ANC12LA026

NTSB accident investigation · Dehavilland Beaver DHC-2 · Ketchikan, AK · March 13, 2012

Accident · Serious injuriesLimited investigationFinal report
Date
March 13, 2012, 10:40 local (18:40 UTC)
Place
Ketchikan, AK
Injuries
1 serious, 1 minor
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N82SFDehavilland Beaver DHC-2
Defining event
Maneuvering: Controlled flight into terr/obj (CFIT)
Weather
Instrument (IMC) · Day
Status
Completed · report October 9, 2012
Report
Approved by Office Director
NTSB office
Alaska Regional Office
Parties
FAA Juneau FSDO
FAA report
20120313004109A
Case key
83129

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

The pilot's decision to depart in marginal visual meteorological conditions, and his continued visual flight into instrument meteorological conditions.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Ceiling/visibility/precip: below VFR minimaEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomeDehavilland BEAVER DHC-2: 1 caseAll aircraft: 184 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot departed from an off-airport site in marginal visual flight rules conditions. Shortly after departure, the weather worsened, and flight visibility dropped to near zero in heavy snow. He attempted to follow the shoreline at a low altitude but was unable to maintain visual contact with the ground. He stated that he saw trees immediately in front of the airplane and attempted a right turn toward what he thought was an open bay. During the turn, the right float contacted a rock outcrop, and the airplane impacted the water. The pilot did not report any mechanical anomalies that would have precluded normal operation.

Factual narrative

On March 13, 2012, about 1040 Alaska daylight time, a float-equipped de Havilland DHC-2 (Beaver) airplane, N82SF, collided with water and terrain approximately 23 miles southwest of Ketchikan, Alaska. The airplane was being operated by Southeast Aviation, Ketchikan, as a visual flight rules on-demand charter flight under 14 Code of Federal Regulations Part 135. The pilot sustained serious injuries and the sole passenger sustained minor injuries. Marginal visual meteorological conditions were reported at the time of departure, and company flight following procedures were in effect. The airplane departed the Niblack mine site, bound for Ketchikan, about 1033. After the airplane failed to arrive in Ketchikan, company personnel initiated a search to see if the airplane had diverted due to weather. A worker stationed at the mine where the airplane departed from initiated a search by boat to try and locate the airplane. He found the airplane partially submerged in a cove, approximately 1.5 miles from the departure point, and picked up the pilot and passenger, who had evacuated the airplane. During a telephone conversation with the NTSB investigator-in-charge on March 22, the pilot reported that he was departing from the Niblack mine site in marginal weather conditions. Shortly after departure, the weather worsened, and flight visibility dropped to near zero in heavy snow. He attempted to follow the shoreline at low altitude, but was unable to maintain visual contact with the ground. He then stated that he saw trees immediately in front of the airplane, and attempted a right turn toward what he thought was an open bay. During the turn, the right float contacted a rock outcrop, and the airplane impacted the water. The airplane sustained substantial damage to the wings, fuselage, and the horizontal stabilizer. The closest weather reporting facility is the Ketchikan International Airport (PAKT), approximately 23 miles northeast of the accident site. At 1042, approximately the same time as the accident, a special Aviation Routine Weather Report (METAR) was reporting, in part: Wind 150 degrees (true) at 9 knots; visibility 2.5 statute miles; light snow; sky condition, few clouds at 1,600 feet, broken clouds at 2,800 feet, overcast at 3,700 feet; temperature, 36 degrees F; dew point, 27 degrees F; altimeter, 29.21 in Hg. About 16 minutes after the accident, at 1056, another special METAR reported conditions at Ketchikan as; Wind, 140 degrees at 15 knots, gusting to 21 knots; visibility, 1.5 statute miles; light snow; sky condition, broken 2,000 feet, overcast 2,800 feet.

Aircraft

Registration
N82SF
Reported as
Dehavilland Beaver DHC-2
Category
Airplane
Serial number
839
Airframe hours
17,574
Engine
P&W R-985 SERIES, 450 horsepower, reciprocating
Damage
Substantial damage
Flight
Part 135
Operator
Southeast Aviation, LLC
Registered owner
Snow Mountain Enterprises LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 30, 2012
Departed
Ketchikan, AK
Destination
PAKT · Ketchikan, AK
Flight plan
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
64
Injuries
Serious
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
May 5, 2011
Seat
Left
Flight hours
23,000 total · 12,000 in this make and model

Weather

Conditions
Instrument (IMC) · Day
Wind
150° at 9 knots
Visibility
2 statute miles
Lowest ceiling
2,800 ft broken
Temperature
36 °F, dew point 27 °F
Altimeter
29.20 inHg
Observed at
PAKT, 23 nm away

Docket · 3

The files NTSB released with the investigation on July 27, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.0 MB in all.

FAA reports on this event · 1

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