Wednesday, July 11, 2018

Loss of Visual Reference: de Havilland Canada DHC-3T Vazar Turbine Otter, N3952B; accident occurred July 10, 2018 in Hydaburg, Alaska

The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Fairbanks, Alaska
Federal Aviation Administration; Fort Worth, Texas
Taquan Air; Ketchikan, Alaska
 
Aviation Accident Factual Report - National Transportation Safety Board: https://app.ntsb.gov/pdf


Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms 
 
http://registry.faa.gov/N3952B


Location: Hydaburg, AK
Accident Number: ANC18FA053
Date & Time: 07/10/2018, 0835 AKD
Registration: N3952B
Aircraft: De Havilland DHC 3
Aircraft Damage: Substantial
Defining Event: Loss of visual reference
Injuries: 6 Serious, 4 Minor, 1 None
Flight Conducted Under: Part 135: Air Taxi & Commuter - Non-scheduled

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, safety officer, and check airmen all stated that operational control could be and was routinely delegated to senior pilots in the absence of the chief pilot.

The GOM stated that "The Director of Operations routinely delegates the duty of Operational control to the Flight Coordinator on duty." However, the flight coordinator on duty at the time of the accident stated that she had no operational control as she was "the flight follower" (a term not defined by the GOM). She added that she did have the authority to cancel a flight for weather or profitability concerns, in addition to, arranging a flight "with concurrence with the person that's in operational control."

The president of the company described operational control as "having someone…that has the ability to check the weather." He stated that the person with operational control was there to assist the pilot and flight coordinator when trying to make a launch decision, whether for weight, pilot experience or weather concerns. When asked who had the ultimate authority for operational control, he said the DO did and added "but he's not here."

Flight Risk Assessment

The Taquan Flight Operations Manual, Operations Specifications, and Training Manual did not include mention of a risk assessment process. Details on the risk assessment process was found in a document titled "Medallion Operational Risk Management (ORM) Implementation Manual" and stated in part:

Taquan Air has provided a form to assess the total risk involved for each flight. Prior to any company flight dispatch, the risk assessment form must be filled out and include all pertinent signatures. The flight coordinator will gather information for each flight to fill out the risk assessment form. The flight coordinator and the PIC for that flight will each sign the form indicating that they are both aware of the information on the form and are equally responsible for the dispatching of that flight. In the event a flight will be made outside of normal business hours, the pilot shall gather all pertinent information, fill out a risk assessment form, sign it, and leave it in the dispatch office. If the risk number is above 10, he/she must contact management before proceeding with the flight…

Company pilots described the flight risk assessment form as highlighting areas of potential risk and then assigning a number and then the number corresponds with certain types of actions. One pilot viewed the form as "…just a piece of paper with some ink on it" and based go/no-go decisions on his experience and research instead.

According to a flight coordinator, the form is typically filled out in its entirety by flight coordinators. According to the DO, flight coordinators complete the first section of the form, and pilots complete the "Manpower" section.

Line pilots, management, and flight coordinators all stated that the pilot has the authority to change, add, or update information to the form. While dispatch and management believed that pilots provided feedback to the assessment often, line pilots stated that while they all had the authority to make changes, none could recall an instance where they had provided feedback to the risk assessment.

CFIT Training

The CFIT training, policies, and procedures were not contained, nor were they required to be, in the FAA-accepted GOM or the FAA-approved training program. Taquan had developed, in conjunction with their Medallion Foundation, a CFIT Avoidance Training Manual; however, there was no regulatory requirement for compliance with the policies contained in the manual.

Section IV of the manual contained the following guidance for inadvertent flight into instrument meteorological conditions (IMC):

"In the advent of inadvertent flight into IMC the crewmember shall immediately initiate corrective action in the form of either a level 180 degree turn away from terrain, a level attitude descent straight ahead or when conditions will not safely allow for either of the preceding maneuvers a immediate climb straight ahead or in a holding pattern to a safe altitude that will allow for terrain clearance to be maintained, followed by a radio call to either flight service or center and request assistance for continued instrument flight until a safe let down can be accomplished, and a call to company to inform them of the situation."

During interviews, multiple pilots stated that the company CFIT escape maneuver was to complete a 180° turn, enable TAWS, descend to 300 ft and set up for a glassy water landing. The accident pilot said that after setting up for the landing, the procedure was to continue below 300ft "until you arrive at the water, or break out of the cloud, I assume." When asked if there was a different procedure for flights over land versus over water, he replied "Not really."

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."

ADDITIONAL INFORMATION

Federal Aviation Administration Oversight

The Juneau Flight Standards District Office (JNU FSDO) was assigned oversight of 102 commercial certificates at the time of the accident. The office manager stated in an interview that there were a total of 12 inspectors assigned to the JNU FSDO. Two of those 12 were principal operations inspectors (POIs); one was in JNU and the other was in Kenai. He said that the FSDO was allocated 5 POIs, but were unable to attract applicants for the position.

The POI for Taquan stated that his workload was "heavy" and he did not have time to complete all his oversight tasks. According to a work assignment letter, he was responsible for the oversight of 24 Part 135 certificates, seven Part 133 certificates and two Part 137 certificates.

Director of Operations Approval

Numerous interviews with FAA management personnel and inspectors responsible for the Grant Aviation and the Taquan air carrier certificates revealed that the FAA was made aware, on multiple occasions, that the DO for Taquan was serving as a management official for two Part 135 certificates; however, there was a belief by the FAA's inspectors and management personnel responsible for the certificates, that this was not contrary to the Federal Aviation Regulations or guidance contained in FAA Order 8900.1. In addition, little to no coordination or communication was established between the POIs responsible for the two certificates.

FAA Order 8900.1, Volume 2, Chapter 2, Section 3, 2-158D, Management Personnel Serving Multiple Certificate Holders, D, states, in part:

NOTE: Headquarters (HQ) will not approve part 135 commuter operations or part 121 operations to share part 119 management personnel, as provided for in this paragraph.

For further operations or human performance information, see the Operational Factors/Human Performance Factual Report located in the public docket for this investigation.

TAWS

Numerous Part 135 operators are authorized to conduct flights under VFR at altitudes below their respective TAWS class required terrain clearance (RTC), and the NTSB has investigated several other fatal CFIT accidents involving operations with TAWS alerts inhibited. As a result, the NTSB issued Safety Recommendation A-17-35, which asked the FAA to implement ways to provide effective TAWS protections while mitigating nuisance alerts for single-engine airplanes operated under Part 135 that frequently operate at altitudes below their respective TAWS class design alerting threshold. 

Pilot Information

Certificate: Airline Transport
Age: 71, Male
Airplane Rating(s): Multi-engine Land; Multi-engine Sea; Single-engine Land; Single-engine Sea
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): Airplane Single-engine
Toxicology Performed: No
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 12/06/2017
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time:  27400 hours (Total, all aircraft), 306 hours (Total, this make and model), 16770 hours (Pilot In Command, all aircraft), 135 hours (Last 90 days, all aircraft), 84 hours (Last 30 days, all aircraft), 6 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: De Havilland
Registration: N3952B
Model/Series: DHC 3 Undesignated
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 225
Landing Gear Type: Float
Seats: 11
Date/Type of Last Inspection: 07/07/2018, AAIP
Certified Max Gross Wt.: 8367 lbs
Time Since Last Inspection: 10 Hours
Engines: 1 Turbo Prop
Airframe Total Time: 16918 Hours as of last inspection
Engine Manufacturer: Pratt & Whitney
ELT: C126 installed, activated, aided in locating accident
Engine Model/Series: PT6A-34
Registered Owner: Blue Aircraft LLC
Rated Power: 750 hp
Operator: Taquan Air
Operating Certificate(s) Held: On-demand Air Taxi (135)

Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument Conditions
Condition of Light: Day
Observation Facility, Elevation: PAHY, 0 ft msl
Distance from Accident Site: 9 Nautical Miles
Observation Time: 0847 AKD
Direction from Accident Site: 90°
Lowest Cloud Condition: Few / 900 ft agl
Visibility:  5 Miles
Lowest Ceiling: Overcast / 1700 ft agl
Visibility (RVR):
Wind Speed/Gusts: 13 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 110°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 30.16 inches Hg
Temperature/Dew Point: 14°C / 13°C
Precipitation and Obscuration: Light - Rain; Moderate - Mist
Departure Point: Klawock, AK
Type of Flight Plan Filed: Company VFR
Destination: Ketchikan, AK
Type of Clearance: None
Departure Time: 0747 AKD
Type of Airspace: Class G

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: 6 Serious, 4 Minor
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 6 Serious, 4 Minor, 1 None
Latitude, Longitude: 55.257500, -132.603611 (est)

ANCHORAGE, Alaska In July of 2018, a floatplane operated by Taquan Air crashed high in the mountains near Ketchikan with 11 people on board, leading to serious injuries for six passengers.

On Thursday, the National Transportation Safety Board (NTSB) released a factual report of the crash, describing that pilot Mikes Hudgins, 71 at the time, had flown into heavy rain and clouds before crashing into a mountain.

Passengers on board the plane told the NTSB that there was “serious fog” during the flight and expressed concern about visibility.
The NTSB report raises questions about how Taquan Air was being operated at the time of the crash and who had the authority to cancel flights because of bad weather.

At the time of the crash, the operations director for Taquan Air was based out of Anchorage and was also working as the director of operations for Grant Aviation. Employees told the NTSB that he visited Taquan Air's Ketchikan base “about once a month but was available by phone, if necessary.”

With the operations director not present, the NTSB describes that no one in Ketchikan had the ultimate authority to cancel a flight.

As a result of the operations director being based in Anchorage, Taquan Air’s chief pilot 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,” the NTSB report detailed.

Clint Johnson, the chief of the regional NTSB, said in his 22 years at the agency he couldn’t personally remember a time when an operations director would be working in the same position at a different company.

“I’m sure it’s probably been done in the past, but I personally don’t recall anything like this,” he said. “Keep in mind, these are two pretty good-sized operations, these are not one ship operations.”

According to the NTSB report, the FAA was made aware on “multiple occasions” that the director of operations for Taquan Air was also working for Grant Aviation.

FAA regulations bar an operations director working for two such companies at the same time. A representative for the FAA said Thursday afternoon the agency had just received the NTSB’s report and could not immediately comment.

Taquan Air’s then-operations director told NTSB investigators on July 10, 2018 that he was planning to leave the company at the end of the season. In the meantime, he worked remotely while Taquan Air looked for a replacement.

“My understanding was, it's much better to have you in that position doing what you do rather than have nobody in that position. And that was the FAA's position,” he told NTSB investigators.

Brian Salazar, the CEO of Taquan Air, told NTSB investigators in July of 2018 that a new operations director was starting soon at the company. Representatives for Taquan Air did not immediately respond to a request for comment about how operations had changed since the 2018 crash.

In 2019, Taquan Air had two deadly crashes within a week of each other. A midair collision near Ketchikan saw six passengers killed, one week later, two people died in a floatplane crash near Metlakatla.


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Location: Hydaburg, AK
Accident Number: ANC18FA053
Date & Time: 07/10/2018, 0835 AKD
Registration: N3952B
Aircraft: De Havilland DHC 3
Injuries: 6 Serious, 4 Minor, 1 None
Flight Conducted Under: Part 135: Air Taxi & Commuter - Non-scheduled 

On July 10, 2018, about 0835 Alaska daylight time, a single-engine, turbine-powered, float-equipped de Havilland DHC3T Otter airplane, N3952B, sustained substantial damage during an impact with rocky, mountainous, rising terrain about 9 miles west of Hydaburg, Alaska. The airplane was registered to Blue Aircraft, LLC and operated by Taquan Air as a visual flight rules (VFR) on-demand commercial flight under the provisions of 14 Code of Federal Regulations Part 135 when the accident occurred. Of the 11 occupants on board, the airline transport pilot was uninjured, four passengers sustained minor injuries, and six passengers sustained serious injuries. Marginal visual meteorological conditions prevailed, and company flight following procedures were in effect. The flight departed Steamboat Bay about 0747 destined for Ketchikan, Alaska.

The area between Steamboat Bay and Ketchikan consists of remote inland fjords, coastal waterways, and steep mountainous terrain.

During an initial telephone interview with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) on July 11, the accident pilot reported that while in level cruise flight at about 1,100 ft mean sea level (MSL), and as the flight progressed into an area known as Sulzer Portage, visibility decreased rapidly from about 3-5 miles to nil. In an attempt to turnaround and return to VFR conditions, he initiated a climbing right turn. Prior to 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, emergency climb to avoid rising terrain ahead. As the steep emergency climb continued, the airspeed decayed, and the airplane subsequently collided with an area of rocky, rising terrain. During the initial impact, the airplane's floats were sheared off. The airplane wreckage came to rest in an area known as Jumbo Mountain, sustaining substantial damage to wings and fuselage.

The pilot stated that the Terrain Awareness and Warning System (TAWS) was in the inhibit mode at the time of the accident.

According to the passenger seated in the right front seat, after departure, they proceeded to Klawock and then made what he perceived to be as a 180° turn. He said there were numerous course deviations as they 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 loom directly in front of the airplane, knowing they could not out climb the mountain he presumed there must be a pass through the area. As they continued to approach the mountain they entered a cloud and he observed the pilot add power and pitch up, but the airplane impacted the side of the mountain.

According to a second passenger seated towards 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 consistent 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 (AST) that a float plane had crashed near Sulzer Portage on Prince of Wales Island. Two MH-60J Sea Hawk helicopters were launched from USCG Air Station Sitka, and AST activated the Ketchikan Volunteer Rescue Squad (KVRS) and other rescue personnel utilizing Temsco Helicopters, Inc. of Ketchikan. Five helicopters were dispatched from Temsco to the search area and a staging area was established near the believed to be 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. After receiving word that the USCG was approaching the search area, he returned to the staging area. A "First Alert" was received from the accident airplane's onboard emergency locator transmitter (ELT) at 0911. About the same time, 911 dispatch in Ketchikan talked to a survivor 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 (DF) bearing from the ELT at the crash scene. The DF bearing, and the survivor's description of the accident area were used to direct search assets in close proximity to the accident site, so the survivors could hear the USCG helicopters. Two-way radio communications were established between the survivors and USCG by utilizing 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 by Temsco Helicopters.

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 closest weather reporting facility was Hydaburg Seaplane Base (PAHY), Hydaburg, Alaska, about 9 miles west of the accident site. At 0847, an METAR from PAHY was reporting, in part: wind from 110° at 13 knots; visibility, 5 statute miles in light rain and mist; clouds and sky condition, few clouds at 900 ft, overcast clouds at 1,700 ft; temperature, 57° F; dew point 55° F; altimeter, 30.16 inches of mercury.

A detailed wreckage examination is pending.

ADDITIONAL INFORMATION

On April 25, 2017, the NTSB adopted its final report concerning the June 25, 2015, accident in which a single-engine, turbine-powered, float-equipped de Havilland DHC-3 (Otter) airplane, N270PA, collided with mountainous, tree-covered terrain about 24 miles east-northeast of Ketchikan, Alaska. As a result of that investigation, the NTSB issued numerous safety recommendations. One such recommendation, A-17-35, was issued to the FAA and stated in part: Implement ways to provide effective terrain awareness and warning system (TAWS) protections while mitigating nuisance alerts for single-engine airplanes operated under 14 Code of Federal Regulations Part 135 that frequently operate at altitudes below their respective TAWS class design alerting threshold. This recommendation was reiterated during a separate investigation on April 26, 2018 is currently Open-Acceptable Response.

Aircraft and Owner/Operator Information

Aircraft Make: De Havilland
Registration: N3952B
Model/Series: DHC 3 Undesignated
Aircraft Category: Airplane
Amateur Built: No
Operator: Taquan Air
Operating Certificate(s) Held: On-demand Air Taxi (135) 

Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument Conditions
Condition of Light: Day
Observation Facility, Elevation: PAHY, 0 ft msl
Observation Time: 0847 AKD
Distance from Accident Site: 9 Nautical Miles
Temperature/Dew Point: 14°C / 13°C
Lowest Cloud Condition: Few / 900 ft agl
Wind Speed/Gusts, Direction: 13 knots / , 110°
Lowest Ceiling: Overcast / 1700 ft agl
Visibility:  5 Miles
Altimeter Setting: 30.16 inches Hg
Type of Flight Plan Filed: Company VFR
Departure Point: Klawock, AK
Destination: Ketchikan, AK

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: 6 Serious, 4 Minor
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 6 Serious, 4 Minor, 1 None
Latitude, Longitude:  55.257500, -132.603611 (est)




Four of the 11 people involved in Tuesday's Ketchikan plane crash have been flown to Seattle for further treatment.

A spokeswoman for Ketchikan PeaceHealth Medical Center, Mischa Chernick, said Wednesday that six people were assessed and released in Ketchikan Tuesday, with a seventh admitted and in fair condition Wednesday. The other patients were medevaced to Seattle.

Susan Gregg, a spokeswoman at Harborview Medical Center in Seattle, said one of the four people -- a male -- was admitted in satisfactory condition. One was treated and released, with the others set to be discharged Wednesday.

Chris John, commander of the Ketchikan Volunteer Rescue Squad, said the occupants were all in Ketchikan after a U.S. Coast Guard helicopter reached the plane shortly after noon Tuesday, in a mountainous area with peaks up to 3,500 feet in height.

Coast Guard Petty Officer 1st Class Jon-Paul Rios said word of the crash about 34 nautical miles southwest of Ketchikan, involving a plane carrying a pilot and 10 passengers, first reached the Coast Guard at about 9:20 a.m. Tuesday. The plane had reportedly hit the side of Mount Jumbo, at an altitude of 2,000 feet, with its emergency locator transmitter activated soon afterward.

By 1 p.m., he said, the helicopter crew was "in the process of hoisting individuals." Soon afterward, the plane's occupants were en route to Ketchikan aboard Temsco helicopters for a proper medical assessment of their injuries, which the Coast Guard initially reported as minor.

The passengers weren't immediately identified Tuesday, but Alaska State Troopers said in an online dispatch that the pilot was 72-year-old Mike Hudgins of Ketchikan.

Clint Johnson, the National Transportation Safety Board’s Alaska chief, said the crashed aircraft was a de Havilland DHC-3T Turbine Otter floatplane operated by Taquan Air. The plane had departed a seaplane base at Steamboat Bay on Noyes Island at about 7:30 a.m., and was en route to Ketchikan.

Taquan Air staff said in a statement after the plane occupants' rescue that they were "thankful for their safe transport and at this time our focus is on assisting these passenger, the pilot, their families and loved ones."

"Taquan Air has suspended all scheduled flights today and is cooperating fully with the NTSB, FAA and other authorities to examine every aspect of this event," company officials wrote. "It is imperative we understand the factors surrounding this incident to help prevent similar ones."

Several cruise ships were in Ketchikan Tuesday, but Holland America Lines and Princess Cruises said in a joint statement that no cruise passengers were on board the plane.

“Guests booked on the impacted excursions will receive refunds,” staff at the cruise lines wrote. “We will continue to offer flightseeing excursions in Alaska with other operators.”

Two MH-60 Jayhawk helicopters were sent to the scene from Air Station Sitka, Rios said. In addition, KVRS had chartered four helicopters to assist the Coast Guard.

Rescuers had been in intermittent cellphone and text-message contact with the people on board, John said Tuesday afternoon, after clouds had hampered morning attempts to reach the crash site.

Story and video ➤ http://www.ktva.com

5 comments:

Jim B said...


I would like for someone to explain to me with Garmin 430's, 530's, 650's, G-1000, Foreflight, Garmin Pilot (and many other useful tools) with terrain/object avoidance features that aircraft are still doing Controlled Flight Into Terrain and/or hitting towers and power lines.

Educate me. I do not get it at all.

John Pruitt said...

"Low, Slow, and Heavy"

Anonymous said...

The same reason people are still landing “gear up.”

Anonymous said...

Vfr into imc... Scud running in the mountains and ignoring all the high tech stuff. Hold my beer I got this.

Anonymous said...

Look at the flight path on Flight Aware. The pilot was clearly disoriented. He left Steamboat Bay and flew WNW and looped back to avoid the low ceiling. He followed the shore and flew at or below 800 ft the majority of the route. The climb to the 1800' crash sight was directly towards the 3000+ foot Mt. Jumbo. If he were 1.25 miles north, he would have been in the valley and in the clear. I'm not sure what VFR regulations allow you to fly into the cloud bank. Hundreds of miles of open water to land but he had a schedule to keep. Risking passenger lives for money. Amazing that they all lived.