NTSB · Safety Recommendation
Safety Recommendation A-21-023
Recommendation
TO AVIATION INDUSTRY GROUPS (AIRCRAFT OWNERS AND PILOTS ASSOCIATION, EXPERIMENTAL AIRCRAFT ASSOCIATION, NATIONAL BUSINESS AVIATION ASSOCIATION, TOUR OPERATORS PROGRAM OF SAFETY, TONGASS AIRCRAFT PILOTS ASSOCIATION, AND HELICOPTER ASSOCIATION INTERNATIONAL): Inform your members about the circumstances of this accident and encourage them to take the following actions: (1) become familiar with the traffic display equipment installed in their aircraft; (2) if their equipment does not provide an aural alert concerning proximate targets that might pose a collision threat, encourage pilots/operators to supplement the equipment with devices that provide both an aural and visual alert; and (3) remind pilots to include the traffic display when scanning for traffic through the aircraft’s windows.
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
July 16, 2025 · Recipient Response · Experimental Aircraft Association
-From Jack J. Pelton, CEO and Chairman of the Board: For more than 70 years, the Experimental Aircraft Association (EAA) has contributed significantly to the continual improvement of the general aviation safety record. When the NTSB approached us in 2011 with the intent to study the root causes of experimental amateur-built aircraft fatal accidents, we agreed to support the effort. We assisted the NTSB by completing survey work that resulted in the 2012 Safety Study: The Safety of Experimental Amateur-Built Aircraft. In the past 13 years, EAA has been actively working to address the recommendations designated to us in this study and additional recommendations directed to us in 2021.
We have made significant progress and are continually working to improve the experimental safety record, as demonstrated by the reduction in experimental aircraft fatal accidents. To wit, in FAA Fiscal Year 2012 there were 73 fatal accidents in experimental aircraft. In Fiscal Year 2024, there were 37 accidents. This is despite the hours flown in experimental aircraft increasing by more than 350,000 from Calendar Years 2012 to 2023. We are not resting on our laurels by any means. There is ongoing involvement with the General Aviation Joint Safety Committee (GAJSC) to find non-regulatory solutions to improving safety records in general aviation.
EAA has created, promoted, and helped to implement the usage of multiple safety improvement tools in the past five years, including the EAA Flight Test Manual 2.0, which creates a framework for flight testing a homebuilt aircraft and is now part of a formal task-based flight testing program incorporated, optionally, into homebuilt operating limitations.
Additionally, EAA has published a guide for non-builder owners of experimental aircraft, to assist prospective buyers and owners of experimental amateur-built aircraft. This non-builder, or “second owner” demographic, was identified as a significant opportunity for improvement in the 2012 NTSB safety study. There is ongoing involvement with the GAJSC to find non-regulatory solutions to improving general aviation safety records.
In this communication, we respond to the safety recommendations and provide updates on the progress to address the recommendations since they were issued: