6 fatalities

2021-08-05: De Havilland DHC-2 Beaver (N1249K) — Southeast Aviation (AK) — Ketchikan, United States of America

Ketchikan, United States of AmericaFlight

On August 5, 2021, a De Havilland DHC-2 Beaver (registration N1249K) operated by Southeast Aviation (AK) was involved in an aviation accident near Ketchikan, United States of America in flight. 6 people were killed. Investigators recorded the probable cause as: The pilot’s decision to continue visual flight rules (VFR) flight into instrument meteorological conditions (IMC), which resulted in controlled flight into terrain. This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A); 1 related events involving the same aircraft type or operator are linked below.

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781189969Data APIEditorial standards

A sightseeing flight on its return leg impacted mountainous terrain at 1,750 ft in Misty Fjords National Monument. The pilot encountered instrument meteorological conditions after not obtaining updated weather. No pre-impact failures were found; the propeller was under power. The operator lacked safety management protocols and the FAA's reliance on voluntary compliance was cited.

Background

The accident flight was the pilot's second passenger sightseeing flight of the day, overflying remote inland fjords, coastal waterways, and mountainous, tree-covered terrain in the Misty Fjords National Monument.

Flight Events

Limited radar coverage and 1-minute interval flight tracking data showed the airplane was on the return leg, flying on the right side of a valley during the final minutes. The airplane impacted mountainous terrain at 1,750 ft mean sea level, about 250 ft below the summit. Wreckage orientation and distribution indicated a left-wing-low attitude upon impacting a tree, likely as the pilot attempted to maneuver away from terrain.

Weather Conditions

Weather analysis revealed a conditionally unstable environment below 6,000 ft with rain bands. Satellite imagery showed one band moving northeast across the accident site at the time of the accident. FAA weather cameras and local observations indicated lower visibility and mountain obscuration progressing northward. Photos from passenger cell phones and FAA cameras confirmed the flight encountered mountain obscuration, rain, reduced visibility, and cloud ceilings, resulting in instrument meteorological conditions (IMC) before impact.

The pilot reviewed weather before the first flight but did not obtain updated conditions before the accident flight. After landing from the first flight in lowering visibility and precipitation, the pilot departed into precipitation, based on passenger photos, indicating knowledge of the weather along the route.

Aircraft and Wreckage Examination

Examination found no pre-impact failures or malfunctions that would have precluded normal operation. The propeller showed evidence of rotation and power at impact, consistent with controlled flight into terrain.

Operator Policies and Training

The operator had policies for inadvertent IMC encounters, but the pilot's training records indicated sign-off for cue-based training that was never completed. Cue-based training is intended to improve weather assessment and decision-making. The operator's lack of safety management protocols resulted in the pilot not receiving required training, allowed continued operations with minimal remedial training after a previous accident, and permitted the accident airplane to operate without a valid FAA registration.

Letter of Agreement

The operator was signatory to a voluntary letter of agreement (LOA) for safety in the Misty Fjords National Monument area, but the investigation found multiple instances where LOA policies were ignored, including the accident flight. The accident flight did not follow the standard route or recommended altitudes. FAA inspectors reported operators disregarded the LOA because it was voluntary, and the FAA's reliance on voluntary compliance failed to improve safety in the region.

Probable cause

The pilot’s decision to continue visual flight rules (VFR) flight into instrument meteorological conditions (IMC), which resulted in controlled flight into terrain. Contributing to the accident was the FAA’s reliance on voluntary compliance with the Ketchikan Operator’s Letter of Agreement.