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NTSB Publishes Preliminary Report for Investigation of Ketchikan Mid-Air Collision, Calls for Greater Safety Measures for For-Hire Flights

Posted, Edited By MARY KAUFFMAN

May 24, 2019
Friday PM

(SitNews) Ketchikan, Alaska - The National Transportation Safety Board  on Wednesday released the preliminary report for its investigation of the May 13, 2019, fatal mid-air collision near Ketchikan, one in a string of recent accidents involving for-hire aircraft.

The collision between a float-equipped Mountain Air de Havilland DHC-2 Beaver and a float-equipped Taquan de Havilland DHC-3 Turbine Otter occurred about seven miles northeast of Ketchikan. The Mountain Air DHC-2 commercial pilot and four passengers sustained fatal injuries and the Taquan DHC-3 certificated airline transport pilot sustained minor injuries, nine passengers sustained serious injuries and one passenger sustained fatal injuries. 

Both aircraft involved in the mid-air collision were operating under Part 135 of FAA regulations, which govern the operation of business and charter flights. So was the airplane that crashed Monday, May 20th in Metlakatla, Alaska and the helicopter that crashed in Hawaii April 29.

jpg NTSB Publishes Preliminary Report for Investigation of Ketchikan Mid-Air Collision

Ketchikan, Alaska (May 15, 2019) - NTSB investigator Clint Crookshanks and Member Jennifer Homendy near the site of some of the wreckage of the DHC-2 Beaver that was involved in a midair collision near Ketchikan, Alaska, on May 13, 2019.
NTSB Photo by Peter Knudson

“While these tragic accidents are still under investigation, and no findings or causes have been determined, each crash underscores the urgency of improving the safety of charter flights by implementing existing NTSB safety recommendations,” said Robert L. Sumwalt, Chairman of the National Transportation Safety Board. “The need for those improvements is why the NTSB put Part 135 aircraft flight operations on the 2019 – 2020 Most Wanted List of transportation safety improvements.”

The NTSB’s safety recommendations call on Part 135 operators to implement safety management systems, record and analyze flight data, and ensure pilots receive controlled-flight-into-terrain avoidance training. Major passenger airlines, which operate under Part 121, have adopted these measures and have seen a great improvement in safety.

“A customer who pays for a ticket should trust that the operator is using the industry’s best practices when it comes to safety,’’ Sumwalt said. “And it shouldn’t matter if the operator has one airplane or 100. Travelers should have an equivalent level of safety regardless of the nature of the flight for which they paid.” 

The preliminary report on the investigation of the May 13 mid-air collision does not discuss probable cause. The report contains information gathered thus far in the investigation.

Determination of probable cause and the issuance of any safety recommendations comes at the end of an investigation. Investigations involving fatalities and other major NTSB investigations currently take between 12 and 24 months to complete. 

Quoting the preliminary report:

On Monday, May 13, 2019, about 12:21 PM Alaska daylight time, a float-equipped De Havilland DHC-2 (Beaver) airplane, N952DB, and a float-equipped De Havilland DHC-3 (Turbine Otter) airplane, N959PA, collided in midair PM, about 7 miles northeast of Ketchikan, Alaska.

The Taquan DHC-3 airline transport pilot sustained minor injuries, nine passengers sustained serious injuries, and one passenger sustained fatal injuries. The DHC-3 sustained substantial damage during the collision and impact with the water.

The Mountain Air DHC-2 was destroyed during the collision, uncontrolled descent, and impact with tree covered terrain and water. The DHC-2 was registered to and operated by Mountain Air Service, LLC, Ketchikan, Alaska, under the provisions of Title 14 Code of Federal Regulations (CFR) Part 135 as an on-demand sightseeing flight, and a Federal Aviation Administration flight plan was filed for the DHC-2.

The Taquan DHC-3 was registered to Pantechnicon Aviation LTD, Minden, Nevada, and operated by Venture Travel, LLC, dba Taquan Air, Ketchikan, Alaska, under the provisions of Title 14 CFR Part 135 as an on-demand sightseeing flight, and company flight following procedures were in effect for the DHC-3.

Visual meteorological conditions prevailed in the area at the time of the accident. Both airplanes were based at the Ketchikan Harbor Seaplane Base (5KE), and both were returning to Ketchikan at the time of the accident.

According to information provided by both operators, the purpose of both flights was to transport passengers to Ketchikan from the Misty Fjords National Monument area which was located about 30 nautical miles northeast of Ketchikan.

Preliminary flight track data revealed the DHC-3 was traveling southwest about 3,700 ft mean sea level (msl) and gradually descending at 126 knots (kts) when it crossed the east side of the George Inlet. The DHC-2 was traveling west/southwest about 3,350 ft msl at 107 kts when it crossed the east side of the George Inlet. The airplanes collided about 3,350 ft msl near the west side of the George Inlet, east of Mahoney Lake, and data signals were lost. See Figure 1. Flight Track.

The Taquan DHC-3 pilot stated the flight from the Misty Fjords area had proceeded normally, and he had descended and was maneuvering the airplane to show passengers a waterfall near Mahoney Lake when the collision occurred. He had not observed any potential conflicting traffic on his flight display that included Automatic Dependent Surveillance-Broadcast (ADS- B) system data. He last recalled looking at his ADS-B display when he was flying over Carroll Inlet. Just prior to the collision, he saw a flash from his left side, and experienced a large, loud impact. According to the pilot, the DHC-3 airplane then rolled right and pitched about 40 degrees nose down toward the water in George Inlet. He stated that he was able to maintain some control and flare the airplane prior to impact. The pilot estimated that the airplane impacted the water about five seconds after the collision. The pilot, some passengers, and some bystanders helped the passengers of the DHC-3 evacuate the airplane and move to the shore.

The DHC-3 main wreckage came to rest about 80 ft underwater about 400 ft off the east shore of George Inlet about 1.75 miles northeast of the DHC-2 main wreckage. The DHC-3 floats were separated and found tied off by rescue personnel to a tree about 65 ft north of the main wreckage.

The Mountain Air DHC-2 airplane broke up in-flight after the collision, and the wreckage was scattered over water and mountainous tree-covered terrain northeast of Mahoney Lake on the west shore of George Inlet. The main wreckage included the floats, engine, firewall, instrument panel, lower fuselage structure, and right fuselage structure and was located in saltwater near the mouth of Mahoney Creek. The debris field was about 2,000 ft long by about 1,000 ft wide, and contained separated fuselage, empennage, and cabin structure.

Examination of the DHC-2 wreckage showed the right wing had several mechanical cuts from the right aileron inboard to the wing root. Each successive cut penetrated further inboard and forward into the wing structure. Each cut had distinct downward deformation of the upper and lower wing skins, consistent with impacts from propeller blades.

Neither airplane was equipped, nor was required to be equipped, with a crashworthy flight data or cockpit voice recorder. Several avionics components and personal electronic devices were recovered from the wreckage areas. These components and devices were shipped to the National Transportation Safety Board Vehicle Recorders Laboratory, Washington, D.C. for further examination.

The NTSB preliminary report for the Metlakatla crash has not yet been developed.


On the Web:

NTSB Preliminary Report - May 22, 2019 pdf

Related News:

Two planes crash south of Ketchikan; Four Confirmed Dead, Two Still Missing -- Reports to USCG Confirms Mid-Air Collision
SitNews - May 13, 2019

Last Two Missing Passengers of Flights Found Tonight Bringing Fatalities to 6SitNews - May 14, 2019

Floatplane Crash in Metlakatla Harbor Claims Two Lives; Deceased Identified by Melakatla Police Chief
Sitnews- May 20, 2019


Source of News:

National Transportation Safety Board



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