25 Jun 2015: DEHAVILLAND DHC-3 (N270PA) — Promech Air, Inc. — Ketchikan, AK

9 fatalitiesKetchikan, AK, United States

A sightseeing flight involving nine people ended in a fatal crash into mountainous terrain in Alaska.

What happened

On June 25, 2015, at approximately 1215 Alaska daylight time, a turbine-powered, float-equipped de Havilland DHC-3 (Otter) crashed into tree-covered mountains about 24 miles east-northeast of Ketchikan, Alaska. The aircraft, registration N270PA, was operating as an on-demand sightseeing flight under 14 CFR Part 135.

The flight departed Rudyerd Bay at approximately 1207, traveling toward the Ketchikan Harbor Seaplane Base. At the time of the accident, the area was experiencing marginal visual flight rules conditions, with a wind of 130 degrees at 15 knots and visibility of 6 statute miles. The impact resulted in 9 fatal injuries, involving the commercial pilot and eight passengers. The aircraft was destroyed in the accident.

Findings

Investigation into the accident identified that the pilot made the decision to continue visual flight into an area characterized by instrument meteorological conditions. This action led to geographic disorientation and the subsequent controlled flight into terrain. Additionally, the operator's company culture was found to have tacitly endorsed flying in hazardous weather and failed to manage risks stemming from competitive pressures in the Ketchikan air tour industry. The operator also lacked a formal safety program and maintained inadequate operational control regarding flight releases.

Probable cause

The pilot's decision to continue visual flight into instrument meteorological conditions, causing geographic disorientation and controlled flight into terrain, combined with the operator's company culture that endorsed flying in hazardous weather, a lack of a formal safety program, and inadequate operational control of flight releases.

Contributing factors

PilotOperatorDecision related to conditionDesign