# NTSB ANC17CA038: Dehavilland DHC 2, N364RA, Dilllingham, AK, July 21, 2017 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: July 21, 2017, 12:00 local (20:00 UTC) - Place: Dilllingham, AK - Coordinates: 59.199443, -158.741943 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=59.1994&lon=-158.7419&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: No injuries - Injuries: 3 uninjured - Status: Completed, report January 11, 2018 - Report: Approved by Office Director - NTSB office: Alaska Regional Office - Parties: Federal Aviation Administration - NTSB case key (mKey): 95678 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC17CA038 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/95678/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=95678 - Page: https://openairdocs.org/ntsb/ANC17CA038 ## Probable cause The pilot's failure to set the wing flaps to the "takeoff" position, which resulted in a longer-than-normal takeoff run and collision with terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Flight control system: lE flap control system](https://openairdocs.org/ntsb-findings/01022780): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [All aircraft, 3 cases](https://openairdocs.org/ntsb-findings/01022780/cases.md) - [Terrain](https://openairdocs.org/ntsb-findings/03021000): Environmental issues › Physical environment · Effect on operation (probable cause); cases with it: [All aircraft, 267 cases](https://openairdocs.org/ntsb-findings/03021000/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: [All aircraft, 1,309 cases](https://openairdocs.org/ntsb-events/490/sequence.md) - [Takeoff: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot stated that he was departing on a postmaintenance flight check in a float-equipped airplane from a short water lane at a remote, unimproved seaplane base. While taxiing for departure, he left the wing flaps in the "up" position to aid in turning the airplane on the water. After aligning the airplane for the takeoff run, he applied full power, and the airplane accelerated onto the step. While attempting to rotate, he realized that he had forgotten to reset the wing flaps to the "takeoff" position. He attempted to reset the manually operated, hydraulically actuated wing flaps, but the incorrect flap setting led to a longer-than-normal takeoff run, and the airplane subsequently impacted the water lane's far bank, which resulted in substantial damage to the left wing and left-wing strut. The pilot reported that there were no preaccident mechanical anomalies with the airplane that would have precluded normal operation. ## Factual narrative The pilot stated that he was departing on a post-maintenance flight check in a float-equipped airplane from a short waterlane, at a remote unimproved seaplane base. While taxiing for departure, he left the wing flaps in the up position to aid in turning the airplane on the water. After aligning the airplane for the takeoff run, he applied full power and the airplane accelerated onto the step. While attempting to rotate, he realized that he had forgot to reset the wing flaps to the takeoff position. He attempted to reset the manually operated hydraulically actuated wing flaps, but the airplane impacted the waterlane's far bank sustaining substantial damage to the left wing, and left-wing strut. The pilot stated that there were no preaccident mechanical anomalies that would have precluded normal operation. In the recommendation section of the NTSB Accident/Incident Reporting Form 6120.1, the pilot stated that the accident may have been prevented if he would have utilized the airplane's checklist or rechecked the position of the wing flaps. ## Aircraft - Registration: N364RA (not matched to a registry record) - Reported make and model: DEHAVILLAND DHC 2 (MARKI) - Category: Airplane - Serial number: 364 - Year built: 1951 - Airframe hours: 15677 - Engines: P&W R-985 SERIES 450 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Bay Air Inc - Registered owner: Bay Air Inc - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, July 13, 2017 - Departed: OZ3, Dilllingham, AK - Destination: OZ3, Dilllingham, AK - Airport: OZ3, Shannon Pond - Equipment: ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: none; 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 October 13, 2016; seat: left; restraint: 3-point; flight hours: 23,732 total, 6,972 in this make and model, 23,601 as pilot in command, 110 in the last 90 days, 110 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 180° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 64 °F, dew point 52 °F - Altimeter: 29.96 inHg - Observed at: PADL, 3 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 20170721012619A](https://openairdocs.org/incident/20170721012619A), Jul 21, 2017: Dehavilland DHC-2, Dillingham, AK, Substantial damage. Pilot had been flying for about 6 weeks straight during the fishing season. Pilot had taken a few days off to rest and was going flying that day with 1… ## Docket (1 files) The files NTSB released with the investigation on December 8, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=95678. 3.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458635&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-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.