ANC17LA032

NTSB accident investigation · Dehavilland DHC-2 · Ketchikan, AK · June 18, 2017

Accident · Minor injuriesClass 2 · LimitedFinal report
Date
June 18, 2017, 13:30 local (21:30 UTC)
Place
Ketchikan, AK
Injuries
7 minor
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N930TGDehavilland DHC-2
Defining event
Takeoff-rejected takeoff: Collision during takeoff/land
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 2
NTSB office
Alaska Regional Office
Parties
Transportation Safety Board of Canada, FAA AVP-100, Viking Air Ltd., FAA Juneau FSDO
FAA report
20170618005769A
Case key
95404

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

On this page

Probable cause

The NTSB’s determination of the probable cause, and any contributing factors.

The pilot's misjudgment of the takeoff distance needed to depart the lake, and his subsequent failure to maintain clearance from the water during a turn to avoid terrain, which resulted in impact with water.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings.

Analysis

The pilot landed the float-equipped airplane at a remote mountain lake as part of a sightseeing tour flight. During the subsequent takeoff, the pilot realized that the airplane was not going to clear trees in the intended direction of departure. The pilot decided to lower the nose and turn 180° to remain over the lake while continuing to climb; however, during the turn, the airplane impacted the water and began to sink. All of the occupants egressed and swam to shore. The operator reported no preimpact mechanical failures or malfunctions with the airframe and engine that would have precluded normal operation of the airplane. Another airplane of the same make and model as the accident airplane successfully departed the lake shortly after the accident. Given the lack of mechanical malfunctions with the accident airplane and the fact that the other airplane performed a successful takeoff, it is likely that the accident pilot misjudged the required departure distance and altitude needed to safely depart the lake, then failed to maintain sufficient clearance from the water during the turn to avoid terrain.

Factual narrative

The factual narrative756 words

On June 18, 2017, about 1330 Alaska daylight time, a float-equipped de Havilland DHC-2 Mk.1 (Beaver) airplane, N930TG, was substantially damaged when it was involved in an accident near Ketchikan, Alaska. The commercial pilot and six passengers sustained minor injuries. The airplane was operated as a 14 Code of Federal Regulations (CFR) Part 135 on-demand sightseeing flight. The accident flight was a 2-hour tour that the cruise ship passengers had purchased from the cruise line as a shore excursion. The flight overflew remote mountainous terrain in the Misty Fjords National Monument. The pilot reported that the route of flight included a stop at Big Goat Lake for scenery viewing, as shown in Figure 1, and a stop at Walker Cove for coastal brown bear viewing. Figure 1. Aerial view of Big Goat Lake and the rocky shore, consisting of a small peninsula (courtesy of Taquan Air). The airplane landed at Big Goat Lake around 1300 and passengers were onshore for about 20 minutes. Big Goat Lake, a freshwater lake about 1,780 ft above mean sea level (msl), is surrounded by steep, mountainous terrain. Postaccident statements from the passengers revealed that the pilot attempted a takeoff but was unsuccessful. The pilot reported to the passengers after the attempted first takeoff, "we missed that takeoff, we are going to try again." The pilot reported that the weather conditions at the time of the second takeoff included an east wind at less than 5 knots and a temperature of 65°F. He initiated the takeoff downwind on a westerly heading, and after the airplane was established on the step, he performed a right 180° step turn to the east. Once established into the wind, he applied full power, and by the time the airplane reached the pilot's go/no-go decision point, the airplane was airborne and climbing between 100 and 200 ft per minute. He adjusted the flaps and power setting for a climb configuration, and the airplane continued over about ¾ of the lake's length; however, the airplane "wasn't climbing efficiently" and the pilot realized that the airplane was not going to climb above a heavily-wooded area ahead. He decided to lower the airplane's nose and turn to the left; about 130° into the 180° turn, the airplane's left wing impacted the water. Two passengers reported that, during the takeoff sequence and subsequent turn, they did not hear the engine decelerate or "turn off" until the airplane impacted the water. Upon impact, the floats separated and the airplane began to sink. One passenger reported that the airplane started to quickly sink nose-first. All of the occupants successfully egressed from the sinking airplane and swam in the cold water to a rocky shoreline. None of the occupants was wearing a personal floatation device (PFD), nor were they required to by regulation for that phase of flight. One passenger estimated that the duration of the swim to the shore was about 20 minutes and a distance of about “2 to 3 football fields." Another passengerfound a PFD floating in its storage bag while she was swimming, which she opened, inflated, and gave to another passenger who was struggling to swim. The airplane subsequently sank to the bottom of the lake. Another tour company from Ketchikan, operating a DHC-2 with one pilot and six passengers onboard, conducted a welfare check on the accident pilot and passengers after spotting the stranded occupants on the shore. The pilot of that airplane reported that he landed on the lake around 1400 and noticed the water was not glassy, and the wind was about 5 knots from the east. After conducting the welfare check, he reported no issues with taking off from the lake. The accident pilot reported to the Federal Aviation Administration (FAA) that he was at Big Goat Lake in the airplane about 2 hours before the accident and departed with no issues. A pilot for another tour company landed at Big Goat Lake shortly after the accident in a DHC-2. He reported to an FAA ASI that he set the power to a climb setting after takeoff and immediately realized that that power setting would be insufficient to climb out from the lake. He then increased the power to a maximum continuous setting and departed the lake with no issues. The operator reported that there were no preimpact mechanical failures or malfunctions with the accident airplane that would have precluded normal operation and that the airplane was below its maximum gross weight at the time of the accident and within center of gravity limits.

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident.

Aircraft

Registration
N930TG
Reported as
Dehavilland DHC-2
Category
Airplane
Serial number
1041
Built
1956
Airframe hours
21,240
Engine
Pratt & Whitney R-985-14B, 450 horsepower, reciprocating
Damage
Substantial damage
Flight
Part 135
Operator
RDM Pilot/Guide Ltd., doing business as Alaska Seaplane Tours
Registered owner
RDM Pilot/Guide Ltd.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · June 13, 2017
Departed
5KE · Ketchikan, AK
Destination
Ketchikan, AK
Flight plan
Company VFR
Equipment
None

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
30
Injuries
Minor
Certificate
Commercial
Airplane ratings
Single-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
May 27, 2017
Seat
Left
Restraint
3-point
Flight hours
2,000 total · 1,000 in this make and model · 1,400 as pilot in command · 25 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
320° at 8 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 39 °F
Altimeter
30.03 inHg
Observed at
PAKT, 40 nm away

Docket · 11

The files NTSB released with the investigation on December 3, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 20.0 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.

Other investigations on N930TG · 2

Matched to the same aircraft by N-number and date.