Culture Of Carelessness?

Weather conditions left something to be desired, and the pilot had a choice to make: whether to take a longer route largely over various bodies of water, which would allow him to duck below low-lying ragged clouds without having to worry too much about terrain features and even make a water landing, if necessary, or take a shorter route, which would save about five minutes. The shorter route would take them largely over land, which included undulating hills, ridges and modest mountains. Even though some higher terrain, and even lower terrain, was obscured by clouds, the pilot decided to take the shorter route.

The accident took place during the second round of tours that day. Earlier, the accident pilot had to fly his plane as low as 375 feet over water to remain VFR, the company's president had to fly his plane as low as 250 feet, and a third pilot got down to only 225 feet above the water. That pilot told investigators that when he arrived for work that morning, he told Promech's president he was worried about the weather, but his concerns were dismissed. This pilot said that during the tour, the weather conditions encountered were so bad that he felt lucky to return from that flight. He was surprised that the company continued operating that day. The owner of another tour company told investigators that, after flying one tour, she decided to cancel.

The airplane was owned by a company in Minden, Nevada, and was operated on the Part 135 on-demand sightseeing flight by Promech. Promech shut down its Ketchikan operations in August 2016 and a competitor purchased its assets.

Promech could fly both Part 135 on-demand and commuter flights. Between 2005 and October 2014, it flew air taxi and scheduled passenger flights, carried the mail for the U.S. Postal Service and was the biggest air freight operator serving some communities in Southeast Alaska. However, another company landed the mail contract, and Promech began losing money during the winters because of a falloff in passenger loads. The company shifted its focus to air tours and lodge transportation. By the summer of 2015, about 90 percent of its business came from air tours.

At the time of the accident, it had contracts with cruise ship operators to provide sightseeing tours to their passengers. It operated nine airplanes in Ketchikan and two more in Key West, Florida, where it also ran air tours. The company President/CEO, Director of Operations, Assistant Chief Pilot and Director of Maintenance were located in Ketchikan, and the Chief Pilot was located in Key West. The management personnel also had flying duties.

The DHC-3 Otter was designed in the early 1950s. The model was originally powered by a radial engine; however, the accident airplane was modified to use a Pratt & Whitney PT6A-135A turboprop engine in accordance with an STC.

The airplane was maintained under an FAA-approved inspection program that required regular inspections and maintenance, but didn't fix a specific overhaul time for the engine. A review of maintenance records showed that, as of the day before the accident, the airframe had 24,439.5 hours, the engine had 14,575.9 hours, and the propeller had 3,700.4 hours.

The airplane was equipped with an electronic flight instrument system (EFIS), which included two identical display units that could be configured either as a primary flight display (PFD) or a multifunction display (MFD). The PFD showed data such as altitude, airspeed, vertical speed, heading and attitude. Among the displays that could be put on the MFD was a moving map showing position and navigation information. It could also show terrain warnings when obstructions loomed ahead. The equipment was old, however, and had been provided free by the FAA when it was operating its Capstone Project in Alaska from 1999 to 2006. Capstone was the forerunner of ADS-B. The EFIS in the accident airplane didn't have updated software installed, which meant that bodies of water were displayed in the same color as land, instead of in blue as on displays using updated software.

The MFD could depict potentially hazardous proximity to terrain as a red warning or yellow caution overlay on the terrain map and issue an aural warning. Some company pilots interviewed by investigators reported that the red and yellow overlays could, at times, obscure the terrain depiction. One Promech pilot described this as an issue if a pilot needed to use the map for situational awareness in a CFIT-avoidance situation.

The system also included a switch that could be used to turn off the aural and flag alerts. Data recovered from the accident airplane's EFIS revealed that the terrain warning alerting function was turned off at the time of impact. The toggle switch itself was found in the inhibit position in the wreckage, and a digital image from the camera of a passenger on the accident flight showed that the switch was in the inhibit position during the flight.

Specifications for the terrain warning system met FAA requirements allowing a clearance of 700 feet AGL during cruise flight and 500 feet AGL during descent. However, because it had floats, the airplane was legally allowed to cruise over water with as little as 500 feet clearance. That would result in aural and on-screen terrain warnings being triggered during normal tour operations. Several Promech pilots reported that frequent nuisance alerts sometimes prompted them to inhibit the terrain warning system.

On the morning of the accident, the four Promech airplanes, three DHC-3s and one DHC-2, were scheduled to depart Ketchikan Harbor Seaplane Base at 11 a.m. with cruise ship passengers. They would fly over remote inland fjords, coastal waterways and mountainous, tree-covered terrain in the Misty Fjords National Monument Wilderness.

At 11:20, the accident airplane was the third to take off. The company President/CEO made a radio transmission to the airplanes, saying, "Hey, guys, don't forget about your 12:30 all-aboard."

The airplanes took the longer, 30-minute route to Rudyerd Bay, considered to be the most scenic bay in Misty Fjords. They landed at a floating dock. At 12:07, the accident airplane departed for the return trip to Ketchikan. The pilot of the first Promech flight to depart Rudyerd Bay said he decided to take the short route based on his personal observations that the weather was generally improving.

The pilot of the second Promech flight to depart Rudyerd Bay said that he decided on the long route because he saw low clouds and didn't like what other pilots were saying on the radio. He recalled hearing fragments of radio conversations, specifically the words "scattered layers" and "ragged." He told investigators that he had been forced to turn around in Ella Lake earlier in the day because of low clouds.

One pilot told investigators that during initial training, the company's Assistant Chief Pilot told him and a group of other Promech pilots that they had to bend the rules when it came to weather minimums because they were operating in Alaska. The Assistant Chief Pilot reportedly said that if one pilot turned around while the others made it through, he and that pilot were going to "have a conversation." This pilot chalked it up to the culture in Alaska; "!it's like, ’we push through, we push through.'"

One pilot, who had about 26,000 flight hours with 5,000 hours in float-equipped airplanes, described flying a trip and, upon seeing the accident pilot's airplane disappear into clouds, making a radio call to ask, "How's the weather up there because it looks IFR here?" He said that company management had heard the radio exchange and ridiculed him for mentioning IFR on the radio. He said that he was told to never say "IFR" on the radio or he would be fired.

The accident pilot, age 64, held a commercial pilot certificate for single-engine land and sea airplanes and an instrument rating. His second class FAA medical certificate required glasses. His estimated flight experience was 4,070 hours, including about 500 hours in DHC-2 airplanes and about 40 hours in the DHC-3. He accumulated about 1,200 of his flying hours in Alaska. The pilot received training from Promech in avoiding controlled flight into terrain. He had about 152 flight hours for the company.

Data recovered from the EFIS showed that as the airplane transited terrain named Ella Narrows, it descended rapidly from about 1,300 feet to about 1,000 feet MSL before gradually climbing again. After going through the narrows and reaching the northeast end of Ella Lake, the flight was at about 1,200 feet and turned southwest and overflew the lake while climbing to about 1,300 feet MSL (about 1,050 feet AGL). It subsequently turned west and climbed to about 1,500 feet MSL while crossing over a ridge on the lake's west shore. The airplane continued on a relatively constant heading between 1,400 and 1,500 feet MSL for about 30 seconds.

Investigators recovered photos from the camera of a passenger on the accident flight. One photo, looking down, determined to have been taken 28 seconds before the collision, showed some treetops partially obstructed by cloud cover. A picture looking ahead through the right windscreen, taken about 7 seconds later, showed that the terrain was mostly obscured. Rain can be seen on the windscreen.

EFIS data showed that, about 2 seconds before the collision, the airplane began to pitch up rapidly, experiencing about 2 G's of vertical acceleration and climbing before it collided with terrain. The airplane struck the terrain at an elevation of about 1,600 feet MSL.

The Safety Board said that evidence from the accident tour flight and the pilot's previous tour flights support the conclusion that the pilot's decisions regarding his tour flights were influenced by schedule pressure; his attempt to emulate the behavior of other, more experienced pilots whose flights he was following; and Promech's organizational culture, which tacitly endorsed flying in hazardous weather conditions.

The NTSB determined that the probable cause of the accident was: 1) the pilot's decision to continue visual flight into an area of instrument meteorological conditions, which resulted in his geographic disorientation and controlled flight into terrain; and 2) Promech's company culture, which tacitly endorsed flying in hazardous weather and failed to manage the risks associated with the competitive pressures affecting Ketchikan-area air tour operators; its lack of a formal safety program; and its inadequate operational control of flight releases.

While all of that's supported by the NTSB's report, the Safety Board overlooks the fundamental flaw identified by the accident pilot's colleagues and reported by the NTSB's own investigators, which all pilots would do well to identify and eliminate: a false belief of being invincible.

As I mentioned, one pilot told investigators about a tour in which he was behind the accident pilot's plane when it disappeared into what looked like instrument conditions in the Ella Lake area. He radioed the accident pilot about the weather, and the accident pilot stated that it was fine. This pilot thought that the accident pilot seemed to think he was invincible or more skilled than he actually was. Another Promech pilot said that, early in the 2015 season, he was flying out of the Ella Lake area when he encountered the accident pilot flying in the other direction. He warned him that the area was closed due to weather, but the accident pilot disregarded the report. The accident pilot continued toward Ella Lake but had to backtrack out of the area and ran low on fuel.

Both of those pilots described warning the accident pilot via the radio about an area of severe downdrafts that they had encountered in the Rudyerd Bay area during a previous Misty Fjords tour. They said he disregarded their warning. They said when the accident pilot attempted to fly through the area, he encountered a downdraft, and the airplane's floats struck trees. An entry in the accident pilot's logbook that investigators determined was for that flight, dated June 14, 2015, included the note, "Misty Trip, Thought I was dead." If only the pilot had allowed his motivation to write that note to also trigger some soul-searching and rethinking of his approach to aeronautical decision-making, he and his eight passengers might have survived the "Misty Trip" just 11 days later.

Peter Katz is editor and publisher of NTSB Reporter, an independent monthly update on aircraft accident investigations and other news concerning the National Transportation Safety Board. To subscribe, visit www.ntsbreporter.us or write to: NTSB Reporter, Subscription Dept., P.O. Box 831, White Plains, NY 10602-0831.