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2019 Alaska mid-air collision

13 May 2019 · George Inlet, Alaska, United States

Mountain Air Service De Havilland DHC-2 and Venture Travel De Havilland DHC-3 · Mid-air collision, failure to see and avoid conflicting air traffic

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Event

NTSB case
CEN19MA141
Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
Accident
InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
Completed
Event fatalities
6 · all aircraft and ground
Ground fatalities
Unknown
Occupants
16
Survivors
10
InjuriesFatal: death within 30 days. Serious: over 48 hours in hospital within a week, most broken bones, severe bleeding, nerve or organ damage, or serious burns. Minor: anything less. Glossary
10
OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
Charter & commuter
WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
Visual Meteorological Cond

Aircraft 1 · De Havilland DHC-2

Aircraft type
de Havilland DHC-2
Category
Airplane
RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
N952DB
Onboard fatalities
Unknown
Occupants
5
Survivors
0
InjuriesFatal: death within 30 days. Serious: over 48 hours in hospital within a week, most broken bones, severe bleeding, nerve or organ damage, or serious burns. Minor: anything less. Glossary
None · no survivors
Route
From Rudyerd BayTo Ketchikan Harbor Seaplane Base (5KE), Ketchikan, AK
Aircraft age
About 67 years (built 1952)
Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
Part 135: Air Taxi & Commuter
Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
Maneuvering
Defining eventThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
Midair collision
DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
Destroyed

Aircraft 2 · De Havilland DHC-3

Aircraft type
de Havilland DHC-3
Category
Airplane
RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
N959PA
Onboard fatalities
Unknown
Occupants
11
Survivors
10
InjuriesFatal: death within 30 days. Serious: over 48 hours in hospital within a week, most broken bones, severe bleeding, nerve or organ damage, or serious burns. Minor: anything less. Glossary
10
Route
From Rudyerd Bay, AKTo Ketchikan Harbor Seaplane Base (5KE), Ketchikan, AK
Aircraft age
About 63 years (built 1956)
Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
Part 135: Air Taxi & Commuter
Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
Maneuvering
Defining eventThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
Midair collision
DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
Substantial

Cause areas

  • Aircraft › Aircraft systems
  • Organizational issues › Development
  • Organizational issues › Management
  • Personnel issues › Physical

Approximate · Coordinates as recorded by the NTSB; no uncertainty radius is established.

From the Wikipedia article

On May 13, 2019, a de Havilland Canada DHC-2 Beaver floatplane operated by Mountain Air Service collided with a Taquan Air de Havilland Canada DHC-3 Turbine Otter floatplane over George Inlet, Alaska, United States. The DHC-2 broke up in mid-air with the loss of all four passengers and the pilot. The DHC-3 pilot was able to maintain partial control – enough to perform a forced landing on George Inlet – but the aircraft sustained substantial damage in the collision and the landing; the pilot suffered minor injuries, nine passengers suffered serious injuries, and one passenger was killed. Both aircraft were conducting sightseeing flights under visual flight rules, which state that the pilot of each aircraft is responsible for visually ensuring adequate separation from other air traffic, commonly known as "see and avoid".

In April 2021, the National Transportation Safety Board (NTSB) attributed the accident to the inherent limitations of the see-and-avoid concept, along with the absence of alerts from both airplanes' traffic display systems." Due to the angle of approach, the DHC-2 pilot's view was obscured by the aircraft structure and the passenger sitting in the right-hand seat, while the DHC-2 was blocked from the DHC-3 pilot's view by the left front window post. Both aircraft were equipped with Automatic Dependent Surveillance–Broadcast (ADS–B) traffic alert systems, but the DHC-3 automatic alert feature had been disabled by an equipment change, while the alert features of the DHC-2 system did not trigger because avionics in the DHC-3 were not broadcasting the aircraft's altitude. The NTSB also identified Taquan's inadequate preflight checklist and the Federal Aviation Administration's failure to require Taquan to implement a safety management system as contributing factors.

Accident

Both aircraft were returning to Ketchikan Harbor Seaplane Base approximately 7 miles southwest. The DHC-2 was flying at 107 kn at an altitude of about 3350 ft mean sea level (MSL) while the DHC-3 was gradually descending at 126 kn from an altitude of 3700 ft MSL. Visual meteorological conditions prevailed. The DHC-3 was equipped with an Automatic Dependent Surveillance–Broadcast (ADS–B) collision warning system, but the pilot did not perceive any ADS–B collision warnings before he saw a "flash" to his left, and the two aircraft collided at 12:21 PM local time at an altitude of about 3350 ft MSL. One of the passengers in the DHC-3 reportedly saw the other aircraft before the collision and yelled "Pull up! Pull up!" before impact. The collision broke the windshield and separated the left rear door from the DHC-3.

The DHC-2 broke up in mid-air, creating an approximately 2,000 by 1,000 ft debris field about 1.75 miles southwest of the DHC-3 crash site. The DHC-2 fuselage, empennage, and cabin structure were separated from one another, and the right wing showed damage consistent with propeller impacts. The pilot and all 4 passengers were killed.

The DHC-3 pitched about 27 degrees nose down, but the pilot was able to maintain partial control and perform a landing flare before touching down in George Inlet. On landing, the aircraft shuddered violently, the floats separated from the aircraft, and the cabin immediately flooded through the left rear door opening and broken windshield and began to sink. The pilot suffered head injuries in the collision and landing but was able to open the right rear door and help passengers exit. The pilot and surviving passengers were rescued by a nearby boater in a small skiff, who immediately called the United States Coast Guard and ferried the survivors to shore before a Coast Guard boat and helicopter arrived. The female passenger in the right front seat was severely injured and was seen motionless and slumped over in her seat as the aircraft sank. She was the only fatality on the DHC-3.

The DHC-3 came to rest under about 80 ft of water. The fuselage forward of the bulkhead separating the passenger cabin from the cockpit was found mostly broken away from the rear fuselage, and the left side of the forward fuselage was more heavily damaged than the right side. Two propeller blades were partially broken off, while all three were bent and gouged in a manner consistent with heavy rotational contact with a solid object, and were smeared with white paint.

Investigation and cause

Investigation

The National Transportation Safety Board (NTSB) immediately began an investigation of the accident. A preliminary NTSB accident report was published on May 22, 2019.

In a meeting held on April 20, 2021, the NTSB attributed the accident to the inherent limitations of the see-and-avoid concept along with the absence of alerts from both airplanes' traffic display systems." The NTSB examined Automatic Dependent Surveillance–Broadcast (ADS–B) aircraft position data, recorded data from the accident aircraft avionics, and photos taken by passengers in the accident aircraft. The NTSB found that the DHC-2 had been gradually climbing and had leveled off at an altitude of 3350 ft and a heading of about 255°, while the DHC-3 was descending from 4000 ft at a track ranging from 224° and 237°. The agency determined that the DHC-2 pilot would have been unable to see the DHC-3 approaching from his right due to the DHC-2 cockpit structure, the right-hand wing, and the passenger sitting in the right-hand front seat, while the left front window post in the DHC-3 obscured the DHC-2 from the pilot's view for 11 seconds leading up to the collision.

Both aircraft were equipped with ADS–B-based Cockpit Display of Traffic Information (CDTI). However, an FAA-provided equipment upgrade to the Garmin GSL 71 system in the DHC-3, implemented due to the phaseout of the FAA Capstone Program, had disabled the auditory traffic alert feature. Furthermore, the pressure altitude broadcasting feature of the GSL 71 was disabled because the control knob was set to the OFF position, and the Taquan Air preflight checklist (which listed the name of a different operator) did not require the pilot to set the knob to the appropriate position to broadcast pressure altitude. According to data records examined by the NTSB, the DHC-3 had not broadcast pressure altitude since April 29, 2019. The absence of pressure altitude broadcasts effectively disabled the automatic alert features in the ForeFlight mobile app CDTI used by the DHC-2 pilot, which was not designed to provide alerts when the target aircraft is not broadcasting pressure altitude. The lack of dedicated auditory or visual warnings left both pilots dependent on visually checking their CDTI display screens periodically.

The NTSB recommended that the FAA require Part 135 operators to implement safety management systems, which could have mitigated the lack of alerting capability of the CDTI in the Taquan DHC-3, and prompted the airline to update its preflight checklist to include appropriate CDTI settings. Additionally, the NTSB recommended that ForeFlight upgrade their software such that automatic alerts are provided by default when the target aircraft is not broadcasting pressure altitude.

Text from the Wikipedia article “2019 Alaska mid-air collision” (revision 1369183428, retrieved 2026-09-18) by its authors, under CC BY-SA 4.0. Extracted as plain text: references, tables, images and some sections are left out. Read the article

NTSB narrative

On May 13, 2019, about 1221 Alaska daylight time, a float-equipped de Havilland DHC 2 (Beaver) airplane, N952DB, and a float-equipped de Havilland DHC-3 (Otter) airplane, N959PA, collided in midair about 8 miles northeast of Ketchikan, Alaska. The DHC-2 pilot and four passengers sustained fatal injuries. The DHC-3 pilot sustained minor injuries, nine passengers sustained serious injuries, and one passenger sustained fatal injuries. The DHC-2 was destroyed, and the DHC-3 sustained substantial damage. The DHC-2 was registered to and operated by Mountain Air Service LLC, Ketchikan, Alaska, under the provisions of Title 14 Code of Federal Regulations (CFR) Part 135 as an on-demand sightseeing flight. The DHC-3 was registered to Pantechnicon Aviation LTD, Minden, Nevada, and operated by Venture Travel, LLC, dba Taquan Air, Ketchikan, Alaska, under the provisions of Part 135 as an on-demand sightseeing flight. Visual meteorological conditions prevailed in the area at the time of the accident.

Probable cause

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.

Verbatim NTSB analysis and probable cause from the NTSB dataset

Sources

Wikipedia article: 2019 Alaska mid-air collision
Article
2019 Alaska mid-air collision
Revision
1369183428 · 2026-08-13 · retrieved 2026-09-18
Wikidata
Q64684168
Licence
Text CC BY-SA 4.0, by the article's authors; Wikidata CC0; town positions GeoNames (CC BY 4.0)
NTSB record CEN19MA141
Event ID
20190514X70427
Case number
CEN19MA141
Dataset
full-current
Source SHA-256
5cf380f0061817c0331a6b2d8cc7e0ee3a79bea469a1001dc5c10e56f35f5ab3
Where each value comes from
Record
Wikipedia article "2019 Alaska mid-air collision" (page 60838572, revision 1369183428); merged with NTSB case CEN19MA141 (events / aircraft)
Date
NTSB record CEN19MA141: NTSB narrative opening date, consistent with the API date and time (local date)
Place and country
Wikipedia infobox: site; country from NTSB record CEN19MA141
Map position
NTSB record CEN19MA141: events decimal coordinates
Aircraft, operator and route
NTSB record CEN19MA141: aircraft; gaps from Wikipedia infobox: aircraft type, registration, operator, origin and destination; route airports from the linked airport articles' Wikidata codes (OurAirports)
Operation
NTSB record CEN19MA141: operated under Part 135: Air Taxi & Commuter
Fatalities
NTSB record CEN19MA141: NTSB API totalFatal
Ground fatalities
NTSB record CEN19MA141: events.inj_f_grnd
Summary
Wikipedia infobox: summary
Source notes (3)
  • One occurrence in two sources, merged: the Wikipedia article "2019 Alaska mid-air collision" and NTSB case CEN19MA141, matched by the same aircraft registration and date. For this US event the NTSB's values are used where the two differ; each value names its source.
  • Filled from the NTSB case API where the bulk record had no value: investigation status, cause areas. Values present in the bulk record are kept.
  • The date is the local date, which is the same as the UTC date the NTSB stores.