NTSB · Safety Recommendation
Safety Recommendation A-21-018
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: Review current and future supplemental type certificate installation instructions and flight manual supplements to ensure they provide provisions to prevent the inadvertent disabling of the broadcast of pressure altitude data, by design, where practicable.
Safety Issue and Context
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.
According to information provided by the operators, both airplanes had been conducting sightseeing flights and were both converging on a scenic waterfall before returning to the Ketchikan Harbor Seaplane Base (5KE), Ketchikan, Alaska, when the accident occurred. Automatic dependent surveillance-broadcast (ADS-B) tracking data for both airplanes revealed that, at 1217:15, the DHC-3 was about level at 4,000 ft mean sea level (msl) on a track of 225°, and the DHC-2 was 4.2 nautical miles (nm) south of the DHC-3, climbing through 2,800 ft msl, on a track of 255°.1 About 1219, the DHC-3 started a descent from 4,000 ft, and the DHC-2 was at 3,175 ft and climbing.
During the next 1 minute 21 seconds, the DHC-3 continued to descend on a track between 224° and 237°, and the DHC-2 leveled out at 3,350 ft on a track of about 255°. The airplanes collided at 1221:14 at an altitude of 3,350 ft, 7.4 nm northeast of 5KE.
Response History
February 9, 2026 · NTSB Correspondence · FAA
As discussed in our previous meeting, we are currently reviewing several FAA letters submitted during the previous administration and would like to confirm that those letters still reflect the FAA position.
We issued Safety Recommendations A-21-15 through -19 as a result of our investigation of the 2019 midair collision in Ketchikan Alaska.
A-21-15: Identify high-traffic air tour areas and require, through a special federal aviation regulation or other means, that Title 14 Code of Federal Regulations Parts 91 and 135 air tour operators that operate within those areas be equipped with an Automatic Dependent Surveillance-Broadcast Out- and In-supported traffic advisory system that 1) includes both visual and aural alerts, 2) is driven by an algorithm designed to minimize nuisance alerts, and 3) is operational during all flight operations.
A-21-16: In the high-traffic air tour areas identified in Safety Recommendation A-21-15, require that all non–air tour aircraft operating within the airspace be equipped with Automatic Dependent Surveillance-Broadcast Out.
A-21-17: Require the installation of Automatic Dependent Surveillance-Broadcast Out- and In-supported airborne traffic advisory systems that include aural and visual alerting functions in all aircraft conducting operations under Title 14 Code of Federal Regulations Part 135.
A-21-18: Review current and future supplemental type certificate installation instructions and flight manual supplements to ensure they provide provisions to prevent the inadvertent disabling of the broadcast of pressure altitude data, by design, where practicable.
In his November 6, 2024, letter, former Administrator Whitaker told us that the FAA actions on these recommendations were compete.