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NTSB: Disorientation Led to Fatal Plane Crash

The National Transportation Safety Board (NTSB) has issued its report into a fatal 2015 plane crash that killed nine people, finding that the pilot was under pressure from his company to return his passengers to a cruise ship, which led to him becoming disoriented in cloudy weather. Investigators blamed both the pilot's disorientation and the company's culture for the tragedy, which occurred on June 25, 2015.

Nine Died When Plane Crashed into Mountainous Terrain 

All eight passengers and the pilot died when the single-engine de Havilland DHC-3 (Otter) airplane they were in crashed into mountainous terrain near Ketchikan Alaska. The crashed plane was part of a sightseeing tour for passengers onboard a cruise ship that had been docked in Ketchikan. Two groups of passengers were scheduled to depart the cruise ship for a floating dock in Rudyerd Bay, with one group leaving by plane and the other by boat. At the floating dock, the two groups were to switch their transportation modes to head back to the cruise ship.

The doomed plane was the third of four float planes operated by Promech to take a tour over the Misty Fjords National Monument Wilderness, with each plane leaving approximately five minutes after the one before. When the plane did not return to Ketchikan, a search was initiated and an emergency locator transmitter signal was found. The plane itself was ultimately located "in an area of heavily forested, steep terrain," according to the NTSB preliminary report.

Fox News reported at the time of the crash that the plane was found with the fuselage largely intact, although the wings and tail broke off in the crash.

Pilot Inexperience, Company Culture Led to Plane Crash 

Bryan Krill, the pilot of the downed plane, had fewer than two months' experience flying air tours in that area, and reportedly showed difficulty with assessing his own capacity for risk. The NTSB report notes that Krill continued to fly under visual flight rules even though weather conditions warranted a switch to instrument flight rules.

The pilot had the option of taking a short route or a long route back to the cruise ship. The long route was known for being less scenic, but, because it was primarily over water, was also the preferred option during poor weather conditions. Krill and two others chose to return via the short route, while the fourth pilot chose the long route. The NTSB notes that Krill's decision to use the short route may have been influenced by other, more experienced pilots also choosing the short route and by the pressure to get cruise ship passengers back to the ship on time.

Despite choosing to take the short route, Krill moved off the designated route and turned west early, putting his plane on a collision course with a 1,900-foot mountain. Just prior to colliding, the plane pitched up indicating the pilot attempted at the last minute to avoid a collision.

"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 Pomech's organizational culture which tacitly endorsed flying in hazardous weather conditions," the NTSB wrote.

The NTSB found that two other tour operators who also flew passengers in the same area where the crash occurred had cancelled that day's flights, but Promech and one other tour operator took more risks and were able to bring in more revenue as a result.

"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."

NTSB Issues Recommendations Following Alaska Plane Crash 

Following its investigation into the plane crash, the NTSB made a variety of recommendations for cruise ships and local tour operators. These recommendations may be timely because according to the NTSB, there have been four fatal crashes involving cruise-ship passengers in Alaska in the eight years before this crash occurred.

Among the NTSB's recommendations:

  • That Ketchikan air tour operators make training improvements to address pilot human factors, including assessment of weather conditions;
  • That conservative weather minimums for Ketchikan air tour operators be implemented to encourage operators to avoid flying in poor weather; and
  • That the cruise line industry be aware that schedule pressures affect how air tours are operated if they must return passengers to a cruise ship in a short time.

Victims of Cruise Ship Tour Plane Crash Remembered 

Everyone on the plane with the exception of the pilot was a guest aboard the Westerdam, a Holland America Line cruise ship, which had left Seattle on June 20. Among the victims of the plane crash were pilot Bryan Krill, Rowland Cheney, Mary Doucette, June Kranenburg, Leonard Kranenburg, Margie Apodaca, Raymond Apodaca, Glenda Cambiaso, and Hugo Cambiaso.

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