N952DBDe Havilland DHC-22019-05-13 NTSB Accident Report

Destroyed
Fatal

De Havilland DHC-2S/N: 237

Summary

On May 13, 2019, a De Havilland DHC-3 (N959PA) was involved in an accident near Ketchikan, AK. The accident resulted in 6 fatal injuries, 9 serious injuries, 1 minor injury. The aircraft sustained substantial damage.

The National Transportation Safety Board determined the probable cause of this accident to be: The inherent limitations of the see-and-avoid concept, which prevented the two pilots from seeing the other airplane before the collision, and the absence of visual and aural alerts from both airplanes’ traffic display systems, while operating in a geographic area with a high concentration of air tour activity. Contributing to the accident were (1) the Federal Aviation Administration’s provision of new transceivers that lacked alerting capability to Capstone Program operators without adequately mitigating the increased risk associated with the consequent loss of the previously available alerting capability and (2) the absence of a requirement for airborne traffic advisory systems with aural alerting among operators who carry passengers for hire.

This accident is documented in NTSB report CEN19MA141. AviatorDB cross-references NTSB investigation data with FAA registry records to provide comprehensive safety information for aircraft N959PA.

Accident Details

Date
Monday, May 13, 2019
NTSB Number
CEN19MA141
Location
Ketchikan, AK
Event ID
20190514X70427
Coordinates
55.425556, -131.505000
Aircraft Damage
Destroyed
Highest Injury
Fatal
Fatalities
6
Serious Injuries
9
Minor Injuries
1
Uninjured
0
Total Aboard
16

Probable Cause and Findings

The inherent limitations of the see-and-avoid concept, which prevented the two pilots from seeing the other airplane before the collision, and the absence of visual and aural alerts from both airplanes’ traffic display systems, while operating in a geographic area with a high concentration of air tour activity. Contributing to the accident were (1) the Federal Aviation Administration’s provision of new transceivers that lacked alerting capability to Capstone Program operators without adequately mitigating the increased risk associated with the consequent loss of the previously available alerting capability and (2) the absence of a requirement for airborne traffic advisory systems with aural alerting among operators who carry passengers for hire.

Aircraft Information

Registration
Make
DE HAVILLAND
Serial Number
237
Engine Type
Reciprocating
Model / ICAO
DHC-2DH82
Aircraft Type
Fixed Wing Single Engine
No. of Engines
1

Registered Owner (Historical)

Name
MOUNTAIN AIR SERVICE LLC
Address
PO BOX 7313
Status
Deregistered
City
KETCHIKAN
State / Zip Code
AK 99901-2313
Country
United States

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# CEN19MA141