This report discusses the June 25, 2015, accident in which a turbine-powered, float-equipped de Havilland DHC-3 airplane, N270PA, operated by Promech Air, Inc., collided with mountainous, tree-covered terrain about 24 miles east-northeast of Ketchikan, Alaska. The commercial pilot and eight passengers sustained fatal injuries, and the airplane was destroyed. Safety issues discussed in this report relate to the need for training program improvements for Ketchikan air tour operators that address pilot human factors issues, such as assessment of safe weather conditions, recognition of potentially hazardous local weather patterns, and operational influences on decision-making; the need for collaboration among Ketchikan air tour operators to identify and mitigate operational hazards through analysis of automatic dependent surveillance-broadcast data; the lack of conservative weather minimums for Ketchikan air tour operators; the lack of defined curriculum segments for controlled flight into terrain-avoidance training for all 14 Code of Federal Regulations Part 135 operators; nuisance alerts from the Class B terrain awareness and warning system during tour operations; the limitations of older software and terrain database versions for the legacy Chelton Flight Systems FlightLogic electronic flight instrument system; the lack of minimum training requirements for operational control personnel and the lack of guidance for Federal Aviation Administration inspectors for performing oversight of operational control training programs; the need for cruise industry awareness of schedule pressures associated with air tours sold as shore excursions; the lack of a requirement for a safety management system for Part 135 operators; and the lack of a crash-resistant flight recorder system.


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