National Transportation Safety Board
Aviation Accident Final Report

 

 

Location:

Ketchikan, AK

Accident Number:

ANC15MA041

Date & Time:

06/25/2015, 1215 AKD

Registration:

N270PA

Aircraft:

DEHAVILLAND DHC-3

Aircraft Damage:

Substantial

Defining Event:

Controlled flight into terr/obj (CFIT)

Injuries:

9 Fatal

Flight Conducted Under:

Part 135: Air Taxi & Commuter - Non-scheduled - Sightseeing

Analysis

 

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.

 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
 

(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.

 

Findings

Personnel issues

Decision making/judgment - Pilot (Cause)

Geographic disorient (lost) - Pilot (Cause)

Environmental issues

Ceiling/visibility/precip - Decision related to condition (Cause)

Organizational issues

Safety - Operator (Cause)

Pressures/demands - Operator (Cause)

Standard operating practices - Operator (Cause)

Oversight of operation - Operator (Cause)

Factual Information

 

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.

 

 

History of Flight

Enroute-cruise

Controlled flight into terr/obj (CFIT) (Defining event)

 

 

Pilot Information

Certificate:

Commercial

Age:

64

Airplane Rating(s):

Single-engine Land; Single-engine Sea

Seat Occupied:

Left

Other Aircraft Rating(s):

None

Restraint Used:

3-point

Instrument Rating(s):

Airplane

Second Pilot Present:

No

Instructor Rating(s):

None

Toxicology Performed:

Yes

Medical Certification:

Class 2 Without Waivers/Limitations

Last FAA Medical Exam:

03/23/2015

Occupational Pilot:

Yes

Last Flight Review or Equivalent:

 

Flight Time:

3912 hours (Total, all aircraft), 37 hours (Total, this make and model), 3912 hours (Pilot In Command, all aircraft), 153 hours (Last 90 days, all aircraft), 91 hours (Last 30 days, all aircraft), 3 hours (Last 24 hours, all aircraft)

 

 

Aircraft and Owner/Operator Information

Aircraft Make:

DEHAVILLAND

Registration:

N270PA

Model/Series:

DHC-3

Aircraft Category:

Airplane

Year of Manufacture:

1958

Amateur Built:

No

Airworthiness Certificate:

Normal

Serial Number:

270

Landing Gear Type:

Float

Seats:

 

Date/Type of Last Inspection:

06/10/2015, AAIP

Certified Max Gross Wt.:

 

Time Since Last Inspection:

 

Engines:

1 Turbo Prop

Airframe Total Time:

24439.5 Hours at time of accident

Engine Manufacturer:

 

ELT:

C91A installed, activated, aided in locating accident

Engine Model/Series:

 

Registered Owner:

PANTECHNICON AVIATION LTD

Rated Power:

 

Operator:

Promech Air, Inc.

Operating Certificate(s) Held:

On-demand Air Taxi (135)

Operator Does Business As:

 

Operator Designator Code:

Q5IA

 

Meteorological Information and Flight Plan

Conditions at Accident Site:

Visual Conditions

Condition of Light:

Day

Observation Facility, Elevation:

KTN, 92 ft msl

Distance from Accident Site:

24 Nautical Miles

Observation Time:

1953 UTC

Direction from Accident Site:

71°

Lowest Cloud Condition:

Few / 800 ft agl

Visibility

6 Miles

Lowest Ceiling:

Broken / 1200 ft agl

Visibility (RVR):

 

Wind Speed/Gusts:

15 knots / 23 knots

Turbulence Type Forecast/Actual:

/

Wind Direction:

130°

Turbulence Severity Forecast/Actual:

/

Altimeter Setting:

29.91 inches Hg

Temperature/Dew Point:

16°C / 14°C

Precipitation and Obscuration:

Moderate - Mist; Moderate - Rain

Departure Point:

Ketchikan, AK

Type of Flight Plan Filed:

Company VFR

Destination:

Ketchikan, AK

Type of Clearance:

None

Departure Time:

1200 AKD

Type of Airspace:

Class G

 

 

Wreckage and Impact Information

Crew Injuries:

1 Fatal

Aircraft Damage:

Substantial

Passenger Injuries:

8 Fatal

Aircraft Fire:

None

Ground Injuries:

N/A

Aircraft Explosion:

None

Total Injuries:

9 Fatal

Latitude, Longitude:

55.456389, -131.146111 (est)

 


 


Administrative Information

Investigator In Charge (IIC):

David B Banning

Report Date:

05/17/2017

Additional Participating Persons:

Patrick Hempen; Federal Aviation Administration; Washington, DC

Karen Reich; Holland America Group; CA

Les Doud; Hartzell Propeller

Marcus Sessoms; Promech Air; FL

Clark Hassell; Promech Air; Ketchikan, AK

Robert DuRall; Genesys Aerosystems; TX

Bob Grace; Promech Air; Ketchikan, AK

Publish Date:

11/15/2017

Note:

The NTSB traveled to the scene of this accident.

Investigation Docket:

http://dms.ntsb.gov/pubdms/search/dockList.cfm?mKey=91435