# NTSB ANC19LA028: De Havilland DHC-2, N94DC, Ketchikan, AK, June 27, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: June 27, 2019, 09:45 local (17:45 UTC) - Place: Ketchikan, AK - Coordinates: 55.351943, -132.491943 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=55.3519&lon=-132.4919&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-flare/touchdown: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: No injuries - Injuries: 5 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Alaska Regional Office - NTSB case key (mKey): 99719 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC19LA028 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99719/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99719 - Page: https://openairdocs.org/ntsb/ANC19LA028 ## Probable cause A loss of directional control while landing, which resulted in a water loop. ## 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); cases with it: [Dehavilland DHC-2 MK 1, 2 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2808006), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Runway/land/takeoff/taxi surface](https://openairdocs.org/ntsb-findings/03023000): Environmental issues › Physical environment · Effect on equipment (probable cause); cases with it: [Dehavilland DHC-2 MK 1, 1 case](https://openairdocs.org/ntsb-findings/03023000/cases.md?model=2808006), [All aircraft, 253 cases](https://openairdocs.org/ntsb-findings/03023000/cases.md) - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Dehavilland DHC-2 MK 1, 1 case](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=2808006), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-flare/touchdown: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Dehavilland DHC-2 MK 1, 1 case](https://openairdocs.org/ntsb-events/230/sequence.md?model=2808006), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Dehavilland DHC-2 MK 1, 2 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2808006), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Dehavilland DHC-2 MK 1, 1 case](https://openairdocs.org/ntsb-events/096/sequence.md?model=2808006), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## 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](https://openairdocs.org/aircraft/N94DC), registered now, S/N 238, built 1951 (OpenAirDocs) - Reported make and model: De Havilland DHC-2 - Registry model: [Dehavilland DHC-2 MK 1](https://openairdocs.org/model/dehavilland-dhc-2-mk-1) (registry code 2808006) (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: 238 - Year built: 1951 - Airframe hours: 19674 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 45; injuries: none; 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 ## 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 20190627008119A](https://openairdocs.org/incident/20190627008119A), Jun 27, 2019: Dehavilland DHC-2 MK 1, Ketchikan, AK, Substantial damage. On Thursday June 27st 2019 at approximately 09:45 am, a DHC-2-MK1, N94DC registered to V2 aviation LLC and operated by pacific airways, inc., made a hard water… ## Other investigations on N94DC (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 ANC99LA007](https://openairdocs.org/ntsb/ANC99LA007), Oct 18, 1998: de Havilland DHC-2 (N94DC), Chitina, AK, substantial damage. Probable cause: The pilot's inadequate preflight which failed to detect water contamination in the fuel system. A factor was the unsuitable terrain in the emergency landing area. - [NTSB ANC83LA024](https://openairdocs.org/ntsb/ANC83LA024), Dec 18, 1982: de Havilland DHC-2 (N94DC), Near Port Alswo, AK, substantial damage ## Docket (2 files) The files NTSB released with the investigation on April 21, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99719. 4.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 4.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482784&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Photos (item 2, .PDF, 334 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482785&FileExtension=.PDF&FileName=Photos-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.