History of Flight
On July 10, 2018, about 0835 Alaska daylight time, a float-equipped de Havilland DHC-3T Otter, registration N3952B, impacted rocky, mountainous terrain about 9 miles east of Hydaburg, Alaska. The airplane was operated by Taquan Air as a Title 14 Code of Federal Regulations Part 135 on-demand commercial flight. Marginal visual meteorological conditions prevailed for the visual flight rules flight, and company flight following procedures were in effect. The flight departed Steamboat Bay about 0747, destined for Ketchikan, Alaska, carrying 11 occupants: the airline transport pilot was uninjured, four passengers sustained minor injuries, and six passengers sustained serious injuries.
The flight was transporting guests from the Steamboat Bay Fishing Club on Noyes Island back to Ketchikan. The area between Noyes Island and Ketchikan consists of remote inland fjords, coastal waterways, and steep mountainous terrain. GPS data from the Chelton Integrated Display Unit showed the flight proceeded easterly towards Klawock and the northwest edge of Klawock Lake, then made a 270° turn and continued southerly along the west coast of Prince of Wales Island towards Waterfall Seaplane Base, then turned easterly towards Hydaburg and an area known as Sulzer Portage.
According to the pilot, while in level cruise at about 1,100 ft mean sea level, visibility decreased rapidly in heavy rain and clouds as the flight entered Sulzer Portage. He initiated a climbing right turn intending to return to VFR conditions. Before completing the 180° turn, he saw what he believed to be a body of water and became momentarily disoriented, leveling the wings. Shortly thereafter, he realized the airplane was approaching snow-covered mountainous terrain and applied full power with a steep climb. Airspeed decayed, and the airplane collided with the mountain. During initial impact, the floats partially separated from the fuselage. The wreckage came to rest in the Jumbo Mountain area. The pilot reported no airplane issues, stating the airplane was running great.
A passenger in the right front seat observed the flight proceed to Klawock then make what he thought was a 180° turn. He noted the flight made numerous course deviations maneuvering around weather, and at times all forward visibility was lost as they briefly flew in and out of clouds. He became uncomfortable, thinking it prudent to land on the water. Shortly thereafter, he saw a large mountain directly ahead and believed there must be a pass; then the airplane entered a cloud, the pilot added power and pitched up, and the airplane impacted the mountain.
A second passenger seated toward the back stated the weather at Steamboat Bay departure was rain and low clouds. During the flight, he could occasionally see land and water but sometimes could not, and noted serious fog all around. After passing Waterfall Resort, he became concerned they were headed the wrong direction and texted the front-seat passenger to ask the pilot to land and wait for weather improvement. He did not see the mountain until they were right on it and observed the pilot add power just before impact.
At 0843, the United States Coast Guard Sector Juneau received a report from Alaska State Troopers that a floatplane had crashed near Sulzer Portage. Two Coast Guard helicopters and five Alaska State Trooper helicopters were dispatched; a staging area was established near the accident site. One helicopter pilot reported inability to search upper levels due to low cloud ceiling and poor visibility. A "First Alert" from the airplane's emergency locator transmitter was received at 0911. A 911 dispatcher in Ketchikan communicated with a passenger via cell phone, who provided GPS position and elevation from her iPhone. At 1047, Coast Guard helicopters arrived; one obtained a weak direction finding bearing from the ELT. Using the bearing and the survivor's description, search assets were directed near the site, allowing passengers to hear the helicopters. Two-way radio communication was established between passengers and Coast Guard using the airplane's radio. The accident site was located at 1156. At 1308, all 11 survivors were hoisted into the Coast Guard helicopter and transferred to the staging area for transport to Ketchikan.
Personnel Information
The pilot held an airline transport pilot certificate with airplane single-engine land and sea, multi-engine land and sea, and instrument ratings. A second-class medical certificate was issued on December 6, 2017, with a limitation requiring corrective lenses. According to operator training records, the pilot was hired with 26,618 total flight hours, including 2,700 hours in Alaska. At the time of the accident, the pilot reported about 306 hours in the accident airplane make and model. His most recent airman competency check was completed on May 13, 2018. In June 2018, the pilot was on duty for 25 days and flew about 84 hours, with 5 days off. In July 2018, he was on duty for 7 days, including the accident day, and flew about 28 hours, with 3 days off.
Aircraft Information
The de Havilland DHC-3 Otter is a single-engine, propeller-driven, single-pilot, high-wing, short-takeoff-and-landing airplane originally designed in the early 1950s. The original airplane used a reciprocating radial engine but could be converted to turbine power via supplemental type certificate (STC). The accident airplane was powered by a Pratt & Whitney Canada PT6A turboprop engine per Vazar, Inc. STC SA3777NM and equipped with International Aeroproducts Model 8100 floats per Anew Sioux Enterprises, Ltd. STC SQ01825NY. The type certificate is owned by Viking Air Limited.
The airplane was equipped with two Chelton Flight Systems FlightLogic EFIS Integrated Display Units configured as primary flight displays and multi-function displays. The system included a terrain awareness and warning system (TAWS) that provided color-coded terrain warnings and, when enabled, aural alerts. The TAWS functionality was set to Class B specifications as required by 14 CFR 135.154. The airplane was authorized to cruise as low as 500 ft above ground level per 14 CFR 135.203(a)(1), below the Class B TAWS design alerting threshold, so normal operations could trigger TAWS alerts. A TAWS inhibit switch, a toggle type, could manually inhibit the alerting function; it was found in the "inhibit" mode after the accident.
Meteorological Information
The closest weather reporting facility was Hydaburg Seaplane Base, about 9 miles west of the accident site. At 0847, a METAR reported wind from 110° at 13 knots, 5 statute miles visibility in light rain and mist, few clouds at 900 ft, overcast at 1,700 ft, temperature 57°F, dew point 55°F, altimeter 30.16 inHg. An area forecast valid at the accident time included scattered clouds at 2,500 ft msl, overcast at 5,000 ft msl with tops to 14,000 ft, isolated broken clouds at 2,500 ft with light rain. No significant turbulence was expected. Moderate in-cloud icing was forecast between 12,000 ft and FL190, freezing level at 9,000 ft. AIRMET SIERRA for "mountains obscured in clouds/precipitation" was active at the accident time; conditions were expected to deteriorate.
Wreckage and Impact Information
The accident site was on a rock face on the east side of Jumbo Mountain at about 2,557 ft msl. All major components were present. The cockpit and fuselage were largely intact but sustained impact damage. The power lever and propeller lever were full forward; the condition lever was in idle cutoff. Cockpit seats remained attached with lap belts and shoulder harnesses; fuselage seats had lap belts only. The right wing remained attached with leading edge impact damage about ¾ span outboard. The left wing remained attached with leading edge impact damage about midspan. Both horizontal stabilizers, vertical stabilizer, rudder, and servo tabs remained attached and relatively undamaged; elevators remained attached with impact damage. The stabilizer jackscrew remained attached with no excessive inner movement. The engine remained attached; control continuity was established. The three-blade Hartzell propeller separated at the reduction gearbox; all blades remained attached with broken tips, torsional twisting, chordwise scratching, and leading-edge gouging. All flight control surfaces remained attached, and control continuity was verified. The pilot reported no mechanical malfunctions or anomalies; examination revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.
Organizational and Management Information
Taquan Air was a Part 135 air carrier holding on-demand and commuter operations specifications, authorized to conduct business as "Venture Capital, LLC" or "Taquan Air." The company operated 15 airplanes, including 3 DHC-3T Turbine Otters, and employed about 25 pilots, mostly seasonal. The Director of Operations (DO) was hired at Taquan in January 2016; in October 2017, he became chief pilot for Grant Aviation in Anchorage, then DO at Grant Aviation in April 2018, but continued as DO at Taquan. According to company personnel, the DO visited Taquan's Ketchikan base about once a month and was available by phone. The company president stated the chief pilot had taken over "officer of the deck" and they were using the DO primarily for recordkeeping.
The chief pilot was hired at Taquan in September 2014, previously a line pilot and instructor at Promech Air. He had about 16,000 total flight hours, 5,000 in Alaska. Due to the DO's absence, he assumed many of the DO's responsibilities. The Taquan General Operations Manual did not explain procedures for flight initiation or conduct, nor list anyone by name for operational control except the DO, chief pilot, and president. The DO, chief pilot, flight coordinator, safety officer, and check airmen stated operational control could be and was routinely delegated to senior pilots. The GOM stated the DO delegates operational control to the flight coordinator on duty, but the accident flight coordinator stated she had no operational control, only flight following, though she could cancel a flight for weather or profitability. The president described operational control as having someone to assist with launch decisions.
Taquan's manuals did not include a risk assessment process; a separate Medallion Operational Risk Management Implementation Manual described a risk assessment form to be filled out and signed by the flight coordinator and pilot-in-command. Company pilots described the form as highlighting potential risk areas. One pilot viewed it as "just a piece of paper." The form was typically completed by flight coordinators, and the DO stated pilots completed the "Manpower" section. Though dispatch and management believed pilots provided feedback, line pilots stated none could recall providing feedback.
CFIT training, policies, and procedures were not in the FAA-accepted GOM or approved training program. Taquan had a CFIT Avoidance Training Manual developed with the Medallion Foundation, but no regulatory requirement for compliance. Section IV provided guidance for inadvertent flight into IMC. Multiple pilots stated the company CFIT escape maneuver was to complete a 180° turn, enable TAWS, descend to 300 ft, and set up for a glassy water landing. The accident pilot said the procedure continued below 300 ft until reaching water or breaking out of clouds. All pilots interviewed stated the TAWS inhibit switch remained in inhibit unless a CFIT escape maneuver was being accomplished, but the check airman who administered the accident pilot's competency check stated "No, it never gets moved."
Additional Information
The Juneau Flight Standards District Office oversaw 102 commercial certificates; the office manager stated there were 12 inspectors, with two principal operations inspectors, but were allocated five POIs. The POI for Taquan reported a "heavy" workload and inability to complete all oversight tasks; he was responsible for 24 Part 135, seven Part 133, and two Part 137 certificates. Numerous interviews with FAA personnel revealed the FAA was aware the Taquan DO also served as a management official for Grant Aviation, but believed this was not contrary to regulations or FAA Order 8900.1. Little coordination existed between the POIs for the two certificates.