# NTSB ANC95FA078: de Havilland DHC-2, N1348, Nondalton, AK, June 21, 1995 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 20, 1995, 16:45 local (Jun 21, 1995, 00:45 UTC) - Place: Nondalton, AK - Coordinates: 59.959598, -154.870834 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=59.9596&lon=-154.8708&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 5 fatal - Status: Completed, report February 8, 1996 - Report: Approved by Office Director - NTSB office: Alaska Regional Office - NTSB case key (mKey): 2584 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC95FA078 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/2584/pdf - Page: https://openairdocs.org/ntsb/ANC95FA078 ## Probable cause (aircraft 2) THE FAILURE OF BOTH PILOTS TO MAINTAIN ADEQUATE VISUAL LOOKOUT. ## Probable cause (aircraft 1) THE FAILURE OF BOTH PILOTS TO MAINTAIN ADEQUATE VISUAL LOOKOUT. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Midair collision, cruise - visual lookout - inadequate, pilot in command (cause) - visual lookout - inadequate, pilot of other aircraft (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - water - Midair collision, cruise - visual lookout - inadequate, pilot in command (cause) - visual lookout - inadequate, pilot of other aircraft (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - water ## Analysis (aircraft 2) THE CERTIFICATED AIRLINE TRANSPORT PILOT OF N1348 AND 3 PASSENGERS WERE NORTHWEST BOUND AT 200 FEET OVER A REMOTE RIVER. THE BUSINESS FLIGHT WAS EN ROUTE TO A FISHING LODGE AFTER PICKING UP LODGE CLIENTS FROM A REMOTE LAKE. THE CERTIFICATED COMMERCIAL PILOT AND SOLE OCCUPANT OF N7832H WAS SOUTHBOUND AT 200 FEET OVER THE SAME AREA OF THE RIVER. WITNESSES OBSERVED THE TWO AIRPLANES COLLIDE AND DESCEND INTO THE RIVER. THE WITNESSES DID NOT OBSERVE EITHER AIRPLANE TAKE EVASIVE ACTION. THE WEATHER CONDITIONS WERE REPORTED AS SCATTERED CLOUDS AT 3,500 FEET AND A VISIBILITY OF 25 MILES. ## Analysis (aircraft 1) THE CERTIFICATED AIRLINE TRANSPORT PILOT OF N1348 AND 3 PASSENGERS WERE NORTHWEST BOUND AT 200 FEET OVER A REMOTE RIVER. THE BUSINESS FLIGHT WAS EN ROUTE TO A FISHING LODGE AFTER PICKING UP LODGE CLIENTS FROM A REMOTE LAKE. THE CERTIFICATED COMMERCIAL PILOT AND SOLE OCCUPANT OF N7832H WAS SOUTHBOUND AT 200 FEET OVER THE SAME AREA OF THE RIVER. WITNESSES OBSERVED THE TWO AIRPLANES COLLIDE AND DESCEND INTO THE RIVER. THE WITNESSES DID NOT OBSERVE EITHER AIRPLANE TAKE EVASIVE ACTION. THE WEATHER CONDITIONS WERE REPORTED AS SCATTERED CLOUDS AT 3,500 FEET AND A VISIBILITY OF 25 MILES. ## Factual narrative (aircraft 2) SAME AS NARRATIVE ANC-95-F-A078A ## Factual narrative (aircraft 1) History of the Flight On June 20, 1995, about 1645 Alaska daylight time, a float equipped De Havilland DHC-2, N1348, collided with a float equipped Piper PA12, N7832H, over the Tazimina River, about 3 miles southeast of Nondalton, Alaska. N1348 was being operated as a visual flight rules (VFR) local area business flight to transport fishing lodge clients from Kukaklek Lake to a lodge at Port Alsworth, Alaska, under Title 14 CFR Part 91. N7832H was being operated as a personal VFR flight from Anchorage, Alaska, to Iliamna, Alaska. Both airplanes were destroyed. The certificated airline transport pilot of N1348 and three passengers sustained fatal injuries. The certificated commercial pilot, the sole occupant of N7832H, also sustained fatal injuries. Visual meteorological conditions prevailed. A VFR flight plan was filed by the pilot of N7832H. Witnesses reported that they were fishing on the Tazimina river located in the Lake Clark National Preserve, a remote area of Alaska that is accessible only by floatplane or boat. N7832H was observed heading in a southerly direction in level flight, about 200 feet above the river. N1348 was observed heading in a northwesterly direction at the same altitude. Witnesses indicated that prior to the collision, neither aircraft appeared to take any evasive maneuvers. The accident occurred during the hours of daylight at latitude 59 degrees, 55.70 minutes north and longitude 154 degrees, 48.88 minutes west. Meteorological Information The closest official weather observation station is Iliamna, Alaska, which is located 11 nautical miles south of the accident site. At 1650, a surface observation was reporting in part: Sky condition and ceiling, 3,500 feet scattered, 13,000 feet thin scattered; visibility, 25 miles; temperature, 57 degrees F; dew point, 42 degrees F; wind, 190 degrees at 8 knots; altimeter, 30.09 inHg. Wreckage and Impact Information Safety Board investigators examined both airplanes at the accident site on June 21, 1995. The main wreckage of N1348 was located in a river channel of the Tazimina River at latitude 59 degrees, 55.76 minutes N and longitude 154 degrees, 49.02 minutes W in about 4 feet of water. The river current was moving about 6 to 7 knots. The right wing of the airplane separated from its aft attach point and the entire wing was pivoted forward 90 degrees at the forward attach point. It displayed upward and aft crushing at the inboard end of the leading edge and similar aft and upward crushing at the leading edge wingtip. The lift strut remained attached to the wing. The flap and aileron assemblies remain attached to the wing. The entire left wing of the airplane separated from the fuselage at the inboard attach points and was also separated into two segments about midspan. The inboard half of the wing displayed semi-circular aft crushing and folding of the leading edge about 3 feet, beginning about 2 1/2 feet outboard from the fuselage attach points and curving aft about 5 feet outboard from the forward attach point. The forward face of the wing spar was crushed rearward at the top edge of the spar. The outboard end of the separated wing structure was curved forward of the inboard end of the leading edge. A small section of white metal tubing and a small piece of plexiglass was found embedded in the leading edge of the wing at the lift strut attach point. The inboard section of the wing flap assembly remained attached to the wing. The outboard half of the left wing separated about 4 feet inboard of the pitot tube, at a point that was about 2 feet outboard of the landing light housing that was retained in the inboard section. The separated edges of the wing structure displayed forward bending. The outboard end of the wingtip displayed downward and inward folding crushing. The wing position light bulb filament was broken from its support posts but was tightly coiled. The underside of the wing displayed slight white and blue paint smudges from the leading edge to the trailing edge from the pitot tube in an outboard direction about 4 feet. The paint pattern was slightly curved in an inboard direction about midway through the pattern. The left aileron assembly separated from the wing and exhibited buckling about midspan. The right float assembly separated from its attach points and was downstream from the fuselage about 30 feet. The forward portion of the float was bent to the right about 30 degrees about 6 feet aft of the front of the float. The left float assembly was fragmented and torn open about midway along the longitudinal axis of the float. The tail assembly of the airplane did not display any obvious heavy impact damage. The engine was crushed in an aft and downward direction about 45 degrees. Evidence of tree bark was found embedded in the engine cylinder cooling fins of the number 8 and number 2 cylinders. The propeller assembly remained connected to the engine crankshaft. One propeller blade was separated about 3 feet outboard from the hub. The second blade exhibited leading edge gouging, torsional twisting, "S" bending and trailing edge gouging about 6 inches inboard from the tip. The third blade was bent aft about 90 degrees, about 8 inches outboard from the hub and exhibited leading edge gouging and torsional twisting. Due to the condition and point of rest of both airplanes, Safety Board investigators were unable to operate the flight controls of either airplane by their respective control mechanisms. The fuselage of N7832H was located at latitude 59 degrees, 55.61 minutes N and longitude 154 degrees, 49.00 minutes W. The airplane came to rest inverted in a slough area of the river in about 3 feet of water. The right wing of the airplane remained attached to the airframe and was folded back about 180 degrees onto the top surface of the wing about midspan, just inboard of the wing lift strut attach point. An aft and upward semicircular crush mark was evident on the underside of the leading edge of the wing, just outboard from the forward attach point. The aileron and flap assemblies remained attached to the wing and were also folded along with the wing. The wing position light bulb filament was intact and tightly coiled. The left wing of the airplane separated from the fuselage at the forward wing attach point. It exhibited tearing of the wing structure oriented on about a 45 degree angle from the inboard leading edge to the trailing edge in an outboard direction, about 3 1/2 feet outboard from the rear wing attach point. The inboard end of the separated forward spar, including the spar caps, exhibited aft bending and buckling. The inboard 3 1/2 feet of the rear spar remained attached to the fuselage carrythrough along with the inboard section of wing flap mechanism. The remaining outboard section of the aft spar that remained with the separated wing, was buckled in an aft direction and exhibited blue paint smudges on the aft surface of the spar. The aileron remained attached to the separated wing at the inboard end and was buckled about mid-span in an inboard direction. The wing lift strut was separated about midspan. The underside of the leading edge of the wing, about 3 feet outboard from the inboard end exhibited a vertical tear oriented on a 45 degree angle from the leading edge to the trailing edge in an outboard direction. The landing light bulbs and the wing position light bulb filaments were all intact and tightly coiled. The tail assembly consisting of the vertical stabilizer, rudder, and elevator, separated from the fuselage just forward of the tail lift handles. The vertical stabilizer and rudder were crushed in an aft direction and folded to the right at the bottom and trailing edge of the assembly. The left side of the fuselage, just aft of the firewall, displayed semicircular aft and inward crushing. An 8 inch long diagonal tear, oriented at a 45 degree an ## Aircraft 1 - Registration: [N1348](https://openairdocs.org/deregistered/N1348-2005-03-16), registration cancelled 2005-03-16, S/N 1348 (OpenAirDocs) - Reported make and model: de Havilland DHC-2 - Registry model: [Dehavilland DHC-2-L20A](https://openairdocs.org/model/dehavilland-dhc-2-l20a) (registry code 2800103) (OpenAirDocs) - Category: Airplane - Serial number: 1348 - Airframe hours: 9499 - Engines: P&W R-985-14 450 horsepower reciprocating - Damage: Destroyed - Flight: Business, Part 91 - Registered owner: Alaska Wilderness Lodge Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 20, 1995, 35 hours before - Departed: KUKAKLEK LAKE, AK - Destination: PORT ALSWORTH, AK ## Aircraft 2 - Registration: [N7832H](https://openairdocs.org/deregistered/N7832H-2013-02-27), registration cancelled 2013-02-27, S/N 12-732, built 1946 (OpenAirDocs) - Reported make and model: PIPER PA-12 - Registry model: [Piper PA-12](https://openairdocs.org/model/piper-pa-12) (registry code 7101202) (OpenAirDocs) - Registry engine: [Lycoming 0-235 series](https://openairdocs.org/engine/lycoming-0-235-series) (registry code 41505, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 12-732 - Airframe hours: 3279 - Engines: LYCOMING O-320-B1A 150 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Thomas M. Bukowski - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 20, 1994, 32 hours before - Departed: LHD, ANCHORAGE, AK - Destination: ILI, ILIAMNA, AK - Flight plan: VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot, aircraft N1348; age 45; flight instructor, airline transport, commercial; airplane ratings: multi-engine land, single-engine sea, multi-engine sea, single-engine land; instrument ratings: helicopter, airplane; medical: class 2, valid medical--no waivers/lim.; toxicology performed; flight hours: 18,300 total, 4,000 in this make and model, 18,300 as pilot in command, 30 in the last 90 days, 30 in the last 30 days, 3 in the last 24 hours - Pilot, aircraft N7832H; age 42; commercial; airplane ratings: single-engine land, single-engine sea; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 1,470 total, 1,400 in this make and model, 1,450 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 190° at 8 knots - Visibility: 25 statute miles - Lowest ceiling: none - Temperature: 57 °F, dew point 43 °F - Altimeter: 30.00 inHg - Observed at: ILI, 11 nm away ## FAA reports on this event (2) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19950620017292A](https://openairdocs.org/incident/19950620017292A), Jun 20, 1995: Dhav DHC2MK2, Nondalton, AK, Destroyed, 4 fatal. Following river low altitude was struck on front left side by N7832H flying river opposite direction. - [Accident 19950620017291A](https://openairdocs.org/incident/19950620017291A), Jun 20, 1995: Piper PA12, Nondalton, AK, Destroyed, 1 fatal. Following river low altitude collided with N1348 coming in opposite direction. Both floatplanes fell into river. 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.