De Havilland DHC-3 Otter

The single engine airplane was flying to Pluto Lake to pick up a family from a fishing camp. On board were a pilot and a passenger. Upon landing on Pluto Lake, the airplane went out of control, lost its wings, plunged into the water and came to rest. The passenger was unhurt and the pilot was injured and airlifted to Chibougamau. This aircraft was already severely damaged in a previous accident on 20 June 1985. It was repaired and returned into service more than 18 years later.

The single engine airplane departed Friday Harbor on a taxi flight to Renton, carrying nine passengers and one pilot. Half way, the airplane climbed from 600 to 1,000 feet when the speed dropped. The float plane crashed into the Mutiny Bay off Whidbey Island. A dead body was quickly found but during the night of September 6, US Coast Guard suspended the search for nine people who are missing. Searches by the USCG and local agencies spanned about 2,100 nautical miles without success.

The single engine airplane departed Yakutat on an on-demand flight to Dry Bay, a remote airstrip located about 30 miles southeast of the Southeast Alaska community of Yakutat. On final approach, the aircraft crashed in a wooded area located short of runway. All four occupants were injured, three critically.

At approximately 0745 Central Daylight Time on 26 October 2019, the Blue Water Aviation float-equipped deHavillandDHC-3 Otteraircraft (registration C-GBTU, serial number 209) departed Bissett Water Aerodrome, Manitoba, with the pilot, 2 passengers, and approximately 800 pounds of freight on board. The destination was Little Grand Rapids, Manitoba, on the eastern shore of Family Lake. At approximately 0845, while on approach to Family Lake, the aircraft’s right wing separated from the fuselage. The aircraft then entered a nose-down attitudeand struck the water surface of the lake. The pilot and the 2 passengers were fatally injured. The aircraft was destroyed by impact forces. The emergency locator transmitter activated momentarily.

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.

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.