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NTSB's Misty Fjords crash investigation will be long and complex

  • Author: Colleen Mondor
  • Updated: September 28, 2016
  • Published July 14, 2015

Last week, the National Transportation Safety Board released a preliminary report on the recent crash of a sightseeing flight in Misty Fjords National Monument near Ketchikan that killed the pilot and eight passengers.

But that report is only the beginning of an extensive investigation. It will likely be a year before a probable cause for the accident is determined, and during that period the NTSB will conduct a staggering amount of research into the circumstances surrounding the crash. This is familiar territory for the agency and also, sadly, all too familiar for Alaskans as well.

Examining the physical evidence

Pilot Brian Krill was flying a single-engine turbine de Havilland Otter aircraft for the air taxi service Promech Air.

Once the Otter's wreckage is transported to Ketchikan by the aircraft insurance company, it will be received by the NTSB.

"The engine will immediately be placed in a sealed can and then shipped to the manufacturer," Clint Johnson, NTSB Alaska Region director said. The turbine engine from this Otter was made by Pratt and Whitney and will likely be shipped to the company's Montreal facility for a detailed post-accident examination. "While transported it will be escorted and later opened under NTSB supervision," Johnson said.

According to Johnson, the fuselage will remain in Ketchikan where it will be examined by an NTSB structural engineer and representatives of the Viking Air Limited Corporation which now owns the type certificate for the de Havilland DHC-3 Otter airplane.

Decision-making pressures

The eight passengers onboard the aircraft were all passengers on the Holland America Westerdam, which sold tickets for the "Cruise/Fly" shore excursion flight to Rudyerd Bay through a previous arrangement with Promech.

As part of its investigation, the NTSB will be speaking with Holland America employees to determine the nature of the interaction between the companies and their personnel, including how directly they engaged with Krill on the day of the accident and whether any pressure might have existed within that relationship.

An unusual aspect of Alaska aviation is the degree of contact commercial pilots have with their customers, whether those customers are employees of the U.S. Postal Service, representatives of a company engaged in charter contracts, or ticketed passengers.

In reports published on Alaskan air safety in 1980 and 1995, the NSTB has documented how pressure from these customers can have a profoundly negative impact on pilot decision-making.

"It is important for pilots, whether they fly for a company or themselves, to always practice good decision making. Establish a set of risk assessment procedures and stick with them; know the minimums under which you will operate and not violate those based on circumstance," says Harry Kieling, Chairman of the Alaskan Aviation Safety Foundation.

The circumstances he refers to includes all manner of pressures, from degrading weather to a desire to get home to the demands of people in the seats.

One very effective way to keep outside pressure from influencing pilot decision-making is through cue-based training -- something recommended by the NTSB for Southeast Alaska air tour operators in 2007 following the crash that year of a Taquan Air flight that killed all five people aboard. This training involves establishing checkpoints along regularly flown routes. If, at any time during the course of a flight along on that route, a checkpoint is not visible, then the pilot must turn around. The decision to continue on -- to "go take a look" -- is thus taken out of the pilot's hands.

A 2012 letter from the FAA to the NTSB said that by 2011, all the region's air tour operators had "added materials and concepts developed as part of the cue-based training project to their training programs." It's unclear, though, if that training expanded beyond videos and ground school discussion to include flight training and published route checkpoints.

Whether or not a company uses cue-based training, there's always a need for established contingency plans if a flight cannot depart or continue.

"You always need to have the option of spending the night if you can't fly back because of weather or other safety concerns," Kieling says.

Denali operators, for example, have gear and supply caches on the glaciers for that reason; in 2013, a Talkeetna Air Taxi flight was forced to remain on Ruth Glacier after the weather closed in during a tour.

It wasn't immediately clear whether Southeast tour operators maintain similar contingency plans. Investigators will try to determine, for example, whether the boat involved in the excursion the day of Misty Fjords crash was capable of ferrying all of the passengers back to the ship from the floating dock in Rudyerd Bay if the aircraft could not fly, and whose decision it would've been to cancel, if necessary, the flying portion of the trip and revert to a contingency plan.

The NTSB won't know, until it completes its long investigation, whether any such pressure may have been exerted on the pilot. And with everything from weather to pilot turnover at Promech to be examined, outside influence is just one element of many to be considered.

Flying into marginal weather

Krill's flying experience will be thoroughly analyzed, including his number of instrument hours flown and instrument currency. His proficiency at flying solely by instruments would affect his ability to react under inadvertent flight into the marginal weather conditions that were noted by the NTSB.

As ADN has noted in the past however, there's a sharp difference between flying under instrument flight rules and attempting to use onboard equipment, such as a GPS, to navigate visually when conditions suddenly diminish.

Tour flights, by their nature, are nearly always operated under visual flight rules and in this case, the pilot's ability to suddenly and successfully transfer to instrument flight would have been influenced by factors including his training, ability, specific knowledge of the aircraft and the altitude at which he was flying.

The fact that, according to the NTSB, the aircraft impacted "a near vertical rock face in a nose high, wings level attitude" suggests Krill was trying to climb.

It's not known whether he could see the terrain around him, but moving map technology would have just served as a guide; it's not intended to replace the situational awareness that is lost when visibility decreases and can never be considered a substitute for instrument flight standards and requirements.

A cascade of factors

Aircraft accidents rarely happen for a single reason.

Usually they are the result of a cascade of factors -- factors that can date back months or longer and combine to create the unique set of circumstances resulting in a crash. The skills and knowledge a pilot did or did not learn, the practices a company did or did not encourage, the customer relationships which did or did not influence decision-making and the regulatory compliance the FAA did or did not enforce can contribute to what occurred on a fateful flight.

That means aircraft accident investigations are complex and the NTSB will have much to look at as it tries to uncover what went wrong at Misty Fjords.

But for Harry Kieling, the air safety advocate, one thing is very clear.

"Every pilot should establish personal weather minimums that are at least equal to those of the Federal Aviation Regulations or even greater," he asserts. "And don't ever let anyone talk you out of them; including yourself."

Contact Colleen Mondor at colleen@alaskadispatch.com.

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