Taquan Air

De Havilland DHC-2 Beaver

The commercial pilot was conducting his first scheduled commuter flight from the company’s seaplane base to a nearby island seaplane base with one passenger and cargo onboard. According to company pilots, the destination harbor was prone to challenging downdrafts and changing wind conditions due to surrounding terrain. Multiple witnesses at the destination stated that the airplane made a westerly approach, and the wind was from the southeast with light chop on the water. Two witnesses reported the wings rocking left and right before touchdown. One witness stated that a wind gust pushed the tail up before the airplane landed. A different witness reported that the airplane was drifting right during the touchdown, and another witness saw the right (downwind) float submerge under water after touchdown, and the airplane nosed over as it pivoted around the right wingtip, which impacted the water. Flight track and performance data from the cockpit display units revealed that, as the airplane descended on the final approach, the wind changed from a right headwind of 6 knots to a left quartering tailwind of 8 knots before touchdown. The crosswind and tailwind components were within the airplane’s operational limitations. Examination of the airframe, engine, and associated systems revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation or egress. During the final approach and descent, the pilot had various wind information available to him; the sea surface wind waves and signatures, the nearest airport observation winds, the cockpit display calculated wind, and the visual relative ground speed. Had the pilot recognized that the winds had shifted to a quartering tailwind and the airplane’s ground speed was faster than normal, he could have aborted the landing and performed another approach into the wind. Although crosswind landings were practiced during flight training, tailwind landings were not because new pilots were not expected to perform them. Although the crosswind component was well within the airplane’s limits, it is possible that combined with the higher ground speed, the inexperienced pilot was unable to counteract the lateral drift during touchdown in a rapidly shifting wind. The pilot was hired the previous month with 5 hours of seaplane experience, and he completed company-required training and competency checks less than 2 weeks before the accident. According to the chief pilot (CP), company policy was to assign newly hired pilots to tour flights while they gained experience before assigning them to commuter flights later in the season. The previous year, the CP distributed a list of each pilot’s clearances for specific types of flights and destinations; however, an updated list had not been generated for the season at the time of the accident, and the flight coordinators, who were delegated operational control for assigning pilots to flights, and station manager were unaware of the pilot’s assignment limitations. Before the flight, the flight coordinator on duty completed a company flight risk assessment that included numerical values based on flight experience levels. The total risk value for the flight was in the caution area, which required management notification before releasing the flight, due to the pilot’s lack of experience in the accident airplane make and model and with the company, and his unfamiliarity with the geographical area; however, the flight coordinator did not notify management before release because the CP had approved a tour flight with the same risk value earlier in the day. Had the CP been notified, he may not have approved of the pilot's assignment to the accident flight. The pilot's minimal operational experience in seaplane operations likely affected his situational awareness in rapidly changing wind conditions and his ability to compensate adequately for a quartering tailwind at a higher-than-normal ground speed, which resulted in a loss of control during the water landing and a subsequent nose-over.

De Havilland DHC-3 Otter

On May 13, 2019, about 1221 Alaska daylight time, a float-equipped de Havilland DHC-2 (Beaver) airplane, N952DB, and a float-equipped de Havilland DHC-3 (Otter) airplane, N959PA, collided in midair about 8 miles northeast of Ketchikan, Alaska. The DHC-2 pilot and four passengers sustained fatal injuries. The DHC-3 pilot sustained minor injuries, nine passengers sustained serious injuries, and one passenger sustained fatal injuries. The DHC-2 was destroyed, and the DHC-3 sustained substantial damage. 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. The 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 Part 135 as an on-demand sightseeing flight. Visual meteorological conditions prevailed in the area at the time of the accident. According to information provided by the operators, both airplanes had been conducting sightseeing flights to the Misty Fjords National Monument area. They were both converging on a scenic waterfall in the Mahoney Lakes area on Revillagigedo Island before returning to the Ketchikan Harbor Seaplane Base (5KE), Ketchikan, Alaska, when the accident occurred. According to recorded avionics data recovered from the DHC-3, it departed from an inlet (Rudyerd Bay) in the Misty Fjords National Monument area about 1203 and followed the inlet westward toward Point Eva and Manzanita Island. At 1209, at an altitude between 1,900 and 2,200 ft, the DHC-3 crossed the Behm Canal then turned to the southwest about 1212 in the vicinity of Lake Grace. Automatic dependent surveillance-broadcast (ADS-B) tracking data for both airplanes, which were provided by the Federal Aviation Administration (FAA), began at 1213:08 for the DHC-3, and at 1213:55 for the DHC-2. At 1217:15, the DHC-3 was about level at 4,000 ft mean sea level (msl) over Carroll Inlet on a track of 225°. The DHC-2 was 4.2 nautical miles (nm) south of the DHC-3, climbing through 2,800 ft, on a track of 255°. The DHC-3 pilot stated that, about this time, he checked his traffic display and “there were two groups of blue triangles, but not on my line. They were to the left of where I was going.” He stated that he did not observe the DHC-2 on his traffic display before the collision. The ADS-B data indicated that, about 1219, the DHC-3 started a descent from 4,000 ft, and the DHC-2 was climbing from 3,175 ft. During the next 1 minute 21 seconds, the DHC-3 continued to descend on a track between 224° and 237°, and the DHC-2 leveled out at 3,350 ft on a track of about 255°. Between 1220:21 and 1221:14, the DHC-3 made a shallow left turn to a track of 210°, then a shallow right turn back to a track of 226°. The airplanes collided at 1221:14 at an altitude of 3,350 ft, 7.4 nm northeast of 5KE. The ADS-B data for both airplanes end about the time of the collision. The DHC-2 was fractured into multiple pieces and impacted the water and terrain northeast of Mahoney Lake. Recorded avionics data for the DHC-3 indicate that at 1221:14, the DHC-3 experienced a brief upset in vertical load factor and soon after entered a right bank, reaching an attitude about 50° right wing down at 1221:19 and 27° nose down at 1221:22. The DHC-3 began descending and completed a 180° turn before impacting George Inlet at 1222:15 along a northeast track.

De Havilland DHC-3 Otter

The airline transport pilot was conducting a commercial visual flight rules (VFR) flight transporting 10 passengers from a remote fishing lodge. According to the pilot, while in level cruise flight about 1,100 ft mean sea level (msl) and as the flight progressed into a mountain pass, visibility decreased rapidly. In an attempt to turn around and return to VFR conditions, the pilot initiated a climbing right turn. Before completing the 180° right turn, he saw what he believed to be a body of water and became momentarily disoriented, so he leveled the wings. Shortly thereafter, he realized that the airplane was approaching an area of snow-covered mountainous terrain, so he applied full power and initiated a steep climb; the airspeed decayed, and the airplane collided with an area of rocky, rising terrain, which resulted in substantial damage to the wings and fuselage. The pilot reported no mechanical malfunctions or anomalies that would have precluded normal operation, and the examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The weather forecast at the accident time included scattered clouds at 2,500 ft msl, overcast clouds at 5,000 ft msl with cloud tops to 14,000 ft and clouds layered above that to flight level 250, and isolated broken clouds at 2,500 ft with light rain. AIRMET advisory SIERRA for "mountains obscured in clouds/precipitation" was valid at the time of the accident. Conditions were expected to deteriorate. Passenger interviews revealed that through the course of the flight, the airplane was operating in marginal visual meteorological conditions and occasional instrument meteorological conditions (IMC) with areas of precipitation, reduced visibility, obscuration, and, at times, little to no forward visibility. Thus, based on weather reports and forecasts, and the pilot's and passengers' statements, it is likely that the flight encountered IMC as it approached mountainous terrain and that the pilot then lost situational awareness. The airplane was equipped with a terrain awareness and warning system (TAWS); however, the alerts were inhibited at the time of the accident. Although the TAWS was required to be installed per Federal Aviation Administration (FAA) regulations, there is no requirement for it to be used. All company pilots interviewed stated that the TAWS inhibit switch remained in the inhibit position unless a controlled flight into terrain (CFIT) escape maneuver was being accomplished. However, the check airman who last administered the accident pilot's competency check stated that the TAWS inhibit switch was never moved, even during a CFIT escape maneuver. The unwritten company policy to leave the TAWS in the inhibit mode and the failure of the pilot to move the TAWS out of the inhibit mode when weather conditions began to deteriorate were inconsistent with the goal of providing the highest level of safety. However, if the pilot had been using TAWS, due to the fact that he was operating at a lower altitude and thus would have likely received numerous nuisance alerts, the investigation could not determine the extent to which TAWS would have impacted the pilot's actions. At the time of the accident, the director of operations (DO) for the company resided in another city and served as DO for another air carrier as well. He traveled to the company's main base of operation about once per month but was available via telephone. According to the chief pilot, he had assumed a large percentage of the DO's duties. The president of the company said that the chief pilot had taken over "officer of the deck" and "we're just basically using him [the DO] for his recordkeeping." The FAA was aware that the company's DO was also DO for another commuter operation. FAA Flight Standards District Office management and principal operations inspectors allowed him to continue to hold those positions, although it was contrary to the guidance provided in FAA Order 8900.1. The company's General Operations Manual (GOM) only listed the DO, the chief pilot, and the president by name as having the authority to exercise operational control. However, numerous company personnel stated that operational control could be and was routinely delegated to senior pilots. The GOM stated that the DO "routinely" delegated the duty of operational control to flight coordinators, but the flight coordinator on duty at the time of the accident stated that she did not have operational control. In addition, the investigation revealed numerous inadequate and missing operational control procedures and processes in company manuals and operations specifications. Based on the FAA's inappropriate approval of the DO, the insufficient company onsite management, the inadequate operational control procedures, and the exercise of operational control by unapproved persons likely resulted in a lack of oversight of flight operations, inattentive and distracted management personnel, and a loss of operational control within the air carrier. However, the investigation could not determine the extent to which any changes to operational control, company management, and FAA oversight would have influenced the pilot's decision to continue the VFR flight into IMC.

De Havilland DHC-2 Beaver

The air taxi float-equipped airplane was the second of three airplanes on an air tour flight over a remote scenic area in southeast Alaska. As the flight of three airplanes flew into mountainous terrain, the first pilot reported low clouds, with rain and fog, which required him to descend to 700 feet msl to maintain VFR flight conditions. The pilot of the third tour airplane, which was about 5 minutes behind the accident airplane, stated that as he approached the area around the accident site, he encountered "a wall of weather" which blocked his intended flight route, and he turned around. The accident airplane's fragmented wreckage was discovered in an area of steep, tree-covered terrain, about 2,500 feet msl, near the area where the third airplane turned around. The NTSB discovered no mechanical problems with the airplane during postaccident inspections. An NTSB weather study revealed instrument meteorological conditions in the area at the time of the accident. Photographs recovered from a passenger's camera depicted deteriorating weather conditions as the flight progressed. A charter boat captain, who had seen numerous float-equipped tour airplanes operating in adverse weather conditions, called the local FAA Flight Standards District Office (FSDO) 9 days before the accident, to report his sightings. According to the FAA, no specific tour operator could be identified during their ensuing investigation, and no enforcement actions or additional surveillance of any operators was initiated. According to the FSDO manager, the local FSDO had lost inspectors due to downsizing. He reported they had not attempted to observe operators' adherence to weather minimums via ground-based viewing locations along the heavily traveled tour routes, and noted that FAA inspectors used to purchase air tour tickets to provide en route, on-board surveillance, but had not done so for approximately the last 10 years. He noted that additional inspector assistance from other FAA offices was not requested

De Havilland DHC-2 Beaver

According to the passenger, he and the pilot had just taken off, and as they were climbing out over an open water portion of a bay, the pilot said, 'here comes a gust.' Reportedly, the pilot added engine power, and the airplane began descending. The right wing started to dip, and the nose started to drop. The pilot had the control yoke turned all the way to the left, then yelled that they were going in. The airplane crashed in the water, and the passenger exited the airplane through the windshield. He did not see the pilot. The deceased pilot was found still strapped in his seat several days later, when a portion of the wreckage was recovered.