# NTSB ANC12LA026: Dehavilland Beaver DHC-2, N82SF, Ketchikan, AK, March 13, 2012 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: March 13, 2012, 10:40 local (18:40 UTC) - Place: Ketchikan, AK - Coordinates: 55.055557, -132.103332 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=55.0556&lon=-132.1033&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) - Highest injury: Serious injuries - Injuries: 1 serious, 1 minor - Status: Completed, report October 9, 2012 - Report: Approved by Office Director - NTSB office: Alaska Regional Office - Parties: FAA Juneau FSDO - NTSB case key (mKey): 83129 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC12LA026 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/83129/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=83129 - Page: https://openairdocs.org/ntsb/ANC12LA026 ## Probable cause The pilot's decision to depart in marginal visual meteorological conditions, and his continued visual flight into instrument meteorological conditions. ## 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 BEAVER DHC-2, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2800108), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Ceiling/visibility/precip: below VFR minima](https://openairdocs.org/ntsb-findings/03035075): Environmental issues › Conditions/weather/phenomena · Contributed to outcome; cases with it: [Dehavilland BEAVER DHC-2, 1 case](https://openairdocs.org/ntsb-findings/03035075/cases.md?model=2800108), [All aircraft, 184 cases](https://openairdocs.org/ntsb-findings/03035075/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401); cases with it: [Dehavilland BEAVER DHC-2, 1 case](https://openairdocs.org/ntsb-events/401/sequence.md?model=2800108), [All aircraft, 392 cases](https://openairdocs.org/ntsb-events/401/sequence.md) - [Maneuvering: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Dehavilland BEAVER DHC-2, 1 case](https://openairdocs.org/ntsb-events/120/sequence.md?model=2800108), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## 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](https://openairdocs.org/deregistered/N82SF-2018-01-09), registration cancelled 2018-01-09, S/N 839, built 1955 (OpenAirDocs) - Reported make and model: DEHAVILLAND BEAVER DHC-2 - Registry model: [Dehavilland BEAVER DHC-2](https://openairdocs.org/model/dehavilland-beaver-dhc-2) (registry code 2800108) (OpenAirDocs) - Registry engine: [Pratt & Whitney R-985 series](https://openairdocs.org/engine/pratt-whitney-r-985-series) (registry code 52008, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 839 - Airframe hours: 17574 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 64; injuries: serious; 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 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20120313004109A](https://openairdocs.org/incident/20120313004109A), Mar 13, 2012: Dehavilland BEAVER DHC-2, Ketchikan, AK, Substantial damage. Description of accident: a float equipped aircraft entered white out conditions in a snow squall shortly after take-off from a remote mining site. Factors:… ## Docket (3 files) The files NTSB released with the investigation on July 27, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=83129. 1.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 925 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40372795&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Record of Conversation - Pilot (item 2, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40372796&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Pilot-Master.PDF - Record of Conversation - Passenger (item 3, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40372797&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Passenger-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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.