ANC05LA110

NTSB accident investigation · de Havilland DHC-3 · Ketchikan, AK · July 28, 2005

Accident · Serious injuriesLimited investigationFinal report
Date
July 28, 2005, 12:55 local (20:55 UTC)
Place
Ketchikan, AK
Injuries
1 serious, 10 uninjured
Damage
Minor damage
Phase of flight
Enroute
Aircraft
N6868Bde Havilland DHC-3
Weather
Visual (VMC) · Day
Status
Completed · report February 28, 2006
Report
Approved by Office Director
NTSB office
Alaska Regional Office
Parties
FAA-AL JNU FSDO 05
FAA report
20050728017669A
Case key
62081

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

An electrical arc on the exterior of a fuel pressure line that initiated a fuel leak and fire during cruise flight, which resulted in serious injuries to the pilot as he performed an emergency landing on the water. A factor contributing to the accident was an inadequate annual inspection of the airplane by company maintenance personnel.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

FireCruise
Maintenance,annual inspection - inadequateCompany maintenance personnelFactor
Electrical system,electric wiring - arcingCause
Fuel system,line - leakCause
Fluid,fuel - fireCause
Forced landingEmergency descent/landing
Terrain condition - water

Analysis

The airline transport certificated pilot was conducting a visual flight rules (VFR) local area sightseeing flight under Title 14, CFR Part 135, in a float-equipped airplane. During cruise flight, a flash fire erupted near the windshield/glare shield area of the cockpit, in front of the pilot. The pilot made an emergency landing, and a passenger assisted by utilizing a fire extinguisher to put out the fire. The airplane received minor damage, but the pilot received second-degree burns to his hands. The airplane was manufactured in 1958, and had accrued 3,742 hours on the airframe, and 6.4 hours since the last annual inspection when a 1,000 hp engine was installed. A postaccident examination of the airplane revealed a pin-size hole in an aluminum fuel pressure bourbon line, utilized as a fixed line between the engine firewall, and an airframe longitudinal former, behind the instrument panel. The bourbon line is located between flexible fuel pressure lines from the engine to the firewall, and from the airframe former to the backside of the fuel pressure gauge. An examination of the line at the NTSB Materials Laboratory revealed a circular-shaped hole about 3 inches from the firewall end of the line. A longitudinal cut was made through the hole which revealed blue and brown tinting, and evidence of metal flow typical of re-solidification. The features of the hole were consistent with heat damage from electrical arcing. The wall of the tube had no evidence of corrosion.

Factual narrative

On July 28, 2005, about 1255 Alaska daylight time, a float-equipped deHavilland DHC-3 airplane, N6868B, received minor damage due to an in-flight fire during cruise flight, about 5 miles southeast of Ketchikan, Alaska. The airplane was being operated as a visual flight rules (VFR) local area sightseeing flight under Title 14, CFR Part 135, when the accident occurred. The airplane was operated by Promech Air, Ketchikan. The airline transport certificated pilot received serious injuries as the result of burns to his hands. The ten passengers were not injured. Visual meteorological conditions prevailed, and VFR company flight following procedures were in effect. The flight originated at the Ketchikan Seaplane Base about 1125, for a flight to the Misty Fjords National Monument.

During a telephone conversation with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC), on July 28, the director of operations for the operator reported that the flight was returning to Ketchikan when a flash fire erupted near the windshield/glare shield area of the cockpit, in front of the pilot. The pilot made an emergency landing, and a passenger assisted by utilizing a fire extinguisher to put out the fire. The pilot received second-degree burns to his hands. A second company airplane landed and assisted the pilot and passengers.

The director of operations for the operator reported that the airplane's engine had recently been removed, and a 1,000 horsepower WSK PZL Kalis engine, model number ASZ-62IR-M18, was installed on July 26, 2005. The airplane then had an annual inspection and returned to service. The airplane was manufactured in 1958, and had accrued 3,742 hours on the airframe, and 6.4 hours since the last annual inspection.

The director of maintenance for the operator reported that a postaccident examination of the airplane revealed a pin-size hole in an aluminum fuel pressure bourbon line, utilized as a fixed line between the engine firewall, and an airframe longitudinal former, behind the instrument panel. The bourbon line is located between flexible fuel pressure lines from the engine to the firewall, and from the airframe former to the backside of the fuel pressure gauge. The director of maintenance indicated that he believed the line was not disturbed during the most recent engine change, and he said the line was located about 20 inches from any electrical wiring. He removed the line and sent it to the NTSB IIC, and the line was then submitted to the NTSB Material Laboratory for examination.

The laboratory examination found a circular-shaped hole about 3 inches from the firewall end of the line. A longitudinal cut was made through the hole which revealed blue and brown tinting, and evidence of metal flow typical of re-solidification. The features of the hole were consistent with heat damage from electrical arcing. The wall of the tube had no evidence of corrosion.

Aircraft

Registration
N6868B
Reported as
de Havilland DHC-3
Category
Airplane
Serial number
274
Airframe hours
3,742
Engine
WSK PZL Kalis ASZ-62IR-M18, 1,000 horsepower, reciprocating
Damage
Minor damage
Fire
In-Flight
Flight
Part 135
Operator
Promech Inc., doing business as Promech Air
Registered owner
PM Air, LLC.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 1, 2005 · 6.4 hours before
Departed
5KE · Ketchikan, AK
Flight plan
Company VFR

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
56
Injuries
Serious
Certificates
Flight engineer, Commercial, Airline transport
Airplane ratings
Single-engine land, Single-engine sea, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
May 1, 2005
Seat
Left
Flight hours
15,251 total · 13 in this make and model · 13,666 as pilot in command · 185 in the last 90 days · 101 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
155° at 3 knots
Visibility
10 statute miles
Lowest ceiling
3,500 ft broken
Temperature
59 °F, dew point 55 °F
Altimeter
30.02 inHg
Observed at
PAKT, 5 nm away

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.