A pilot’s decision to continue flying under visual flight rules in weather conditions warranting instrument flight rules, coupled with a company’s culture and lack of a formal safety program, caused a 2015, Ketchikan, Alaska, plane crash, according to a determination made Tuesday by the National Transportation Safety Board (NTSB).

Nine people died when the de Havilland DHC-3 (Otter) airplane, operated by Promech Air, Inc., of Ketchikan, Alaska, crashed in mountainous, tree-covered terrain near Ketchikan, June 25, 2015.

Pilot influenced by pressure

The NTSB noted in its report that the pilot, who had less than two months’ experience flying air tours in Southeast Alaska, had demonstrated difficulty calibrating his own risk tolerance for conducting tour flights in marginal weather or weather below FAA minimums. Evidence collected in the investigation supported a finding 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; and Promech’s organizational culture which tacitly endorsed flying in hazardous weather conditions.

“Lives depended on the pilot’s decision making,” said NTSB Acting Chairman Robert Sumwalt. “Pilot decisions are informed, for better or worse, by their company’s culture. This company allowed competitive pressure to overwhelm the common-sense needs of passenger safety in its operations. That’s the climate in which the accident pilot worked.”

Competitive pressures

The NTSB determined Promech’s company culture tacitly condoned flying under VFR in hazardous weather conditions, and that Promech failed to manage the risk associated with competitive pressures. Since the Ketchikan air tour industry is competitive, Promech and at least one other operator that was willing to take more weather-related risks were both able to fly more revenue passengers than two other more conservative operators who cancelled flights that day, according to the NTSB’s report.

As a result of the investigation the NTSB issued nine recommendations to the Federal Aviation Administration and one to the Cruise Lines International Association. The NTSB also reiterated three previously issued recommendations to the FAA.

The synopsis, findings, opening and closing statements and all recommendations related to the accident are available online at https://go.usa.gov/x58Cu

The full report will be available in a few weeks at ntsb.gov.