Hydaburg, AK, USA
N3952B
De Havilland DHC 3
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.
HISTORY OF FLIGHT On July 10, 2018, about 0835 Alaska daylight time, a float-equipped de Havilland DHC3T Otter airplane, N3952B, sustained substantial damage during impact with rocky, mountainous, rising terrain about 9 miles east of Hydaburg, Alaska. Of the 11 occupants on board, the airline transport pilot was uninjured, four passengers sustained minor injuries, and six passengers sustained serious injuries. The airplane was registered to Blue Aircraft, LLC, and was operated by Taquan Air as a Title 14 Code of Federal Regulations Part 135 on-demand commercial flight. Marginal visual meteorological conditions prevailed for the visual flight rules (VFR) flight, and company flight following procedures were in effect. The flight departed Steamboat Bay about 0747 destined for Ketchikan, Alaska. The purpose of the flight was to transport guests that were staying at the Steamboat Bay Fishing Club on Noyes Island back to Ketchikan. The area between Noyes Island and Ketchikan consists of remote inland fjords, coastal waterways, and steep mountainous terrain. A review of GPS data extracted from the Chelton Integrated Display Unit (IDU) revealed that after departing Steamboat Bay the flight proceeded easterly towards the village of Klawock and to the northwest edge of Klawock Lake, prior to making about a 270° turn, it then continued on a southerly heading along the west coast of Prince of Wales Island towards Waterfall Seaplane Base (KWF) prior to turning easterly towards Hydaburg and an area known as Sulzer Portage. Figure 1. Google Earth overlay of the entire accident flight on July 10, 2018. Indicated airspeed (IAS) values are shown. For further information, see the Cockpit Displays – Recorded Flight Data Factual Report located in the public docket for this investigation. According to the pilot, while in level cruise flight about 1,100 ft mean sea level (msl) as the flight progressed into an area known as Sulzer Portage, visibility decreased rapidly in heavy rain and clouds. In an attempt to turn around and return to VFR conditions, he initiated a climbing right turn. Before completing the 180° right turn, he saw what he believed to be a body of water, and he 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 to avoid the rising terrain ahead. As the climb continued, the airspeed decayed, and the airplane subsequently collided with the mountain. During the initial impact, the airplane's floats partially separated from the fuselage. The airplane wreckage came to rest in an area known as Jumbo Mountain. When asked if he remembered any issues with the airplane, he replied "…the airplane was running great." According to the passenger seated in the right front seat, after departure, the flight proceeded to Klawock and then made what he thought was a 180° turn. He said the flight made numerous course deviations as the pilot maneuvered around weather, and, at times, all forward visibility was lost as they briefly flew in and out of the clouds. He said he became uncomfortable and was thinking it would be prudent to just land on the water. Shortly thereafter, he observed a large mountain directly in front of the airplane; knowing they could not outclimb the mountain, he presumed there must be a pass through the area. The airplane then entered a cloud and the pilot added power and pitched up, but the airplane impacted the side of the mountain. According to a second passenger, who was seated toward the back of the airplane, the weather at Steamboat Bay when they departed was rain and low clouds. During the flight, he could occasionally see the land and water below, but sometimes he could not. He said that there was "serious fog" all around. After they passed Waterfall Resort, he became very concerned that they were headed in the wrong direction. He texted the right front seat passenger (a friend) and asked him to ask the pilot to land and wait for the weather to improve. He said that he did not see the mountain until they were right on it, and observed the pilot add power right before impact. At 0843, the United States Coast Guard (USCG) Sector Juneau received a report from the Alaska State Troopers that a float plane had crashed near Sulzer Portage on Prince of Wales Island. Two USCG helicopters were launched, and the Alaska State Troopers dispatched five helicopters to the search area; a staging area was established near the accident site. One of the helicopter pilots stated that he was unable to search the upper levels of the mountainous area due to a low cloud ceiling and poor visibility. A "First Alert" was received from the accident airplane's onboard emergency locator transmitter (ELT) at 0911. About the same time, a 911 dispatcher in Ketchikan talked via cell phone to a passenger, who provided GPS position and elevation based on data from her iPhone. At 1047, both USCG helicopters arrived in the search area and one helicopter obtained a weak direction finding bearing from the ELT. The bearing and the survivor's description of the accident area were used to direct search assets near the accident site, so the passengers could hear the USCG helicopters. Two-way radio communications were established between the passengers and USCG by using the accident airplane's radio. The USCG located the accident site at 1156. At 1308, all 11 survivors had been hoisted into the USCG's rescue helicopter and transferred to the staging area for transport back to Ketchikan. PERSONNEL INFORMATION The pilot held an airline transport pilot certificate with airplane single-engine land and sea, multi-engine land and sea, and instrument ratings. A second-class airman medical certificate was issued on December 6, 2017, and contained limitations of must wear corrective lenses. According to the operator's training records, the pilot was hired with 26,618 total hours of flight experience, including 2,700 hours of experience in Alaska. At the time of the accident, the pilot reported that he had accumulated about 306 hours in the accident airplane make and model. His most recent airman competency check, which was administered by a company check airman, was completed on May 13, 2018. In June 2018, the pilot was on duty for 25 days and flew about 84 hours, with 5 days off. In July 2018, the pilot was on duty for 7 days, including the day of the accident, and flew about 28 hours, with 3 days off. AIRCRAFT INFORMATION The de Havilland DHC-3 Otter is a single-engine, propeller-driven, single-pilot, high-wing, short-takeoff-and-landing (STOL) airplane originally designed in the early 1950s. The original airplane was powered by a single reciprocating radial engine but could be converted to turbine engine power by supplemental type certificate (STC). The accident airplane was powered by a Pratt & Whitney Canada PT6A turboprop engine in accordance with Vazar, Inc., STC SA3777NM and equipped with International Aeroproducts Model 8100 floats in accordance with Anew Sioux Enterprises, Ltd., STC SQ01825NY. The type certificate for the airplane is currently owned and maintained by Viking Air Limited, Sidney, British Columbia, Canada. The accident airplane was equipped with two Chelton Flight Systems FlightLogic electronic flight instrument system (EFIS) Integrated Display Units (IDU). The IDUs were identical part numbers and were configured to operate as primary flight displays (PFD) or multi-function displays (MFD). Using sensors, including solid-state air data and attitude heading reference system, the PFD displayed aircraft parameter data including altitude, airspeed, attitude, vertical speed, and heading. The MFD displayed navigational information through a moving map. Additionally, the units in the accident airplane included a terrain awareness and warning system (TAWS) that provided color-coded warnings of terrain on the MFD and, when enabled, aural alerts. As part of the TAWS system, the PFD was capable of providing a profile view of terrain ahead of the aircraft (synthetic vision). The FlightLogic EFIS IDU features integrated Class B TAWS or, optionally, Class A or C TAWS or Class A or B Helicopter TAWS (HTAWS). The IDU provides TSO-C151b TAWS functionality. Depending upon aircraft configuration settings and external sensors/switches, the system is configurable as a Class A, B or C TAWS or a Class A or B HTAWS.4. The accident airplane's TAWS functionality was set to Class B specifications as required by 14 CFR 135.154 and Technical Standard Order (TSO) – C151. 14 CFR 135.154 (b) (2) states, "No person may operate a turbine-powered airplane configured with 6 to 9 passenger seats, excluding any pilot seat, after March 29, 2005, unless that airplane is equipped with an approved terrain awareness and warning system that meets as a minimum the requirements for Class B equipment in Technical Standard Order (TSO)-C151." Although Class B TAWS specifies 700 ft agl during cruise flight and 500 ft during descent (as specified in TSO C-151c), the float-equipped accident airplane was authorized, per 14 CFR 135.203(a)(1), to cruise as low as 500 ft agl, which is below the Class B TAWS design alerting threshold. As a result, Class B TAWS auditory and flag alerts would be triggered during normal operations. A TAWS inhibit switch, which was directly connected to the EFIS IDU, could manually inhibit the TAWS alerting function. The TAWS inhibit switch was a toggle type that provided the pilot with an obvious indication of actuation. The TAWS inhibit switch was found in the "inhibit" mode following the accident. All of the 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 in accordance with 14 CFR 135.293(b), when asked about enabling the TAWS switch during a CFIT escape maneuver, "No, it never gets moved." METEOROLOGICAL INFORMATION The closest weather reporting facility was Hydaburg Seaplane Base (PAHY), Hydaburg, Alaska, about 9 miles west of the accident site. At 0847, a METAR from PAHY reported, in part: wind from 110° at 13 knots; 5 statute miles visibility in light rain and mist; few clouds at 900 ft, overcast clouds at 1,700 ft; temperature 57°F; dew point 55°F; and altimeter setting of 30.16 inches of mercury. An area forecast that included the forecast for the accident location and AIRMET information was issued by the AAWU at 0410 Alaska daylight time. The forecast at the accident time included scattered clouds at 2,500 ft msl, overcast clouds at 5,000 ft msl with clouds tops to 14,000 ft and clouds layered above that to FL250, isolated broken clouds at 2,500 ft with light rain. No significant turbulence was expected. Moderate in-cloud icing was forecast between 12,000 ft and FL190. The freezing level was identified at 9,000 ft. AIRMET advisory SIERRA for "mountains obscured in clouds/precipitation" was issued at 0410 Alaska daylight time and was active for the accident site at the accident time. Conditions were expected to deteriorate. For further information, see the Meteorology Factual Report located in the public docket for this investigation. FLIGHT RECORDERS The accident airplane was not equipped, nor was it required to be equipped with, a cockpit voice recorder or a flight data recorder. WRECKAGE AND IMPACT INFORMATION The accident site was located on a rock face on the east side of Jumbo Mountain at an elevation of about 2,557 ft msl. All the airplane major components were located at the accident site. The cockpit and fuselage were largely intact but sustained impact damage. The power lever and propeller lever were found in the full forward position and the condition lever was in the idle cutoff position. The cockpit seats remained attached and secure with lap belts and shoulder harnesses available. The fuselage seats were equipped with lap belts only. The right wing remained attached to its respective attach points but sustained leading edge impact damage about ¾ span outboard to the tip. The right aileron remained attached to its respective attach points and sustained impact damage about midspan. The left wing remained attached to its respective attached points but sustained leading edge impact damage about midspan. The left aileron remained attached to its respective attach points and was relatively undamaged. The left and right horizontal stabilizers, vertical stabilizer, and rudder, along with both left and right servo tabs and the rudder trim tab remained attached to their respective attach points and were relatively undamaged. The left and right elevators remained attached to their respective attach points but sustained impact damage. The stabilizer jackscrew remained attached to its attach points and no excessive inner movement was present in the jackscrew. The engine remained attached to the airframe and engine control continuity was established from the engine to the cockpit. The three-blade Hartzell propeller separated from the engine at the reduction gearbox. All three propeller blades remained attached to the propeller hub and exhibited broken blade tips, torsional twisting, chordwise scratching and leading-edge gouging. All the primary flight control surfaces remained attached to their respective attachment points, and flight control continuity was verified from all the primary flight control surfaces to the cockpit. 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. ORGANIZATIONAL AND MANAGEMENT INFORMATION Taquan Air was a 14 CFR Part 135 air carrier that held on-demand and commuter operations specifications. The air carrier was authorized to conduct business exclusively under the business names "Venture Capital, LLC" or "Taquan Air." The company headquarters was located in Ketchikan, Alaska. The company operated 15 airplanes of which 3 were DHC-3T Turbine Otters, and employed about 25 pilots, with most working on a seasonal basis. According to the DO, Venture Capital LLC was operating four trips per day per airplane, totaling about 60 operations per day. Director of Operations The DO was hired as DO at Taquan in January 2016. In October 2017, he was hired as the chief pilot for Grant Aviation, a large scheduled Part 135 air carrier that also held commuter and on-demand operations specifications; he was promoted to DO at Grant Aviation in April 2018. Although this new position was based in Anchorage, Alaska, where he moved in October 2017, he continued to hold the DO position at Taquan. In addition, he was also a contract simulator instructor for Alaska Airlines. According to numerous company personnel, the DO would visit Taquan's Ketchikan base about once a month but was available by phone, if necessary. The president of the company said that the chief pilot had taken over "officer of the deck" and "we're just basically using him [DO] for his recordkeeping, as … we need a DO." Chief Pilot The chief pilot was hired as chief pilot at Taquan in September 2014. Before that, he was a line pilot and company instructor at Promech Air, in Ketchikan, Alaska, from May 2010 until September 2014. He had about 16,000 total flight hours, of which about 5,000 hours were accumulated in Alaska. He resided in Ketchikan. According to the chief pilot, due to the absence of the DO, he had assumed a large number of his responsibilities. He said both positions could be accomplished by one person during the wintertime, but it was more difficult during the summer months. Operational Control The Taquan General Operations Manual (GOM) does not explain the procedures used for the initiation or conduct of flight movements. The GOM did not list anyone by name as having operational control other than the DO, chief pilot, and president. The DO, chief pilot, flight coordinator, s
The pilot's decision to continue the visual flight rules flight into instrument meteorological conditions, which resulted in controlled flight into terrain.
Source: NTSB Aviation Accident Database
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