ANC19LA028

NTSB accident investigation · De Havilland DHC-2 · Ketchikan, AK · June 27, 2019

Accident · No injuriesClass 3 · LimitedFinal report
Date
June 27, 2019, 09:45 local (17:45 UTC)
Place
Ketchikan, AK
Injuries
5 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N94DCDe Havilland DHC-2
Defining event
Landing-flare/touchdown: Loss of control on ground
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Alaska Regional Office
FAA report
20190627008119A
Case key
99719

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

A loss of directional control while landing, which resulted in a water loop.

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 surfaceEnvironmental issues › Physical environment · Effect on equipmentDehavilland DHC-2 MK 1: 1 caseAll aircraft: 253 casesProbable cause
Performance/control parameters: directional controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedDehavilland DHC-2 MK 1: 1 caseAll aircraft: 3,958 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

According to the pilot, upon touchdown in the float-equipped airplane, the seaplane skipped, and the right float dug into the water. A video recorded by a cruise ship passenger captured the accident sequence and revealed that the airplane was landing parallel to an ocean swell and touched down in a relatively flat pitch attitude. After touchdown and encountering the swell, the airplane veered to the left, water looped, nosed down, and began to submerge. The airplane sustained substantial damage to the left wing, left lift strut, and fuselage. The pilot reported that there were no preaccident mechanical malfunctions or anomalies that would have precluded normal operation.

Factual narrative

On June 27, 2019, at about 0945 Alaska daylight time, a float-equipped, de Havilland DHC-2 (Beaver) airplane, N94DC, sustained substantial damage following a loss of control during landing at the Ketchikan Harbor Seaplane Base (5KE) Ketchikan, Alaska. The airline transport pilot and four passengers were not injured. The airplane was registered to V2 Aviation LLC, and operated by Pacific Airways, under the provisions of 14 Code of Federal Regulations Part 135. Visual meteorological conditions prevailed and company flight following procedures were in effect. The flight departed the dock at Ketchikan International Airport (PAKT) at 0941 destined for 5KE. According to the pilot, after providing the passengers with a preflight safety briefing, he departed the PAKT airport dock for the short repositioning flight to the company's harbor side dock. After departure, he flew the standard west route, turned back overhead the airport dock, and then turned inside of Pennock Island for final approach to the harbor. Upon touchdown, the airplane skipped, and the right float dug into the water. The airplane water looped, nosed down and began to submerge. After all motion had ceased, he secured the magnetos, assisted the passengers with their life vests and evacuation, and then evacuated the airplane himself. A Good Samaritan fishing boat responded to the scene and assisted with the rescue of the airplane's occupants. The pilot reported that there were no preaccident mechanical malfunctions or anomalies that would have precluded normal operation. A video recorded by a cruise ship passenger captured the accident sequence and revealed that the airplane was landing parallel to an ocean swell and touched down in a relatively flat pitch attitude. After touchdown and encountering the swell, the airplane veered to the left, water looped, nosed down and began to submerge. Water Flying Concepts, Second Edition, by Dr. Dale De Remer is an advance text on wilderness water flying and states in part: The seaplane is very directionally stable as long as it is landed so that its center of gravity is forward of its center of rotation. The seaplane center of rotation in the air is its center of gravity, and on the water it is the center of the wetted side area of the float(s). This is difficult to visualize, as it changes with the speed and attitude of the aircraft on the water. It can be considered to be close to the center of buoyancy. The main thing to remember is to keep the center of rotation aft of the center of gravity. Keep the center of rotation aft, period, until the aircraft has slowed and settled off the step. In the recommendation section of the NTSB Accident/Incident Reporting Form 6120.1, the operator recommended the following three changes to their operations: More extensive training for new pilots on aborted and glassy water landings. No longer allowing first year pilots to execute short approaches into the harbor. Aircraft to refuel at the harbor, prior topassengers boarding at PAKT airport dock for their flights. The closest weather reporting facility is Ketchikan International Airport (PAKT), Ketchikan, Alaska. At 0953, a METAR from PAKT was reporting in part: wind, 320° at 5 knots; visibility, 10 statute miles; sky condition, clear; temperature, 70° F; dew point 57° F; and an altimeter setting of 29.93 inches of mercury.

Aircraft

Registration
N94DC
Reported as
De Havilland DHC-2
Category
Airplane
Serial number
238
Built
1951
Airframe hours
19,674
Engine
Pratt & Whitney, 450 horsepower, reciprocating
Damage
Substantial damage
Flight
Part 135
Operator
Pacific Airways
Registered owner
V2 Aviation LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · June 20, 2019
Departed
KTN · Ketchikan, AK
Destination
5KE · Ketchikan, AK
Flight plan
Company VFR
Airport
5KE · Ketchikan Harbor, runway W, 3,893 × 1,000 ft, water
Equipment
Satellite tracking device, Electronic flight bag or handheld device, Electronic primary flight display

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
45
Injuries
None
Certificates
Flight instructor, Airline transport, Commercial
Airplane ratings
Single-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
May 11, 2019
Seat
Left
Restraint
3-point
Flight hours
3,775 total · 132 in this make and model · 3,545 as pilot in command · 132 in the last 90 days · 72 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
320° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
70 °F, dew point 57 °F
Altimeter
29.93 inHg
Observed at
PAKT

Docket · 2

The files NTSB released with the investigation on April 21, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.4 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.

Other investigations on N94DC · 2

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