Attachment 06 - Chelton Animation Replayform
- Operations & Human Performance Factual - Attachment 07 - Pilot Training Recordsform
- Operations & Human Performance Factual - Attachment 09 - Pilot's Flight and Duty Logform
- Operations & Human Performance Factual - Attachment 10 - Scheduler's Flight Logform
- Operations & Human Performance Factual - Attachment 11 - Promech General Operations Manual Excerptsform
- Operations & Human Performance Factual - Attachment 12 - Chelton Users Manual Excerptsform
- Operations & Human Performance Factual - Attachment 15 - Safety Reporting Forms from GOMform
- Operations & Human Performance Factual - Attachment 16 - Promech CFIT Manualform
- Operations & Human Performance Factual - Attachment 17 - Medallion Foundation CFIT Training Sign-In Logform
- Operations & Human Performance Factual - Attachment 19 - Promech Operations Specifications A008form
- Operations & Human Performance Factual - Attachment 20 - Taquan Air Risk Assessment Form and Cue Based Training Aidform
- Operations & Human Performance Factual - Attachment 21 - FAA Capstone Program Phase II Baseline Reportform
- Operations & Human Performance Factual - Attachment 22 - FAA Capstone Program Phase II Implementation and Impact Assessmentform
- Operations & Human Performance Factual - Attachment 23 - Initial Pilot Statements from Promechform
- Operations and Human Performance Factual Reportform
- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1form
- Interview Summaries - Holland America Line and Carnival Corporationinterview
- Statement of Party Representatives to NTSB Investigationinterview
- Statement of Party Representatives to NTSB Investigation - Hassellinterview
- NTSB AAR-17/02other
- Terrain Awareness Warning System (TAWS) Comparison Class B and Class Cother
- Terrain Awareness Warning System (TAWS) Comparison Class B and Class C - Attachment 1 (Animation) - Shelf Itemother
- Terrain Awareness Warning System (TAWS) Comparison Class B and Class C - Attachment 2 (Tabular Data)other
- Operations & Human Performance Factual - Attachment 02 - Passenger Photos Taken from Preceding Airplanephotos
- Operations & Human Performance Factual - Attachment 03 - Photos Taken by a Passenger on the Pilot's 0800 Tourphotos
- Operations & Human Performance Factual - Attachment 04 - Photos Taken by a Weather Camera Installation in Behm Canalphotos
- Operations & Human Performance Factual - Attachment 08 - Photos of Pilot's Recent Logbook Entriesphotos
- Operations & Human Performance Factual - Attachment 13 - Photo of TAWS Inhibit Switch Positionphotos
- Operations & Human Performance Factual - Attachment 14 - Investigator Photos of Terrain Surroundingphotos
- Operations & Human Performance Factual - Attachment 18 - Photos of Medallion Foundation Approved Training Device (ATD)photos
- Photophotos
- Photosphotos
- Survival Factors 6 - Attachment 1 - Photographs Exemplar Airplanephotos
- Operations & Human Performance Factual - Attachment 05 - ADS-B Traffic near Ketchikan on the Morning of the Accidentradar
- Airworthiness Group Chairman's Factual Reportreport
- Airworthiness Group Chairman's Factual Report - Appendix A - Figuresreport
- Airworthiness Group Chairman's Factual Report - Attachment 1 - Maintenance Recordsreport
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