# NTSB ANC15MA041: Dehavilland DHC-3, N270PA, Ketchikan, AK, June 25, 2015

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Class 1 · Major · Final report
- Date: June 25, 2015, 12:15 local (20:15 UTC)
- Place: Ketchikan, AK
- Coordinates: 55.45639, -131.146118 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=55.4564&lon=-131.1461&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Defining event: [Enroute-cruise: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120)
- Highest injury: Fatal
- Injuries: 9 fatal
- Status: Completed, report May 17, 2017
- Report: Board-adopted at Board Meeting
- Investigation class: Class 1
- NTSB office: Alaska Regional Office
- Parties: Hartzell Propeller, Promech Air, Federal Aviation Administration, Genesys Aerosystems, Holland America Group
- Safety recommendations: Yes
- NTSB case key (mKey): 91435
- NTSB case page: https://www.ntsb.gov/investigations/Pages/ANC15MA041.aspx
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91435/pdf
- Board report AAR1702 (PDF): https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR1702.pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91435
- Page: https://openairdocs.org/ntsb/ANC15MA041

## Probable cause

(1) the pilot's decision to continue visual flight into an area of instrument meteorological conditions, which resulted in his geographic disorientation and controlled flight into terrain; and (2) Promech's company culture, which tacitly endorsed flying in hazardous weather and failed to manage the risks associated with the competitive pressures affecting Ketchikan-area air tour operators; its lack of a formal safety program; and its inadequate operational control of flight releases.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Dehavilland DHC-3, 4 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2802412), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md)
- [Perception/orientation/illusion: geographic disorient (lost)](https://openairdocs.org/ntsb-findings/02022030): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Dehavilland DHC-3, 1 case](https://openairdocs.org/ntsb-findings/02022030/cases.md?model=2802412), [All aircraft, 27 cases](https://openairdocs.org/ntsb-findings/02022030/cases.md)
- [Culture: safety](https://openairdocs.org/ntsb-findings/04024010): Organizational issues › Management · Operator (probable cause); cases with it: [Dehavilland DHC-3, 1 case](https://openairdocs.org/ntsb-findings/04024010/cases.md?model=2802412), [All aircraft, 11 cases](https://openairdocs.org/ntsb-findings/04024010/cases.md)
- [Culture: pressures/demands](https://openairdocs.org/ntsb-findings/04024020): Organizational issues › Management · Operator (probable cause); cases with it: [Dehavilland DHC-3, 1 case](https://openairdocs.org/ntsb-findings/04024020/cases.md?model=2802412), [All aircraft, 5 cases](https://openairdocs.org/ntsb-findings/04024020/cases.md)
- [Culture: standard operating practices](https://openairdocs.org/ntsb-findings/04024015): Organizational issues › Management · Operator (probable cause); cases with it: [Dehavilland DHC-3, 1 case](https://openairdocs.org/ntsb-findings/04024015/cases.md?model=2802412), [All aircraft, 10 cases](https://openairdocs.org/ntsb-findings/04024015/cases.md)
- [Oversight: oversight of operation](https://openairdocs.org/ntsb-findings/04032015): Organizational issues › Support/oversight/monitoring · Operator (probable cause); cases with it: [Dehavilland DHC-3, 1 case](https://openairdocs.org/ntsb-findings/04032015/cases.md?model=2802412), [All aircraft, 61 cases](https://openairdocs.org/ntsb-findings/04032015/cases.md)
- [Ceiling/visibility/precip](https://openairdocs.org/ntsb-findings/03035000): Environmental issues › Conditions/weather/phenomena · Decision related to condition (probable cause); cases with it: [Dehavilland DHC-3, 1 case](https://openairdocs.org/ntsb-findings/03035000/cases.md?model=2802412), [All aircraft, 65 cases](https://openairdocs.org/ntsb-findings/03035000/cases.md)
- [Navigation system: ground proximity system](https://openairdocs.org/ntsb-findings/01023444): Aircraft › Aircraft systems · Design; cases with it: [Dehavilland DHC-3, 1 case](https://openairdocs.org/ntsb-findings/01023444/cases.md?model=2802412), [All aircraft, 7 cases](https://openairdocs.org/ntsb-findings/01023444/cases.md)
- [Navigation system](https://openairdocs.org/ntsb-findings/01023400): Aircraft › Aircraft systems · Design; cases with it: [Dehavilland DHC-3, 2 cases](https://openairdocs.org/ntsb-findings/01023400/cases.md?model=2802412), [All aircraft, 13 cases](https://openairdocs.org/ntsb-findings/01023400/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Enroute-cruise: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Dehavilland DHC-3, 4 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=2802412), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md)

## Analysis

The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-17/02. On June 25, 2015, about 1215 Alaska daylight time, a single-engine, turbine-powered, float-equipped de Havilland DHC-3 (Otter) airplane, N270PA, collided with mountainous, tree-covered terrain about 24 miles east-northeast of Ketchikan, Alaska. The commercial pilot and eight passengers sustained fatal injuries, and the airplane was destroyed. The airplane was owned by Pantechnicon Aviation, of Minden, Nevada, and operated by Promech Air, Inc., of Ketchikan. The flight was conducted under the provisions of 14 Code of Federal Regulations Part 135 as an on-demand sightseeing flight; a company visual flight rules flight plan (by which the company performed its own flight-following) was in effect. Marginal visual flight rules conditions were reported in the area at the time of the accident. The flight departed about 1207 from Rudyerd Bay about 44 miles east-northeast of Ketchikan and was en route to the operator's base at the Ketchikan Harbor Seaplane Base, Ketchikan.

## Factual narrative

The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-17/02. On June 25, 2015, about 1215 Alaska daylight time, a single-engine, turbine-powered, float-equipped de Havilland DHC-3 (Otter) airplane, N270PA, collided with mountainous, tree-covered terrain about 24 miles east-northeast of Ketchikan, Alaska. The commercial pilot and eight passengers sustained fatal injuries, and the airplane was destroyed. The airplane was owned by Pantechnicon Aviation, of Minden, Nevada, and operated by Promech Air, Inc., of Ketchikan. The flight was conducted under the provisions of 14 Code of Federal Regulations Part 135 as an on-demand sightseeing flight; a company visual flight rules flight plan (by which the company performed its own flight-following) was in effect. Marginal visual flight rules conditions were reported in the area at the time of the accident. The flight departed about 1207 from Rudyerd Bay about 44 miles east-northeast of Ketchikan and was en route to the operator's base at the Ketchikan Harbor Seaplane Base, Ketchikan.

## Aircraft

- Registration: [N270PA](https://openairdocs.org/deregistered/N270PA-2018-08-18), registration cancelled 2018-08-18, S/N 270, built 1958 (OpenAirDocs)
- Reported make and model: DEHAVILLAND DHC-3
- Registry model: [Dehavilland DHC-3](https://openairdocs.org/model/dehavilland-dhc-3) (registry code 2802412) (OpenAirDocs)
- Registry engine: [Pratt & Whitney R1340 series](https://openairdocs.org/engine/pratt-whitney-r1340-series) (registry code 52016, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 270
- Year built: 1958
- Airframe hours: 24439.5
- Engines: turbo prop
- Damage: Substantial damage
- Flight: Part 135
- Operator: Promech Air, Inc.
- Registered owner: Pantechnicon Aviation Ltd
- Airworthiness certificate: Standard, Normal
- Last inspection: AAIP, June 10, 2015
- Departed: Ketchikan, AK
- Destination: Ketchikan, AK
- Flight plan: Company VFR
- Equipment: Electronic primary flight display, Electronic multifunction display, ADS-B

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 64; injuries: fatal; commercial; airplane ratings: single-engine land, single-engine sea; instrument ratings: airplane; medical: class 2, without waivers/limitations; seat: left; restraint: 3-point; toxicology performed; flight hours: 3,912 total, 37 in this make and model, 3,912 as pilot in command, 153 in the last 90 days, 91 in the last 30 days, 3 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 130° at 15 knots, gusting 23
- Visibility: 6 statute miles
- Lowest ceiling: 1,200 ft broken
- Temperature: 61 °F, dew point 57 °F
- Altimeter: 29.90 inHg
- Observed at: KTN, 24 nm away

## Docket (59 files)

The files NTSB released with the investigation on March 21, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91435.

- Cockpit Displays – Recorded Flight Data - Specialist's Factual Report (item 1, .PDF, 11 photos, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449785&FileExtension=.PDF&FileName=Cockpit%20Displays%20%E2%80%93%20Recorded%20Flight%20Data%20-%20Specialist%27s%20Factual%20Report-Master.PDF
- Cockpit Displays – Recorded Flight Data - Attachment 1 (IDU 36519 AC.DAT File) (item 2, .TXT, 2 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449786&FileExtension=.txt&FileName=Cockpit%20Displays%20%E2%80%93%20Recorded%20Flight%20Data%20-%20Attachment%201%20(IDU%2036519%20AC.DAT%20File)-Master.txt
- Cockpit Displays – Recorded Flight Data - Attachment 2 (IDU 34790 AC.DAT File) (item 3, .TXT, 2 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449787&FileExtension=.txt&FileName=Cockpit%20Displays%20%E2%80%93%20Recorded%20Flight%20Data%20-%20Attachment%202%20(IDU%2034790%20AC.DAT%20File)-Master.txt
- Cockpit Displays – Recorded Flight Data - Attachment 3 (IDU 36519 SETTINGS.DAT File) (item 4, .TXT): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449788&FileExtension=.txt&FileName=Cockpit%20Displays%20%E2%80%93%20Recorded%20Flight%20Data%20-%20Attachment%203%20(IDU%2036519%20SETTINGS.DAT%20File)-Master.txt
- Cockpit Displays – Recorded Flight Data - Attachment 4 (IDU 34790 AC.DAT File) (item 5, .TXT, 1 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449789&FileExtension=.txt&FileName=Cockpit%20Displays%20%E2%80%93%20Recorded%20Flight%20Data%20-%20Attachment%204%20(IDU%2034790%20AC.DAT%20File)-Master.txt
- Cockpit Displays – Recorded Flight Data - Attachment 5 (Tabular Data) (item 6, .CSV, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449790&FileExtension=.csv&FileName=Cockpit%20Displays%20%E2%80%93%20Recorded%20Flight%20Data%20-%20Attachment%205%20(Tabular%20Data)-Master.csv
- Cockpit Displays – Recorded Flight Data – Addendum 1 (item 7, .PDF, 22 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450057&FileExtension=.PDF&FileName=Cockpit%20Displays%20%E2%80%93%20Recorded%20Flight%20Data%20%E2%80%93%20Addendum%201-Master.PDF
- Cockpit Displays – Recorded Flight Data – Addendum 1 - Attachment 1 (Tabular Data) (item 8, .CSV, 12 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450058&FileExtension=.csv&FileName=Cockpit%20Displays%20%E2%80%93%20Recorded%20Flight%20Data%20%E2%80%93%20Addendum%201%20-%20Attachment%201%20(Tabular%20Data)-Master.csv
- Personal Electronic Devices and Cameras - Group Chairman's Factual Report (item 9, .PDF, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450146&FileExtension=.PDF&FileName=Personal%20Electronic%20Devices%20and%20Cameras%20-%20Group%20Chairman%27s%20Factual%20Report-Master.PDF
- Cockpit Displays – Recorded Flight Data Replay - Specialist's Study Report (item 10, .PDF, 101 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449791&FileExtension=.PDF&FileName=Cockpit%20Displays%20%E2%80%93%20Recorded%20Flight%20Data%20Replay%20-%20Specialist%27s%20Study%20Report-Master.PDF
- Cockpit Displays – Recorded Flight Data Replay - Specialist's Study Report - Attachment 1 (Quicktime Movie) (item 11, .PDF, 193 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449806&FileExtension=.PDF&FileName=Cockpit%20Displays%20%E2%80%93%20Recorded%20Flight%20Data%20Replay%20-%20Specialist%27s%20Study%20Report%20-%20Attachment%201%20(Quicktime%20Movie)-Master.PDF
- Airworthiness Group Chairman's Factual Report (item 12, .PDF, 351 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449792&FileExtension=.PDF&FileName=Airworthiness%20Group%20Chairman%27s%20Factual%20Report-Master.PDF
- Airworthiness Group Chairman's Factual Report - Appendix A - Figures (item 13, .PDF, 6 photos, 754 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449793&FileExtension=.PDF&FileName=Airworthiness%20Group%20Chairman%27s%20Factual%20Report%20-%20Appendix%20A%20-%20Figures-Master.PDF
- Airworthiness Group Chairman's Factual Report - Attachment 1 - Maintenance Records (item 14, .PDF, 8.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449794&FileExtension=.PDF&FileName=Airworthiness%20Group%20Chairman%27s%20Factual%20Report%20-%20Attachment%201%20-%20Maintenance%20Records-Master.PDF
- Airworthiness Group Chairman's Factual Report - Attachment 2 - Operations Specifications (item 15, .PDF, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449795&FileExtension=.PDF&FileName=Airworthiness%20Group%20Chairman%27s%20Factual%20Report%20-%20Attachment%202%20-%20Operations%20Specifications-Master.PDF
- Airworthiness Group Chairman's Factual Report - Attachment 3 - Engine Report (item 16, .PDF, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449796&FileExtension=.PDF&FileName=Airworthiness%20Group%20Chairman%27s%20Factual%20Report%20-%20Attachment%203%20-%20Engine%20Report-Master.PDF
- Airworthiness Group Chairman's Factual Report - Attachment 4 - Propeller Report (item 17, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449797&FileExtension=.PDF&FileName=Airworthiness%20Group%20Chairman%27s%20Factual%20Report%20-%20Attachment%204%20-%20Propeller%20Report-Master.PDF
- Survival Factors 6 – Survival Factors Specialist's Factual Report (item 18, .PDF, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449798&FileExtension=.PDF&FileName=Survival%20Factors%206%20%E2%80%93%20Survival%20Factors%20Specialist%27s%20Factual%20Report-Master.PDF
- Survival Factors 6 - Attachment 1 - Photographs Exemplar Airplane (item 19, .PDF, 524 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449799&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Attachment%201%20-%20Photographs%20Exemplar%20Airplane-Master.PDF
- Operations and Human Performance Factual Report (item 20, .PDF, 10 photos, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450059&FileExtension=.PDF&FileName=Operations%20and%20Human%20Performance%20Factual%20Report-Master.PDF
- Operations & Human Performance Factual - Attachment 01 - Interview Summaries (item 21, .PDF, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449801&FileExtension=.PDF&FileName=Operations%20%26%20Human%20Performance%20Factual%20-%20Attachment%2001%20-%20Interview%20Summaries-Master.PDF
- Operations & Human Performance Factual - Attachment 02 - Passenger Photos Taken from Preceding Airplane (item 22, .PDF, 14 photos, 985 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449802&FileExtension=.PDF&FileName=Operations%20%26%20Human%20Performance%20Factual%20-%20Attachment%2002%20-%20Passenger%20Photos%20Taken%20from%20Preceding%20Airplane-Master.PDF
- Operations & Human Performance Factual - Attachment 03 - Photos Taken by a Passenger on the Pilot's 0800 Tour (item 23, .PDF, 29 photos, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449803&FileExtension=.PDF&FileName=Operations%20%26%20Human%20Performance%20Factual%20-%20Attachment%2003%20-%20Photos%20Taken%20by%20a%20Passenger%20on%20the%20Pilot%27s%200800%20Tour-Master.PDF
- Operations & Human Performance Factual - Attachment 04 - Photos Taken by a Weather Camera Installation in Behm Canal (item 24, ZIP, 8.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449804&FileExtension=zip&FileName=Operations%20%26%20Human%20Performance%20Factual%20-%20Attachment%2004%20-%20Photos%20Taken%20by%20a%20Weather%20Camera%20Installation%20in%20Behm%20Canal-Master
- Operations & Human Performance Factual - Attachment 05 - ADS-B Traffic near Ketchikan on the Morning of the Accident (item 25, .CSV, 5.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449805&FileExtension=.csv&FileName=Operations%20%26%20Human%20Performance%20Factual%20-%20Attachment%2005%20-%20ADS-B%20Traffic%20near%20Ketchikan%20on%20the%20Morning%20of%20the%20Accident-Master.csv
- Operations & Human Performance Factual - Attachment 06 - Chelton Animation Replay (item 26, .PDF, 191 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449807&FileExtension=.PDF&FileName=Operations%20%26%20Human%20Performance%20Factual%20-%20Attachment%2006%20-%20Chelton%20Animation%20Replay-Master.PDF
- Operations & Human Performance Factual - Attachment 07 - Pilot Training Records (item 27, .PDF, 307 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449808&FileExtension=.PDF&FileName=Operations%20%26%20Human%20Performance%20Factual%20-%20Attachment%2007%20-%20Pilot%20Training%20Records-Master.PDF
- Operations & Human Performance Factual - Attachment 08 - Photos of Pilot's Recent Logbook Entries (item 28, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449809&FileExtension=.PDF&FileName=Operations%20%26%20Human%20Performance%20Factual%20-%20Attachment%2008%20-%20Photos%20of%20Pilot%27s%20Recent%20Logbook%20Entries-Master.PDF
- Operations & Human Performance Factual - Attachment 09 - Pilot's Flight and Duty Log (item 29, .PDF, 28 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449810&FileExtension=.PDF&FileName=Operations%20%26%20Human%20Performance%20Factual%20-%20Attachment%2009%20-%20Pilot%27s%20Flight%20and%20Duty%20Log-Master.PDF
- Operations & Human Performance Factual - Attachment 10 - Scheduler's Flight Log (item 30, .PDF, 465 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449811&FileExtension=.PDF&FileName=Operations%20%26%20Human%20Performance%20Factual%20-%20Attachment%2010%20-%20Scheduler%27s%20Flight%20Log-Master.PDF
- Operations & Human Performance Factual - Attachment 11 - Promech General Operations Manual Excerpts (item 31, .PDF, 171 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449812&FileExtension=.PDF&FileName=Operations%20%26%20Human%20Performance%20Factual%20-%20Attachment%2011%20-%20Promech%20General%20Operations%20Manual%20Excerpts-Master.PDF
- Operations & Human Performance Factual - Attachment 12 - Chelton Users Manual Excerpts (item 32, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449813&FileExtension=.PDF&FileName=Operations%20%26%20Human%20Performance%20Factual%20-%20Attachment%2012%20-%20Chelton%20Users%20Manual%20Excerpts-Master.PDF
- Operations & Human Performance Factual - Attachment 13 - Photo of TAWS Inhibit Switch Position (item 33, .PDF, 1 photo, 224 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449814&FileExtension=.PDF&FileName=Operations%20%26%20Human%20Performance%20Factual%20-%20Attachment%2013%20-%20Photo%20of%20TAWS%20Inhibit%20Switch%20Position-Master.PDF
- Operations & Human Performance Factual - Attachment 14 - Investigator Photos of Terrain Surrounding (item 34, .PDF, 4 photos, 387 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449815&FileExtension=.PDF&FileName=Operations%20%26%20Human%20Performance%20Factual%20-%20Attachment%2014%20-%20Investigator%20Photos%20of%20Terrain%20Surrounding-Master.PDF
- Operations & Human Performance Factual - Attachment 15 - Safety Reporting Forms from GOM (item 35, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449816&FileExtension=.PDF&FileName=Operations%20%26%20Human%20Performance%20Factual%20-%20Attachment%2015%20-%20Safety%20Reporting%20Forms%20from%20GOM-Master.PDF
- Operations & Human Performance Factual - Attachment 16 - Promech CFIT Manual (item 36, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449817&FileExtension=.PDF&FileName=Operations%20%26%20Human%20Performance%20Factual%20-%20Attachment%2016%20-%20Promech%20CFIT%20Manual-Master.PDF
- Operations & Human Performance Factual - Attachment 17 - Medallion Foundation CFIT Training Sign-In Log (item 37, .PDF, 84 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449818&FileExtension=.PDF&FileName=Operations%20%26%20Human%20Performance%20Factual%20-%20Attachment%2017%20-%20Medallion%20Foundation%20CFIT%20Training%20Sign-In%20Log-Master.PDF
- Operations & Human Performance Factual - Attachment 18 - Photos of Medallion Foundation Approved Training Device (ATD) (item 38, .PDF, 10 photos, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449819&FileExtension=.PDF&FileName=Operations%20%26%20Human%20Performance%20Factual%20-%20Attachment%2018%20-%20Photos%20of%20Medallion%20Foundation%20Approved%20Training%20Device%20(ATD)-Master.PDF
- Operations & Human Performance Factual - Attachment 19 - Promech Operations Specifications A008 (item 39, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449820&FileExtension=.PDF&FileName=Operations%20%26%20Human%20Performance%20Factual%20-%20Attachment%2019%20-%20Promech%20Operations%20Specifications%20A008-Master.PDF
- Operations & Human Performance Factual - Attachment 20 - Taquan Air Risk Assessment Form and Cue Based Training Aid (item 40, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449821&FileExtension=.PDF&FileName=Operations%20%26%20Human%20Performance%20Factual%20-%20Attachment%2020%20-%20Taquan%20Air%20Risk%20%20Assessment%20Form%20and%20Cue%20Based%20Training%20Aid-Master.PDF
- Operations & Human Performance Factual - Attachment 21 - FAA Capstone Program Phase II Baseline Report (item 41, .PDF, 5.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449822&FileExtension=.PDF&FileName=Operations%20%26%20Human%20Performance%20Factual%20-%20Attachment%2021%20-%20FAA%20Capstone%20Program%20Phase%20II%20Baseline%20Report-Master.PDF
- Operations & Human Performance Factual - Attachment 22 - FAA Capstone Program Phase II Implementation and Impact Assessment (item 42, .PDF, 7.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449823&FileExtension=.PDF&FileName=Operations%20%26%20Human%20Performance%20Factual%20-%20Attachment%2022%20-%20FAA%20Capstone%20Program%20Phase%20II%20Implementation%20and%20Impact%20Assessment-Master.PDF
- Operations & Human Performance Factual - Attachment 23 - Initial Pilot Statements from Promech (item 43, .PDF, 124 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449824&FileExtension=.PDF&FileName=Operations%20%26%20Human%20Performance%20Factual%20-%20Attachment%2023%20-%20Initial%20Pilot%20Statements%20from%20Promech-Master.PDF
- Meteorology Factual Report (item 44, .PDF, 3.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449825&FileExtension=.PDF&FileName=Meteorology%20Factual%20Report-Master.PDF
- Medical Factual (item 45, .PDF, 315 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449826&FileExtension=.PDF&FileName=Medical%20Factual-Master.PDF
- Interview Summaries - Holland America Line and Carnival Corporation (item 46, .PDF, 164 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449827&FileExtension=.PDF&FileName=Interview%20Summaries%20-%20Holland%20America%20Line%20and%20Carnival%20Corporation-Master.PDF
- Statement of Party Representatives to NTSB Investigation - Hassell (item 47, .PDF, 205 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449828&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation%20-%20Hassell-Master.PDF
- Toxicological Report - Pilot (item 48, .PDF, 208 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449829&FileExtension=.PDF&FileName=Toxicological%20Report%20-%20Pilot-Master.PDF
- Photos (item 49, .PDF, 5 photos, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449830&FileExtension=.PDF&FileName=Photos-Master.PDF
- Video - Accident Scene (Shelf Item) (item 50, .PDF, 191 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449831&FileExtension=.PDF&FileName=Video%20-%20Accident%20Scene%20(Shelf%20Item)-Master.PDF
- Terrain Awareness Warning System (TAWS) Comparison Class B and Class C (item 51, .PDF, 575 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468057&FileExtension=.PDF&FileName=Terrain%20Awareness%20Warning%20System%20(TAWS)%20Comparison%20Class%20B%20and%20Class%20C-Master.PDF
- Terrain Awareness Warning System (TAWS) Comparison Class B and Class C - Attachment 1 (Animation) - Shelf Item (item 52, .PDF, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468059&FileExtension=.PDF&FileName=Terrain%20Awareness%20Warning%20System%20(TAWS)%20Comparison%20Class%20B%20and%20Class%20C%20-%20Attachment%201%20(Animation)%20-%20Shelf%20Item-Master.PDF
- Terrain Awareness Warning System (TAWS) Comparison Class B and Class C - Attachment 2 (Tabular Data) (item 53, .CSV, 15 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468058&FileExtension=.csv&FileName=Terrain%20Awareness%20Warning%20System%20(TAWS)%20Comparison%20Class%20B%20and%20Class%20C%20-%20Attachment%202%20(Tabular%20Data)-Master.csv
- Statement of Party Representatives to NTSB Investigation (item 54, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40451233&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF
- Photo (item 55, .PDF, 1 photo, 155 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40451234&FileExtension=.PDF&FileName=Photo-Master.PDF
- NTSB AAR-17/02 (item 56, .PDF, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452246&FileExtension=.PDF&FileName=NTSB%20AAR-17%2F02-Master.PDF
- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 57, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452247&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF
- Evidence Control Form (item 58, .PDF, 134 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452248&FileExtension=.PDF&FileName=Evidence%20Control%20Form-Master.PDF
- Evidence Control Form - Return (item 59, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452249&FileExtension=.PDF&FileName=Evidence%20Control%20Form%20-%20Return-Master.PDF

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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