History of Flight
On August 5, 2021, about 1050 Alaska daylight time, a De Havilland DHC-2 (Beaver), registration N1249K, was destroyed in an accident near Ketchikan, Alaska. The airline transport pilot and five passengers sustained fatal injuries. The airplane was operated by Southeast Aviation, LLC, under 14 CFR Part 135 as an on-demand sightseeing flight.
The pilot began his duty day about 0600. He was scheduled for two flights into Misty Fjords and a flight to Hyder, Alaska. About 0630, he reviewed weather using FAA cameras, ForeFlight, and Windy, concluding the weather was decent. Before the first flight, they rechecked and confirmed the weather looked good.
A fueler noted the pilot performed a preflight inspection and requested the front tank be filled to capacity (35 gallons) and the center tank to 20 gallons. The pilot departed from Ketchikan Harbor Seaplane Base at 0752 and returned about 0921. Passengers on the first flight reported that in the final minutes, the cloud ceiling was dropping, with clouds and fog, and the pilot was maneuvering to avoid clouds.
Between flights, the owner asked about weather; the pilot said the Misty Fjords weather was “good” but recommended canceling the Hyder trip due to insufficient ceiling there.
Before the second flight, the pilot requested the same fuel load. He departed about 0939. The airplane was equipped with a Spidertracks flight tracking system transmitting at 1-minute intervals. Data showed the airplane flew through Misty Fjord Monument and landed on Big Goat Lake about 1018. It departed the lake at 1027 to return to Ketchikan Harbor. The airplane crossed Behm Canal southwest at 2,914 ft msl, then descended while maneuvering through terrain in reduced visibility, as shown in passenger photographs.
The last two Spidertracks returns indicated the airplane was flying alongside the northern side of a valley. The final transmission was at 1048, at 1,730 ft msl, ground track 261° true. About 1050, the US Coast Guard received a 406-MHz ELT signal from the accident airplane. Search and rescue located the airplane about 1120; USCG personnel reached the site later that afternoon and confirmed no survivors.
Personnel Information
The pilot, age 64, held an airline transport pilot certificate with multiengine land and commercial privileges for single-engine land/sea and multiengine sea. His most recent FAA second-class medical was issued April 6, 2021, with corrective lens limitation. According to operator records, he had 15,552 total flight hours, about 8,000 in the accident make/model. In the 30 days before the accident, he flew 40.7 hours, with 5.3 hours in the 24 hours before.
FAA records showed the pilot was involved in a previous accident on July 9, 2021, in another DHC-2 operated by Southeast Aviation at Coffman Cove, Alaska. In that incident, he did not clear his takeoff run due to being in a hurry, contacted a marine buoy, and the airplane nosed over and sank. The pilot was uninjured; the airplane was substantially damaged (ANC21LA057).
Training records indicated the pilot completed initial DHC-2 training on May 12, 2015, with recurrent training in 2016 and 2017, and requalification on May 8, 2019, and May 12, 2021. His most recent recurrent ground training was May 12, 2021, including a check ride covering basic instruments, partial panel, unusual attitudes, and inadvertent IMC recovery; all grades satisfactory. There was no record of additional training after the July 9 accident. The Director of Operations stated they had discussions and had the pilot “take the airplane out and just fly it.” The pilot did not receive a recent instrument proficiency check and was not required to have one.
Aircraft Information
The accident airplane was a fixed-wing, single-engine DHC-2 (Beaver) on floats, configured for a pilot, copilot, and three rows of seats. It was equipped for VFR flight only, with standard flight instruments (altimeter, attitude indicator, airspeed indicator, vertical speed indicator, heading indicator, turn coordinator, clock, magnetic compass) and King KY196 and Garmin GTR200 radios. It was not equipped with TAWS nor required to be.
Maintenance records showed tachometer reading 2,035.4 hours on the accident day. The most recent annual inspection was July 22, 2021, at 14,977 hours total airframe time and 9,811 engine hours. A 100-hour inspection was due at 2,086.0 tachometer hours per a whiteboard. Weight and balance calculations indicated the airplane was within limits. The FAA registration certificate issued June 10, 2015, expired July 30, 2021.
Meteorological Information
The nearest weather reporting station was Ketchikan International Airport (PAKT), 18 miles southwest. At 1048, reported conditions: wind 150° at 7 kts, 3 statute miles visibility, runway visual range varying between 6,000 ft and >6,000 ft, light rain, mist, few clouds at 700 ft agl, broken ceiling at 1,800 ft agl, overcast at 2,500 ft agl, temperature/dew point 13°C/13°C, altimeter 29.90 inHg. Remarks noted visibility varying between 1 and 3 miles with 0.03 inches precipitation since 0953.
Satellite imagery showed cloudy conditions over the accident site with cloud cover moving north-northeastward between 1030 and 1050. Infrared cloud-top temperatures were consistent with tops about 17,000 ft. AIRMET Sierra, issued at 0422, was valid for mountain obscuration due to clouds and precipitation, occasional ceilings below 1,000 ft, and visibilities below 3 miles. An Area Forecast issued at 0422 forecast scattered at 800 ft, broken at 1,200 ft, overcast at 2,000 ft with tops at 20,000 ft, occasional 3 miles visibility, light rain showers, mist, and isolated IFR conditions.
Other pilots flying that morning noted low clouds in the valley of the accident. Search and rescue pilots reported overcast conditions, obscured mountain tops, and ceilings 600 to 800 ft overcast in some valleys. FAA weather cameras from Misty Fjords (11 miles east-northeast) at 1041 showed cloud cover near mountain tops at 2,000 ft msl with visibility >5 miles, dropping to between 2.5 and 1.0 miles between 1051 and 1101. Cameras at Ketchikan, Minx Island, and Twin Island showed degraded visibility and ceilings as early as 0937. The accident pilot departed in precipitation and visibility less than 2.5 miles based on Ketchikan camera images between 0932 and 0952.
Wreckage and Impact Information
The airplane impacted heavily wooded, mountainous terrain about 18 miles northeast of Ketchikan, 1.46 miles from the last Spidertracks point, at an elevation about 1,750 ft msl. The highest part of the mountain was about 2,000 ft msl. Initial impact was with a tree 435 ft from the main wreckage; the outboard left wing section was at the tree base. The inboard left wing was in a tree along the debris path oriented on a magnetic heading of 242°. All major components were in the vicinity of the main wreckage.
The fuselage came to rest on its left side, impact crushed. The right wing remained attached; outboard right wing was impact separated but attached by a cable. The empennage remained attached and impact damaged; rudder and vertical stabilizer attached but tip separated. Left horizontal stabilizer and elevator were impact separated; right horizontal stabilizer attached with leading edge damage; right elevator separated. Floats separated; forward left float impact damaged. Flight control continuity was confirmed from cockpit to all surfaces.
The engine exhibited impact damage but remained attached; several mounts separated. Oil sump damaged and breached. Fuel was noted in the line from firewall to engine. All cylinders secured; crankshaft rotated smoothly with continuity established. Cylinder borescope examination revealed no anomalies. All three propeller blades remained attached to the hub; spinner removed and impact damaged. Blades showed bending and chordwise scratching. No preimpact mechanical malfunctions or failures were found.
Additional Information
A voluntary Ketchikan Commercial Operators Letter of Agreement (LOA) described standard Misty Fjords tour routes, altitudes, reporting points, and best practices. Southeast Aviation, LLC was a signatory. The accident flight did not follow the standard route or recommended altitudes. The FAA principal operations inspector noted the LOA is not regulatory and stated it “is not working,” suggesting moving toward an SFAR similar to Hawaii and Grand Canyon. The principal maintenance inspector recounted an instance where an air tour operator flew contrary to the LOA; the operator stated it was only voluntary.
The airplane was not equipped with any cockpit voice or flight data recorder, nor required to be.
Medical and pathological information: The pilot reported no active conditions or medication on his most recent medical application. Autopsy attributed cause of death to multiple blunt force injuries. Toxicology was negative for carbon monoxide, ethanol, glucose, and tested-for drugs.
Southeast Aviation, LLC held a Part 135 on-demand certificate, authorized for DHC-2-MK1 operations in day VFR only. The company had an FAA-accepted General Operations Manual (GOM). The minimum visibility requirements per 14 CFR 135.205 required at least 2 miles visibility when ceiling less than 1,000 ft; 14 CFR 135.203 prohibited operating during the day below 500 ft above the surface or 500 ft horizontally from obstacles. The company did not have more conservative minimums. The GOM stated pilots were responsible for seeing and avoiding traffic, terrain, and obstacles. Approved weather sources included NWS, FAA-approved sources, etc. The accident pilot accessed weather from ForeFlight, FAA cameras, and Windy, which were approved.
The company was required to perform flight locating per 14 CFR 135.79. The owner acted as flight follower and monitored the flight via Spidertracks. The company had no SMS and did not conduct formal risk assessments before flights. The airplane had no flight data monitoring, and the company was not required to have such a program.
Training: The company had an FAA-approved training program. The director of operations stated pilots were trained to respond to inadvertent IMC by turning 180° and making a possible descent. The company’s training manual stated that all pilots would receive cue-based training annually. The director indicated that in the past, pilots received cue-based training via CD and computer, but the CD had been lost, and the simulator was “in parts over at the airport.” However, the accident pilot’s training record showed a signed recurrent training certificate on May 12, 2021, that included “cue-based evaluation.”