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NTSB releases final cause of 2015 fatal crash in southeast Alaska

The National Transportation Safety Board has released its final determination of what caused a de Havilland DHC-3 Otter carrying cruise ship passengers crashed on June 25, 2015. The plane went down about 24 miles from Ketchikan, killing the pilot and eight passengers.

The NTSB determined that pilot error, the company culture at the firm that operated the flight, and the lack of any formal safety program all contributed to the crash.

As we discussed on the blog before, the pilot involved was considered a mentor by many colleagues and struck his boss as admirably focused on safety. He told the investigators that on one particularly concerning weather day, he excused himself from flying merely because he felt uncomfortable. His boss reported saying, "You never have to say sorry to me for coming back."

Yet others had described the pilot as someone who ignored downdraft warnings. On one occasion, it was reported, he allowed his plane's floats to strike trees.

That rings alarm bells considering how the seaplane went down. The weather indicated the use of instrument flight rules, but the 64 year-old pilot continued to operate on visual flight rules. The plane was returning from a "flightseeing" expedition to Misty Fjords National Monument contracted by Holland America cruises.

Moreover, while the pilot had 4,300 hours of overall flight experience and around 1,700 of that was on single-engine seaplanes, he had less than two months' experience in this particular type of flight -- air tours in southeast Alaska. This didn't give him sufficient experience to "calibrate" how much risk to take in marginal weather.

Beyond than this one pilot's excess risk tolerance, the NTSB found that he was under schedule pressure. He was also attempting to emulate the decisions more experienced pilots were making, rather than relying on his own assessment of the risk. Promech, his employer, had a culture where flying in bad weather was tacitly endorsed.

"Pilot decisions are informed, for better or worse, by their company's culture," said the NTSB's acting chair. "This company allowed competitive pressure to overwhelm the common-sense needs of passenger safety in its operations."

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