# NTSB ANC13LA066: Cessna T207A, N499K, King Salmon, AK, July 21, 2013 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: July 21, 2013, 11:50 local (19:50 UTC) - Place: King Salmon, AK - Coordinates: 58.676387, -156.648605 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=58.6764&lon=-156.6486&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) - Highest injury: Minor injuries - Injuries: 9 minor, 1 uninjured; on the ground: 3 minor - Status: Completed, report August 1, 2016 - Report: Approved by Office Director - NTSB office: Alaska Regional Office - Parties: FAA FSDO - Anchorage - NTSB case key (mKey): 87543 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC13LA066 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/87543/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=87543 - Page: https://openairdocs.org/ntsb/ANC13LA066 ## Probable cause The pilot’s inadequate visual lookout while departing from a multiple-use waterway, which resulted in a collision with a drifting boat. Contributing to the accident were the lack of visual conspicuity of the boat and the limited amount of time the boat operator had to maneuver the boat once he heard and saw the oncoming airplane. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Attention/monitoring: monitoring environment](https://openairdocs.org/ntsb-findings/02021545): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Cessna T207A, 1 case](https://openairdocs.org/ntsb-findings/02021545/cases.md?model=2073615), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/02021545/cases.md) - [Object/animal/substance: ground vehicle](https://openairdocs.org/ntsb-findings/03022025): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Cessna T207A, 1 case](https://openairdocs.org/ntsb-findings/03022025/cases.md?model=2073615), [All aircraft, 132 cases](https://openairdocs.org/ntsb-findings/03022025/cases.md) - [Air traffic/operating proc: traffic congestion](https://openairdocs.org/ntsb-findings/03014070): Environmental issues › Operating environment · Not specified; cases with it: [Cessna T207A, 1 case](https://openairdocs.org/ntsb-findings/03014070/cases.md?model=2073615), [All aircraft, 9 cases](https://openairdocs.org/ntsb-findings/03014070/cases.md) - [Perception/orientation/illusion](https://openairdocs.org/ntsb-findings/02022000): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Cessna T207A, 1 case](https://openairdocs.org/ntsb-findings/02022000/cases.md?model=2073615), [All aircraft, 8 cases](https://openairdocs.org/ntsb-findings/02022000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) (defining event); cases with it: [Cessna T207A, 1 case](https://openairdocs.org/ntsb-events/490/sequence.md?model=2073615), [All aircraft, 1,309 cases](https://openairdocs.org/ntsb-events/490/sequence.md) ## Analysis The commercial pilot was conducting a scheduled commuter flight with six passengers on board the float-equipped airplane. The pilot began the takeoff going up the left side of the river and was aware of boats on the right side of the river. The pilot brought the airplane to the step-taxi position and then backed off the power with the intent to apply full power and take off once the airplane was past the boats. The airplane subsequently struck an18.5-ft open fishing boat and nosed over inverted in the water. The pilot and the passengers reported that they never saw the boat that the airplane hit. The boat operator reported that the boat was idling in neutral as it drifted downriver when he heard and then saw the airplane coming straight toward his boat. The boat operator put the boat into reverse to try to avoid the collision, but, as he backed the boat away, the airplane struck the front right side of it with its left float. The pilot noted that the boat (which was small and olive-drab colored) may have visually blended with other boats and seaplanes parked along the side of the river, and the boat operator said that seaplanes were sometimes difficult to hear when coming from downriver. Both the pilot and the boat operator were familiar with operating in the multiple-use waterway, and each of them were aware of the presence of both seaplane and boat traffic on the morning of the accident. There are no separate designated areas for seaplane traffic and boat traffic in the area in which the accident occurred, and there is no radio contact between the pilots and the boat operators. Although regulations specify right-of-way rules for aircraft and vessels conducting water operations and provide course alteration rules based on their respective positions, the pilot never saw the boat to determine its relative position, and, by the time the boat operator saw the airplane's position, the collision was imminent. ## Factual narrative On July 21, 2013, about 1150 Alaska daylight time, N499K, a turbine-powered (Soloy Turbine Pac 780-1000-1 conversion), float-equipped Cessna T207A airplane collided with an 18.5-foot aluminum fishing boat and nosed over during takeoff in the Naknek River near the King Salmon Airport (PAKN), King Salmon, Alaska. The commercial pilot was uninjured, the six passengers on board the airplane received minor injuries, and the three occupants of the boat received minor injuries. The airplane sustained substantial damage. The airplane was registered to Katmai Air Leasing, LLC, and operated by Katmai Air under the provisions of 14 Code of Federal Regulations (CFR) Part 135. Instrument meteorological conditions prevailed, and the pilot obtained a special visual flight rules (SVFR) clearance from PAKN tower. The flight was originating at the time of the accident and was destined for Brooks Camp in the Katmai National Park and Preserve, Alaska. According to a passenger on board the airplane, the airplane first taxied downriver before turning around to begin its upriver takeoff. The pilot reported that, after he obtained the SVFR clearance and notified the PAKN tower that the flight would "proceed off the river," he began the takeoff going upriver. The pilot stated that he checked the area ahead for boats, saw several boats on the right side of the river, and began the takeoff on the left side of the river. The pilot said that, after bringing the airplane to the step-taxi position, he backed off the power with the intent to apply full power and take off once the airplane had passed the boats. The pilot said that he never saw the boat that the airplane hit. Information documented by the Alaska State Troopers who responded to the scene indicated that none of the airplane passengers, including the passenger sitting in the front seat next to the pilot, ever saw the boat. Shore witnesses interviewed by the Troopers reported that they saw the airplane head straight toward the boat. The airplane struck the boat and immediately nosed over in the water. The pilot stated that he opened the left side door and exited immediately. The airplane was inverted and sinking into the water, and, as passengers began appearing at the door, he pulled on each one as they came through the door. All passengers evacuated, the airplane sank to its floats, and the passengers and pilot stood on the belly of the airplane until help arrived. The boat operator said that, when he first heard the airplane and then turned and saw it, it was about 75 yards away and coming straight toward the boat on a path that looked like it would collide with the middle of the boat. The boat operator said that the boat's motor was idling in neutral as the boat drifted downriver and that he put it in reverse to try to move the boat out of the path of the airplane. The boat operator said that, as he backed the boat away, the airplane struck the front of it. The boat operator and his two fishing clients werethrown into the water and started swimming. The boat operator estimated that there were about 10 to 12 fishing boats in the area and said that several arrived quickly to help. Pre-recovery photographs of the airplane provided by the Alaska State Troopers and the Federal Aviation Administration (FAA) showed that the nose of the airplane's left float was crushed aft and upward, and an outboard section of the right wing was crushed and partially separated. The boat, which was a flat, olive-drab color with a white outboard motor, was crushed inward, upward, and aft on the front right side. ADDITIONAL INFORMATION The pilot stated that he was unsure why he did not see the boat before the collision and that he wondered if it may have come out from the left into the path of the airplane or if it may have visually blended with the other boats and aircraft that were parked on docks along the left side of the river. The boat operator said that it is sometimes difficult to hear the airplanes when they are coming from downriver. The boat operator said that it had been foggy earlier that morning and that "lots of airplanes" were trying "to get out and get caught up." A passenger on the accident airplane, who had arrived in King Salmon on an earlier flight, stated that some flights were delayed because of the weather. In response to a question if any of the boats on the river that day appeared to have any high-visibility markings, the passenger stated that the boats he saw appeared to be "plain boats." The PAKN airport manager said that the area where the accident occurred was not on airport property and that there are no separate designated areas for seaplane traffic and boat traffic there. The Airport/Facility Directory for the King Salmon seaplane base notes, "Landing area Rwy NW-SE also used by boats." The boat operator said that the airplanes take off and land "wherever they want to" and that there is no radio contact between the pilots and the boat operators. Weather conditions reported at PAKN, about 1 mile from the accident site, at 1154 included wind from 050 degrees at 6 knots, visibility 10 miles, and ceilings broken at 700 and 1,300 feet. Title 14 CFR 91.115, which specifies right-of-way rules for water operations, states that "[e]ach person operating an aircraft on water shall, insofar as possible, keep clear of all vessels and avoid impeding their navigation and shall give way to any vessel or other aircraft that is given the right-of-way by any rule of this section." The regulation provides right-of-way and course-alteration rules that address crossing, head-on, and overtaking scenarios. According to FAA Handbook 8083-23, "Seaplane, Skiplane, and Float/Ski Equipped Helicopter Operations Handbook," section 1-2, seaplanes (which meet the general definition of "vessel") are also subject to U.S. Coast Guard (USCG) commandant instruction M16672.2D, "Navigation Rules, International-Inland." USCG M16672.2D, Part B, Section I, Rule 5, "Look-out" states,"[e]very vessel shall at all times maintain a proper look-out by sight and hearing as well as by all available means appropriate in the prevailing circumstances and conditions so as to make a full appraisal of the situation and of the risk of collision." Rule 6, "Safe Speed" states, "[e]very vessel shall at all times proceed at a safe speed…[to enable] proper and effective action to avoid collision…. In determining a safe speed, the following factors shall be among those taken into account:…the traffic density, including concentration of…any other vessels." FAA Handbook 8083-23, section 3-4, notes that "[s]eaplanes often operate in areas with extensive recreational or commercial water traffic. …There is no equivalent of the airport traffic pattern to govern boat traffic…." ## Aircraft - Registration: [N499K](https://openairdocs.org/aircraft/N499K), registered now, S/N 20700632, built 1980 (OpenAirDocs) - Reported make and model: CESSNA T207A - Registry model: [Cessna T207A](https://openairdocs.org/model/cessna-t207a) (registry code 2073614) (OpenAirDocs) - Registry engine: [Allison 250-C20 series](https://openairdocs.org/engine/allison-250-c20-series) (registry code 03020, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 20700632 - Airframe hours: 11536 - Engines: Allison 250-C20S 420 horsepower turbo prop - Damage: Substantial damage - Flight: Part 135 - Operator: Katmai Air LLC - Registered owner: Katmai Air Leasing LLC - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, July 12, 2013, 28 hours before - Departed: King Salmon, AK - Destination: Brooks Camp, AK - Flight plan: Company VFR - Airport: PAKN, King Salmon Airport ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 60; injuries: none; commercial; airplane ratings: multi-engine land, single-engine land, single-engine sea; instrument ratings: airplane; medical: class 2, with waivers/limitations; seat: left; restraint: 3-point; flight hours: 12,770 total, 4,675 in this make and model, 12,650 as pilot in command, 118 in the last 90 days, 75 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Day - Wind: 50° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: 700 ft broken - Temperature: 61 °F, dew point 57 °F - Altimeter: 30.12 inHg - Observed at: PAKN, 1 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 20130721014729A](https://openairdocs.org/incident/20130721014729A), Jul 21, 2013: Cessna T207A, King Salmon, AK, Substantial damage. PIC departed operator dock on naknek river in aircraft on floats with 6 passengers. Weather- visibility 5-7 NM, ceiling 900 feet, svfr. PIC contacted akn… ## Docket (9 files) The files NTSB released with the investigation on June 9, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=87543. 13.9 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 206 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441067&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Airports/Facility Directory Description for PAKN (item 2, .PDF, 86 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441068&FileExtension=.PDF&FileName=Airports%2FFacility%20Directory%20Description%20for%20PAKN-Master.PDF - Memorandum for Record - Telephone Interview, Pilot (item 3, .PDF, 241 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441069&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20Telephone%20Interview,%20Pilot-Master.PDF - Memorandum for Record - Telephone Interview, Boat Operator (item 4, .PDF, 294 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441070&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20Telephone%20Interview,%20Boat%20Operator-Master.PDF - Memorandum for Record - Telephone Interview, Others (item 5, .PDF, 171 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441071&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20Telephone%20Interview,%20Others-Master.PDF - Excerpts from Alaska State Troopers' Report - Interviews and Toxicology (item 6, .PDF, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441072&FileExtension=.PDF&FileName=Excerpts%20from%20Alaska%20State%20Troopers%27%20Report%20-%20Interviews%20and%20Toxicology-Master.PDF - Photo 1. Airplane during recovery, Photo Courtesy of FAA (item 7, .PDF, 1 photo, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441073&FileExtension=.PDF&FileName=Photo%201.%20Airplane%20during%20recovery,%20Photo%20Courtesy%20of%20FAA-Master.PDF - Photo 2. Airplane after recovery, Photo Courtesy of FAA (item 8, .PDF, 1 photo, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441074&FileExtension=.PDF&FileName=Photo%202.%20Airplane%20after%20recovery,%20Photo%20Courtesy%20of%20FAA-Master.PDF - Photo 3. Fishing Boat, Photo Courtesy of FAA (item 9, .PDF, 1 photo, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441075&FileExtension=.PDF&FileName=Photo%203.%20Fishing%20Boat,%20Photo%20Courtesy%20of%20FAA-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.