# NTSB ANC93FA161: De Havilland DHC-2, N64273, Iliamna, AK, August 31, 1993 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: August 31, 1993, 11:05 local (19:05 UTC) - Place: Iliamna, AK - Coordinates: 59.849967, -154.56076 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=59.8500&lon=-154.5608&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal, 3 serious - Status: Completed, report December 2, 1994 - Report: Approved by Office Director - NTSB office: Alaska Regional Office - NTSB case key (mKey): 2313 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC93FA161 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/2313/pdf - Page: https://openairdocs.org/ntsb/ANC93FA161 ## Probable cause THE PILOT'S FAILURE TO MAINTAIN AIRSPEED RESULTING IN AN INADVERTENT STALL. A FACTOR IN THE ACCIDENT WAS THE INADEQUATE RECURRENT TRAINING OF THE PILOT BY THE OPERATOR/MANAGEMENT. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, maneuvering - airspeed - not maintained, pilot in command (cause) - inadequate recurrent training, company/operator management (contributing factor) - stall - inadvertent, pilot in command - In flight collision with terrain/water, maneuvering ## Analysis WHILE MANEUVERING AT LOW ALTITUDE TO OBSERVE MOOSE, THE AIRPLANE STALLED INTO THE GROUND. THE LODGE'S SENIOR PILOT STATED THAT THE LODGE HAD NO RECURRENT TRAINING PROGRAM. ## Factual narrative HISTORY OF FLIGHT On August 31, 1993, at approximately 1105 Alaska daylight time, a wheel equipped de Havilland DHC2 MKE1 airplane, N64273, crashed while maneuvering approximately 6 miles west of Iliamna, Alaska. The airplane was being operated under 14 CFR Part 91 by Rainbow King Lodge of Iliamna, and had departed Iliamna on a company VFR flight plan, in visual meteorological conditions at approximately 1100. The commercial pilot and two passengers were seriously injured and three passengers were fatally injured. The airplane was destroyed. After the accident, while awaiting medical evacuation at the Iliamna Airport, the pilot reportedly told witnesses that while he was maneuvering to look at a moose he lost control of the airplane and collided with the terrain. Investigators interviewed Mr. Harry Ricci, who identified himself as one of the managers of Rainbow King Lodge who had assisted in the medical evacuation of the pilot. Mr. Ricci told investigators that the accident pilot, Mr. Randy Toppen, had completed a preflight and taken off with a guide and four passengers for a landing strip west of Iliamna called Stuyhoke. He said that "Randy flew the same airplane yesterday." Ricci also told investigators that the accident pilot said, as he was carried on a stretcher, "I'm sorry, I'm sorry, I was going to look at a moose, I was in a turn, (the airplane) it got uncontrollable, I pushed the power up, that's it, I'm sorry." NTSB and FAA Investigators interviewed Captain Michael W. McKendry, of Iliamna Air Taxi, a pilot who witnessed the accident airplane fly across the path of his airplane from right to left at a distance of approximately 1/4 to 1/3 mile. This witness said that he was "inbound" to Iliamna with fishing clients and was at an altitude of 700 feet above ground level (agl). He said that the Beaver was seen by him to be in a right wing down turn, near the ground at an altitude that he estimated to be 200 feet agl, and recalled seeing the "bottom of the Beaver's wing" as it turned. He estimated that the heading of the accident Beaver was 340 degrees in a right turn. That pilot also said that he last saw the accident airplane in a 30 degree right bank and nose low, 5 to 8 degrees. He said that he lost site of the Beaver behind a low rise but arriving over that spot moments later, spotted the crashed airplane nose down with a motionless passenger seen at the right side of the airplane. The witness pilot said that while he circled, that passenger showed some movement. The pilot circled over the accident site for about 50 minutes until fuel became a concern, during which time he radioed for and coordinated rescue activities. PERSONNEL INFORMATION Pilot Randy J. Toppen 18866 SW Arrowood (winter) Lake Oswego, OR 97035 P. O. Box 106 Iliamna, AK 99606 (summer) History of licenses: Private pilot license, single engine land, 5/26/88 single engine sea, 5/9/89, instrument 4/5/91 Commercial pilot's certificate 501783120, 4/29/91 Commercial pilot, single engine sea 5/22/91 (DHC-2 Beaver) The pilot, represented by counsel, consented to interview approximately 50 hours after the accident. NTSB and FAA investigators were advised by the attending physician (surgeon) that "there is no reason to delay an interview longer, he's in some pain, but thinking clearly." Investigators from the Safety Board and the FAA met with the accident pilot and his attorney in an Anchorage hospital on September 2, 1993. In that interview, the pilot recalled specific details of the weight and balance, fuel load, heading and altitude of the VFR departure and cruise to the fishing drop-off location. The pilot said that he did not recall looking at a moose and neither could recall the details of the period of time in flight before the crash. A transcript of that recorded interview is attached to this report. During the interview, the pilot said, "I remember making a turn. . . I remember trying to roll outta [sic] the turn and uh, [sic] both pitch and yaw weren't responding as I was rolling outta the turn. I remember pushing the nose down some, adding power, and still wouldn't respond in a nose up position." Investigators then asked if "pushing the nose down and adding power (was) the normal response for what type of problem?" The pilot said, "for a stall. And that's . . . . I was -- I normally would recognize the buffeting associated with a stall. Uh, had that specifically registered in my mind, it just wasn't flying like uh, it felt mushy." Investigators asked, "(the airplane) felt mushy?" The pilot answered "Yeah . . . wasn't responding . . . nose up and wings level." Mr. Toppen told investigators that his experience was approximately 1100 hours total pilot time, 500 hours of that on floats and "five to six hundred (hours) on wheels." He said that most of his "time was in a Beaver, either on floats or on wheels." Mr. Toppen recalled previous instances of circling animals with the Beaver airplane. He stated, in part, "If I'm making a slow, steep turn, after really looking at a bear, sometime or a moose, I'll put in climb flaps and, and uh, circle around these critters with, with climb flaps and, and un, additional prop RPM setting and. . ." To the question, "So at some times you do make slow, steep turns to see animals close," Toppen replied, "Yeah. Or making like I make slow, relatively slow turns when I'm approaching to land, I'm going slower than. . .normal and I make sure that I don't have my flaps up when I'm coming . . . to land." (Investigator's note: The aircraft's trailing edge wing flaps were found to be up in the wreckage, See impact and wreckage information.) Mr. Toppen's log book indicated that he received 14.5 hours of training in a DHC2 Beaver (wheel equipped) between July 26, 1989 and August 28, 1989. Mr. Toppen had logged between approximately 96 hours and 119 hours, inclusively, of total flight time at this point. He said that he began working as a lodge pilot for "Don Louche at Redoubt Mountain Lodge" in April 1991. He said that he started work at that time "with just basically a float ticket" and had "very few hours, couple hundred, two hundred fifty hours' total time and spent a month and half just flyin' with me daily, teachin' me how to fly the Beaver and spent another good two months flying just freight for him." Mr. Louche identified himself as the Rainbow King Lodge "senior pilot." Mr. Toppen's log book indicated that he had 14.5 hours of flight time in a DHC2 Beaver (wheel equipped) and 294.1 total hours when he began work on May 11, 1991. Entries in Mr. Toppen's log book were totalled to August 10, 1993, at which time his total flight time was entered as 905.8 total hours, 515.2 single engine land, and 390.6 single engine sea. Investigators asked the accident pilot if he recalled doing stall training in the (Beaver) aircraft. He said that he did recall that he did. Mr. Toppen's pilot log book showed that he had nine flights in the DHC2 Beaver between May 11, 1991 and May 21, 1991. Six of the flight log entries have annotations indicating training was conducted. Two of the nine flights indicated that the purpose of the flight was maintenance related with "Don" and one flight was "with Don and Dee to look around Kenai." The nine flights totalled 18.3 flight hours during which Mr. Toppen logged the time as 18.3 "pilot in command ('incl. solo)." The six flights which indicated training annotations totalled 13.9 hours flight time. No entries indicated that dual (instructional) flight time was given except the final flight of training on May 21, 1991. That entry indicated 1.6 hours of dual instruction was provided by a "George Chapman, 1257313 who stated, "I have personally instructed this person and consider him ready to take 'comm. sea plane test." The annotations written for this flight stated, "spot landings, emergency prod, step turns, short ## Aircraft - Registration: [N64273](https://openairdocs.org/deregistered/N64273-1998-01-14), registration cancelled 1998-01-14, S/N 897 (OpenAirDocs) - Reported make and model: DE HAVILLAND DHC-2 - Registry model: [Dehavilland BEAVER DHC-2 MK.1](https://openairdocs.org/model/dehavilland-beaver-dhc-2-mk-1) (registry code 2800102) (OpenAirDocs) - Category: Airplane - Serial number: 897 - Airframe hours: 5518 - Engines: P&W R-985-AN14B 450 horsepower reciprocating - Damage: Destroyed - Flight: Part 91 - Operator: Rainbow King, Inc, doing business as Rainbow King Lodge - Registered owner: Rainbow King Lodge, Inc - Airworthiness certificate: Standard, Normal; Standard, Utility - Last inspection: Annual, May 11, 1993, 190 hours before - Destination: STAYHOK RIVER, AK - Flight plan: Company VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; seat: left; flight hours: 1,100 total, 900 in this make and model, 1,000 as pilot in command, 200 in the last 90 days, 70 in the last 30 days, 5 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 45° at 12 knots, gusting 15 - Visibility: 7 statute miles - Lowest ceiling: 1,500 ft broken - Temperature: 61 °F, dew point -0 °F ## 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 19930831032349A](https://openairdocs.org/incident/19930831032349A), Aug 31, 1993: Dhav DHC2MK1, Iliamna, AK, Destroyed, 3 fatal. Circling to look at moose. Lost control. Stalled. Indicates at or near gross weight. Lacked training turning stalls ## Other investigations on N64273 (1) 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 ANC89LA154](https://openairdocs.org/ntsb/ANC89LA154), Sep 1, 1989: de Havilland DHC-2 (N64273), Iliamna, AK, substantial damage. Probable cause: THE PILOT'S SELECTION OF UNSUITABLE TERRAIN FOR AN OFF-AIRPORT OPERATION. FACTORS RELATED TO THE ACCIDENT WERE: THE ADVERSE TERRAIN CONDITIONS. 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.