9 fatalities

2015-06-25: De Havilland DHC-3 Otter (N270PA) — Promech Air — Ella Lake, United States of America

Ella Lake, United States of AmericaFlight

On June 25, 2015, a De Havilland DHC-3 Otter (registration N270PA) operated by Promech Air was involved in an aviation accident near Ella Lake, United States of America in flight. 9 people were killed. Investigators recorded the probable cause as: The accident was caused by the pilot's decision to fly visually into instrument meteorological conditions, compounded by a company culture that failed to manage risks associated with schedule pressure and hazardous weather. This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A); 4 related events involving the same aircraft type or operator are linked below.

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781192973Data APIEditorial standards

A sightseeing flight operated by Promech Air, Inc. crashed into mountainous terrain in the Misty Fjords National Monument Wilderness, resulting in nine fatalities.

What happened

On a scheduled sightseeing excursion departing from Rudyerd Bay, an aircraft operated by Promech Air, Inc. struck heavily forested mountains approximately 24 miles east-northeast of Ketchikan, Alaska. The flight was part of a series of four departures intended to transport cruise ship passengers back to the Ketchikan Harbor Seaplane Base. While the pilot had selected the "short route"—a path primarily over land—the aircraft encountered deteriorating weather characterized by rain, mist, and overcast clouds that restricted visibility.

During the flight, the pilot deviated from the established flight path by turning west prematurely after passing only one of two mountains on the intended route. This deviation placed the aircraft type on a direct path with a 1,900-foot peak. Evidence indicates that just two seconds before impact, the aircraft performed a rapid pitch-up maneuver, suggesting an attempt to avoid the terrain after the pilot realized the collision course. The impact occurred at an elevation of approximately 1,600 feet mean sea level, resulting in the destruction of the plane and 9 fatalities, including the pilot and eight passengers.

Findings

Investigations revealed that the pilot chose to continue visual flight into conditions that had transitioned into instrument meteorological conditions. The pilot's decision-making was influenced by several factors, including schedule pressure to meet cruise ship deadlines and an attempt to follow the lead of other pilots in the area. Furthermore, the company's operational culture lacked sufficient oversight, as there was no formal agreement between the pilot and flight scheduler regarding the safety of the mission. The investigation also noted that the operator's organizational culture tacitly permitted flying in hazardous weather conditions and lacked a robust safety program or adequate operational controls for flight releases.

Probable cause

The accident was caused by the pilot's decision to fly visually into instrument meteorological conditions, compounded by a company culture that failed to manage risks associated with schedule pressure and hazardous weather.