# NTSB ANC17LA032: Dehavilland DHC-2, N930TG, Ketchikan, AK, June 18, 2017 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 2 · Limited · Final report - Date: June 18, 2017, 13:30 local (21:30 UTC) - Place: Ketchikan, AK - Coordinates: 55.531944, -130.59111 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=55.5319&lon=-130.5911&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff-rejected takeoff: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) - Highest injury: Minor injuries - Injuries: 7 minor - 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 - NTSB case key (mKey): 95404 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC17LA032 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/95404/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=95404 - Page: https://openairdocs.org/ntsb/ANC17LA032 ## Probable cause 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 NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause) - [Performance/control parameters: climb rate](https://openairdocs.org/ntsb-findings/01062035): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause) ## 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 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 best describes what happened. - [Takeoff: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060) - [Takeoff-rejected takeoff: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) (defining event) ## Aircraft - Registration: [N930TG](https://openairdocs.org/deregistered/N930TG-2020-05-29), registration cancelled 2020-05-29, S/N 1041, built 1957 (OpenAirDocs) - Reported make and model: DEHAVILLAND DHC-2 - Registry model: [Dehavilland DHC-2 MK. I(L20A)](https://openairdocs.org/model/dehavilland-dhc-2-mk-i-l20a) (registry code 2808002) (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: 1041 - Year built: 1956 - Airframe hours: 21240 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 30; injuries: minor; 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 ## 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 20170618005769A](https://openairdocs.org/incident/20170618005769A), Jun 18, 2017: Dehavilland DHC-2 MK. I(L20A), Ketchikan, AK, Destroyed. Description: N930TG a de havilland DHC-2 beaver floatplane, owned and operated by rdm pilot/ guide ltd (Y3RA) a part 135 air carrier based in Ketchikan, AK,… ## Other investigations on N930TG (2) 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. - [NTSB ANC03CA088](https://openairdocs.org/ntsb/ANC03CA088), Jun 25, 2003: de Havilland DHC-2 (N930TG), Iliamna, AK, substantial damage. Probable cause: The pilot's incorrect selection of the fuel selector valve position during takeoff which resulted in fuel starvation. A factor associated with the accident was inadequate transition training provided… - [NTSB ANC99LA124](https://openairdocs.org/ntsb/ANC99LA124), Aug 25, 1999: de Havilland DHC-2 (N930TG), Iliamna, AK, substantial damage. Probable cause: The pilot's selection of an unsuitable takeoff area, and an inadvertent stall. Factors associated with the accident were large wave/swells, and low light conditions (dawn). ## Docket (11 files) The files NTSB released with the investigation on December 3, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=95404. 20.0 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 13 pages, 10.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7681353&FileExtension=pdf&FileName=NTSB%20Form%206120_1%20Redacted-Rel.pdf - Pilot - record of conversation (item 2, PDF, 1 page, 70 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7682021&FileExtension=pdf&FileName=Pilot%20Record%20of%20Conversation-Rel.pdf - Other pilot - record of conversation (item 3, PDF, 1 page, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7682133&FileExtension=pdf&FileName=Other%20Pilot%20Record%20of%20Conversation-Rel.pdf - Passenger - record of conversation (item 4, PDF, 1 page, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7681659&FileExtension=pdf&FileName=Passenger%20Record%20of%20Conversation-Rel.pdf - Passenger statements (item 5, PDF, 20 pages, 7.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7680600&FileExtension=pdf&FileName=Passenger%20Statements%20Redacted-Rel.pdf - FAA pilot interview notes (item 6, PDF, 1 page, 9 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7682310&FileExtension=pdf&FileName=FAA%20ASI%20Pilot%20Interview%20Notes-Rel.pdf - Operator's flight manifest (item 7, PDF, 1 page, 548 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7682142&FileExtension=pdf&FileName=Flight%20Manifest%20Redacted-Rel.pdf - Operator's general operations manual excerpt (item 8, PDF, 1 page, 281 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7682496&FileExtension=pdf&FileName=Operator%27s%20GOM%20Excerpt-Rel.pdf - Operator's de havilland DHC-2 passenger briefing card (item 9, PDF, 1 page, 509 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7681963&FileExtension=pdf&FileName=Operator%27s%20de%20%20Havilland%20DHC-2%20Passenger%20Briefing%20Card-Rel.pdf - N930TG ELT activation information (item 10, PDF, 2 pages, 334 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7768039&FileExtension=pdf&FileName=N930TG%20ELT%20Activation%20Information%20Redacted-Rel.pdf - Accident photographs (item 11, PDF, 4 pages, 353 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7922004&FileExtension=pdf&FileName=Accident%20Photographs-Rel.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.