Officials determine circumstances, cause of plane crash that killed nine in 2015

The crash site of the de Havilland Otter. Image from NTSB.
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WASHINGTON, D.C. (KTUU) - Investigators with the National Transportation Safety Board presented their findings in a livestream on Tuesday, concluding the investigation into the cause of the charter flight crash that killed nine people near Ketchikan in June of 2015.

Among several other contributing factors, a main cause of the crash highlighted by the NTSB panel was poor weather, and the “company culture” that influenced the pilot to fly regardless. The company in question, Promech Air, was based out of Ketchikan until it was bought by Taquan Air. The Ketchikan Daily News originally reported that acquisition.

The DeHavilland Otter, a single engine float plane operated by Promech, took off from Rudyerd Bay at around noon on June 25, 2015. It eventually crashed into the woods near Ella Lake, approximately 24 miles northeast of Ketchikan. It crashed while crossing over the Misty Fjords National Monument Wilderness. The flight was part of a sightseeing excursion of eight passengers and one pilot.

According to the report, the operator initiated a search for the missing N270PA when the plane failed to return to Ketchikan. An emergency locator transmitter helped helicopter pilots and the Ketchikan Volunteer Rescue Squad locate the wreckage around 2:29 p.m. KVRS confirmed that the occupants sustained fatal injuries.

At the time of the crash, NTSB officials say the airplane “impacted trees and a near vertical rock face in a nose high, wings level attitude at an elevation of about 1,600 feet mean sea level.” Then, the plane rested upright, on top of its floats. The report says the area was a steep, heavily forested terrain.

Acting chairman of the NTSB, Robert Sumwalt, said that while the beauty of these flights is understandable, they also represent a “dynamic weather environment” which constantly changes. Due to this, the evaluation on any given aircraft for when to fly also changes. The NTSB said the decision on whether to fly or not that day was made solely by the pilot.

“When to fly, and which route to fly, can be determined by objective criteria, with a multitude of actors in the decision-making chain. Or it can happen as it happened this day, where the decision can be left to the pilot alone, based on loose expectations rooted in scheduling concerns,” Sumwalt said.

At Tuesday’s meeting, the NTSB released “proposed findings, probable cause, and recommendations from the investigation” to hopefully avoid further accidents of this nature.

Proposed findings

The report put forth by the NTSB, addresses several pieces of evidence that influenced the investigators tasked with finding out what factors contributed to the fatal crash, including an iPad found at the crash site that belonged to a passenger, and had been recording video up until the moment of impact.

Findings in the report were read by the acting managing director, Dennis Jones. Jones identified a total of 23 findings in the report. These findings painted a picture of the difficulties and complications surrounding the flight, as well as dispelled other extraneous explanations for why the airplane went down.

Jones said the pilot was qualified, and that “no evidence suggested their performance was affected by fatigue, medical conditions, toxins, alcohol, or other drugs.” They noted that he had less than two months of flying experience in Southeast Alaska.

The plane itself was also found to have no mechanical abnormalities prior to the crash, however investigators said the aircraft’s Terrain Avoidance and Warning System, which lets pilots know if they’re getting dangerously close to land, was either deactivated or inhibited when the plane went down.

Probable cause

As evidenced by the footage of the terrain captured by the passenger’s iPad, as well as weather conditions available at the time, investigators said that the accident site was likely obscured by clouds, rain, and mist. They say that despite this, the pilot “continued flight in low visibility, at a lower than normal vantage point, and in an area in which he lacked extensive flying experience.”

Investigators say that the decision to keep flying was made by the pilot, who was influenced by “schedule pressure” and attempting to “emulate the behavior of others, more experienced pilots, whose flight he was following.”

Jones said that management at Promech Air “foster a company culture that tacitly endorsed operating in weather conditions that were below Federal Aviation Administration minimums.” Jones said specifically that Promech’s company culture “encouraged the pilot to continue the flight into deteriorating weather conditions.”

Additionally, NTSB officials blasted Promech for having insufficient training and supervision over flight schedules, often leaving the pilots themselves to make sole decisions over safety and control, as was the case with Bryan Krill, 64, who was spending that summer in Ketchikan working as a tour pilot for Promech.

“Lives depended on the pilot’s decision making,” said Sumwalt. “Pilot decisions are informed, for better or worse, by their company’s culture. This company allowed competitive pressure to overwhelm the common-sense needs of passenger safety in its operations. That’s the climate in which [Krill] worked.”

Investigators identified the hazardous reporting system, which they called “underused” by Promech pilots. They said the company's “informal safety processes” were ineffective for identifying major risks, and didn’t help inform pilot decisions.

Recommendations from the investigation

In addition to determining why the Promech flight went down, the NTSB issued recommendations aimed at preventing similar crashes from happening in the future.

Investigators determined that the Ketchikan air tour industry is highly competitive. Several of NTSB's recommendations were targeted at changing that element, which they say encourage flight companies to fly in unsafe conditions in order to turn a profit.

Although passengers were rebooked on Promech and some operators paid an “economic penalty” for safety related decisions. Conversely, they said “those who are willing to operate reaped economic benefits.” Due to this, the NTSB recommended more conservative operating rules to prevent companies from flying in the poor weather, and thus force competitors to “follow suit” in order to remain profitable.

Jones said an “establishment of a more conservative set of weather minimums that are tailored to the type of air tour operations that occur in Ketchikan […] would help balance competing goals of production and safety and remove the incentive of individual operators to adopt the lowest possible weather minimums to stay competitive.”

Looking ahead

In addition to the full report concluded Tuesday on the 2015 crash, the NTSB also announced that they would be having a similar hearing to present the findings of the investigation into an airplane crash in October of 2016 that killed all three people on board.

In that crash, which is still being investigated, a turbine-powered Cessna 208 impacted mountainous terrain on its way from Togiak to Bethel. Sumwalt said that an initial review “indicated the accident took place in an area of low cloud ceilings and reduced visibility,” conditions similar to the Promech crash.

Hageland Aviation Services was operating the aircraft in which two pilots and one passenger were killed. Sumwalt said the investigative hearing into that incident will take place sometime “later this summer, in Alaska.”

Update: Taquan Air Statement
Taquan Air, which bought Promech Air, released this official statement, following NTSB's probable cause release:

"Taquan Air is dedicated to these safety measures to mitigate any future incidents in the Misty Fjords, including its risk assessment forms, its Medallion Foundation membership, recurring flight safety trainings and protocols. Public funding of the vital weather cameras installed in the area and throughout Alaska is also paramount to these efforts. Taquan Air acknowledges the issues the NTSB has identified and will continue to conduct flight operations that propagate our company culture of safety."


An image recorded by one of the passengers killed in the 2015 plane crash. The image was found on the victim's iPad recovered at the crash site. From the NTSB.
An image recorded by one of the passengers killed in the 2015 plane crash. The image was found on the victim's iPad recovered at the crash site. From the NTSB.


 
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