ANC19FA035

NTSB accident investigation · De Havilland Beaver DHC 2 · Seldovia, AK · July 19, 2019

Accident · FatalClass 2 · FieldFinal report
Date
July 19, 2019, 10:10 local (18:10 UTC)
Place
Seldovia, AK
Injuries
1 fatal, 1 serious, 4 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N68083De Havilland Beaver DHC 2
Defining event
Takeoff: Loss of control on ground
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 2
NTSB office
Alaska Regional Office
Parties
Aerocet Inc., Rust's Flying Service, Federal Aviation Administration
FAA report
20190719012189A
Case key
99892

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 airplane's floats impact with an ocean wave or swell, which exceeded the design load specifications of the flying wire assemblies and resulted in a partial separation of the float assemblies.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Runway/land/takeoff/taxi surface: choppy surfaceEnvironmental issues › Physical environment · Decision related to conditionDehavilland BEAVER DHC-2 MK.1: 1 caseAll aircraft: 20 casesProbable cause
Runway/land/takeoff/taxi surface: choppy surfaceEnvironmental issues › Physical environment · Effect on equipmentDehavilland BEAVER DHC-2 MK.1: 1 caseAll aircraft: 20 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot stated that, during takeoff in the float-equipped airplane, he saw the left float begin to move into his peripheral vision from the left cockpit window and the airplane began to yaw to the left. The left wing subsequently impacted the water and the airplane nosed over, separating the right wing from the fuselage. The passengers consistently reported choppy water conditions at the time of the accident; one passenger reported that white caps were visible on the ocean waves in the distance. The passengers said that, during the takeoff, the airplane impacted a swell or wave and nosed over abruptly, and the cabin rapidly filled with water. Examination of the float assembly revealed fractures in the left front flying wire attachment fitting and the right rear flying wire attachment strap and hole elongation in the left rear flying wire attachment fitting. Additionally, the bolts attaching the two left flying wire attachment fittings to the left float were bent, and the two flying wires that had been attached to the fractured attachment fitting and attachment strap were buckled. While some areas of corrosion were observed on the fractured left forward fitting, the total area of corrosion was a small percentage of the total cross-section, and the remainder of the fracture and associated deformation of the lug was consistent with ductile overstress fracture. Similar areas of corrosion were also observed on each of the intact flying wire attachment fittings. Post-accident testing completed by the float manufacturer revealed that buckling of flying wires similar to that observed on the accident airplane was only reproduced at strap and fitting failure loads above 9,000 pounds force; the design specification load was 3,453 pounds of force. This indicates that the small amount of corrosion present on the fractured flying wire attachment fitting did not reduce its load-carrying capability below the design specification load of 3,453 pounds of force, and that both the flying wire attachment fitting and flying wire attachment strap fractured due to overload. Therefore, it is likely that the accident airplane floats were subject to forces that exceeded their design limitations, resulting in overload of the flying wires attached to the left float. It is also likely that, given the lack of damage on either float, the force was due to impact with an ocean wave or swell and not by striking an object.

Factual narrative

On October 8, 2012 Aerocet issued Service Letter SL05-56-15145, which states in part: Float Model Affected: Aerocet Model 5850 Twin Seaplane Float installation on DeHavilland DHC-2 "Beaver" (All) Symptom: Reported corrosion of aluminum fitting beneath flying wire clevis in parts with extensive marine service and prolonged inspection intervals. Regular inspection at normal intervals will prevent possible failures due to corrosion-weakened fittings. Approval: This SL reflects FAA Approved design changes and current recommended inspections, and does not require FAA approval. Corrective Action: NONE – no required action, suggested action only. During next regular inspection per Aerocet Service Manual, A-10034, Rev 1 or later, include partial disassembly of the lower ends of the flying wires at the Aerocet fittings for all flying wires (crossing wires). Particular attention should be focused beneath the flying wire clevises for indications of corrosion. Parts exhibiting corrosion should be replaced. Original 56-15145 (now designated with a "-1") is easily identified as painted aluminum. Replacement part, 56-15145-2, is constructed from corrosion resistant steel (stainless), not painted. Aerocet Test Report A-33162 The flying wires attachment design limit load was 3,453 pounds of force. Testing completed by Aerocet and documented in Test Report A-33162 revealed that buckling of flying wires was only produced at strap and fitting failure loads above 9,000 pounds of force. The airplane was equipped with Aerocet 5850 seaplane floats in accordance with Supplemental Type Certificate (STC) No. SA01722SE. On July 19, 2019, about 1010 Alaska daylight time, a float-equipped de Havilland DHC-2 (Beaver) airplane, N68083, was substantially damaged when it was involved in an accident near Seldovia, Alaska. The pilot and three passengers sustained minor injuries, one passenger was fatally injured, one passenger sustained serious injuries, and one passenger was uninjured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 135 on-demand commercial flight. The purpose of the flight was to transport passengers from a remote lodge located at Tutka Bay, Alaska, to Lake Hood Seaplane Base (PALH), Anchorage, Alaska. The pilot stated that, after loading the passengers and their baggage onboard, he started the airplane's engine and provided a passenger safety briefing. He then taxied out and initiated his takeoff. He stated that as the airplane was accelerating on the step, he saw the left float begin to move into his peripheral vision from the left cockpit window. He said that the airplane felt as if it had "lost its rigidity" on the floats and began to "yaw" to the left. In an effort to correct for the left turning tendency, he applied right aileron, to no avail. The left wing subsequently impacted the water and the airplane nosed over, separating the right wing from the fuselage. He stated that the airplane immediately began to fill with wateras he struggled to exit the submerged wreckage. During hospital interviews, the passengers consistently reported that after the engine was started, the pilot asked them to remove their headsets while he provided the passenger safety briefing. They stated that the briefing was rushed and difficult to hear due to engine noise. They reported choppy water conditions, with one passenger reporting white caps on the ocean waves visible in the distance. The passengers said that, during the takeoff, the airplane impacted a swell or wave and nosed over abruptly, and the cabin rapidly filled with water. One passenger stated that the airplane briefly became airborne before impact. A witness located near the accident site stated that the airplane appeared to accelerate slowly and struggle into the air. He reported that the airplane climbed to an altitude of about 50 to 100 ft, briefly leveled off, then began a gradual descent toward the water. The airplane impacted the water on the nose of the left float and immediately cartwheeled, coming to rest inverted in the ocean waters. He alerted emergency services and drove his boat to the submerged wreckage to assist with the rescue. An Alaska State Trooper reported conditions at the accident site of seas less than 1 ft with a long wavelength and winds less than 10 knots. The trooper recalled that, while at the hospital, the pilot stated that he was taking off parallel to the swells when the airplane impacted a swell and became airborne, the left float broke, and the airplane cartwheeled. The airplane nosed over in ocean waters and came to rest inverted. All major components were recovered except for the right wing, right aileron, and right lift strut. Flight control continuity was verified from the control yoke to the right fuselage bellcrank push/pull tube, the left aileron and elevators, and from the rudder pedals to the rudder. An examination of the floats and their attachment rigging revealed that the front left flying wire attachment fitting (attached to the left float) fractured, and the associated flying wire exhibited compression buckling signatures near the upper attachment point. The right rear flying wire attachment strap (attached to the fuselage) fractured, and the associated flying wire exhibited compression buckling signatures near the lower attach point. (See Figure 1). No significant deformation was present on the underside or nose of either float. Figure 1- Float Assembly Diagram (courtesy of Aerocet) An examination of the left float struts and flying wire attachment components was completed by the National Transportation Safety Board (NTSB) Materials Laboratory personnel. The left float struts had fracture surfaces with rough matte-gray features and deformation consistent with ductile overstress with bending or torsion loads. An examination of the aluminum flying wire attachment fittings revealed that the bolts for attaching the two left flying wire attachment fittings to the left float werebent, and the attachment hole in the intact left rear attachment fitting was elongated. Fractures in the left front attachment fitting and right rear attachment strap were consistent with ductile overstress fracture. Small areas of corrosion were observed on the fractured left forward flying wire attachment fitting; however, the total area of corrosion was a small percentage of the total cross-section, and the remainder of the fracture and associated deformation of the lug exhibited rough matte-gray features consistent with a ductile overstress fracture. In addition, small amounts of corrosion were also observed on the three intact flying wire attachment fittings. A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunction or failures that would have precluded normal operation.

Aircraft

Registration
N68083
Reported as
De Havilland Beaver DHC 2
Category
Airplane
Serial number
1254
Built
1958
Airframe hours
29,448
Engine
Pratt & Whitney R-985-14B, 450 horsepower, reciprocating
Damage
Substantial damage
Flight
Part 135
Operator
Rusts Flying Service
Registered owner
Rust Properties LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · July 10, 2019
Departed
Seldovia, AK
Destination
PALH · Anchorage, AK
Flight plan
Company VFR
Equipment
Handheld GPS, Satellite tracking device, Stall warning system

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
26
Injuries
Minor
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Single-engine sea, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
June 11, 2019
Seat
Left
Restraint
3-point
Toxicology
Performed
Flight hours
2,689 total · 150 in this make and model · 1,782 as pilot in command · 203 in the last 90 days · 74 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
20° at 7 knots
Visibility
6 statute miles
Lowest ceiling
None
Temperature
64 °F, dew point 54 °F
Altimeter
29.95 inHg
Observed at
PASO, 10 nm away

Docket · 9

The files NTSB released with the investigation on October 21, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 32.4 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.