DCA22MA193

NTSB accident investigation · Dehavilland DHC-3 · Freeland, WA · September 4, 2022

Accident · FatalClass 1 · MajorFinal report
Date
September 4, 2022, 15:09 local (22:09 UTC)
Place
Freeland, WA · last ADSB from Soper 1508:51.5 crashed in Mutiny Bay, 1.3 nm from shore of Whidbey Island . Nearest zip code is Freeland, WA
Injuries
10 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N725THDehavilland DHC-3
Defining event
Enroute: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report September 29, 2023
Report
Board-adopted by Notation
Investigation class
Class 1
NTSB office
Major Investigations Division
Parties
Friday Harbor Seaplanes, Viking Air Limited, FAA/AVP, TSB Canada, Northwest Seaplanes
Safety recommendations
Yes
FAA report
20220904020609A
Case key
105855

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 in-flight unthreading of the clamp nut from the horizontal stabilizer trim actuator barrel due to a missing lock ring, which resulted in the horizontal stabilizer moving to an extreme trailing-edge-down position rendering the airplane’s pitch uncontrollable.

Findings · 6

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.

Knowledge: knowledge of equipmentPersonnel issues › Experience/knowledge · Maintenance personnelDehavilland DHC-3: 1 caseAll aircraft: 69 cases
Maintenance: installationPersonnel issues › Task performance · Maintenance personnelDehavilland DHC-3: 1 caseAll aircraft: 371 cases
Policy/procedure: adequacy of policy/procOrganizational issues › Management · Maintenance providerDehavilland DHC-3: 2 casesAll aircraft: 106 cases
Documentation/record keeping: maintenance recordsOrganizational issues › Support/oversight/monitoring · Maintenance providerDehavilland DHC-3: 1 caseAll aircraft: 16 cases

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.

Factual narrative

On September 4, 2022, about 1509 Pacific daylight time, a float-equipped de Havilland DHC-3 (Otter), N725TH, was destroyed when it impacted the water in Mutiny Bay, near Freeland, Washington, and sank. The pilot and nine passengers were fatally injured. The airplane was owned by Northwest Seaplanes, Inc., and operated as a Title 14 Code of Federal Regulations (CFR) Part 135 scheduled passenger flight by West Isle Air dba Friday Harbor Seaplanes. The flight originated at Friday Harbor Seaplane Base (W33), Friday Harbor, Washington, with an intended destination of Will Rogers Wiley Post Memorial Seaplane Base (W36), Renton, Washington. Visual meteorological conditions prevailed at the time of the accident.

Aircraft

Registration
N725TH
Reported as
Dehavilland DHC-3
Category
Airplane
Serial number
466
Built
1967
Airframe hours
24,430
Engine
General Electric H80-200, 777 horsepower, turbo prop
Damage
Destroyed
Flight
Part 135
Operator
West Isle Air, doing business as Friday Harbor Seaplanes
Registered owner
Northwest Seaplanes Inc
Airworthiness certificate
Standard, Commuter
Last inspection
100 hour · September 1, 2022 · 11 hours before
Departed
W33 · Friday Harbor, WA
Destination
RNT · Renton, WA
Flight plan
Company VFR
Equipment
ADS-B

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
43
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land, Single-engine sea, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
July 29, 2022
Seat
Left
Toxicology
Performed
Flight hours
3,686 total · 1,300 in this make and model · 297 in the last 90 days · 111 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
310° at 10 knots
Visibility
10 statute miles
Lowest ceiling
9,000 ft broken
Temperature
68 °F, dew point 57 °F
Altimeter
30.02 inHg
Turbulence
Unknown
Observed at
K0S9, 10 nm away
METAR
K0S9 042215Z AUTO 31010KT 10SM FEW040 FEW075 BKN090 20/14 A3002 RMK AO2

Docket · 66

The files NTSB released with the investigation on August 31, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 833 MB in all.

Pilot/operator aircraft accident report, NTSB form 6120.1Item 1 · PDF · 11 pages · 2.1 MBAviation accident report AIR-22-08 (investigative update)Item 2 · PDF · 7 pages · 671 KBMemorandum for record - update on FAA airworthiness directive 2022-23-08 (one time inspection of actuator)Item 3 · PDF · 1 page · 196 KBWeather factual reportItem 4 · PDF · 30 pages · 2.5 MBWeather attachment 1Item 5 · XLSX · 20 KBWeather attachment 2Item 6 · XLSX · 20 KBWeather attachment 3Item 7 · GIF · 8.9 MBWeather attachment 4Item 8 · GIF · 20.4 MBWeather attachment 5Item 9 · GIF · 20.7 MBWeather attachment 6Item 10 · PDF · 7 pages · 2.6 MBWeather attachment 7Item 11 · MP4 · 113 MBWeather attachment 8Item 12 · PDF · 1 page · 62 KBWeather attachment 9Item 13 · PDF · 2 pages · 145 KBWitness factual reportItem 14 · PDF · 4 pages · 127 KBWitness interviews and statementsItem 15 · PDF · 73 pages · 13.1 MBC bard witness video 1Item 16 · MOV · 2.0 MBC bard witness videoItem 17 · MOV · 826 KBC bard witness video 2Item 18 · MOV · 982 KBC baker witness videoItem 19 · MP4 · 1.6 MBD goodrum witness video 1Item 20 · MP4 · 147 KBD goodrum witness video 2Item 21 · MP4 · 295 KBK reddy witness videoItem 22 · MOV · 18.5 MBM stroker witness videoItem 23 · MOV · 2.4 MBM kelley witness videoItem 24 · MOV · 26.5 MBR jensen witness videoItem 25 · MP4 · 930 KBShore videoItem 26 · AVI · 64.6 MBShore video - enlargedItem 27 · MOV · 102 MBAirplane performance studyItem 28 · PDF · 13 pages · 2.6 MBFAA ADS-B dataItem 29 · CSV · 912 KBSearch and recovery factual reportItem 30 · PDF · 19 pages · 20 photos · 4.6 MBOperational factors group factual reportItem 31 · PDF · 22 pages · 776 KBOperational factors attachment 1 - interview transcript - west isle air chief pilotItem 32 · PDF · 87 pages · 172 KBOperational factors - attachment 2 - interview summaries - FAA poi and previous poiItem 33 · PDF · 15 pages · 137 KBOperational factors attachment 3 - west isle air pilot questionnairesItem 34 · PDF · 30 pages · 3.3 MBOperational factors attachment 4 - interview summary - other airline's pilotItem 35 · PDF · 3 pages · 38 KBOperational factors - attachment 5 - de havilland DHC-3 otter flight manual [excerpts]Item 36 · PDF · 4 pages · 117 KBOperational factors attachment 6 - DHC-3 otter flight manual supplement (FMS#10) [excerpts]Item 37 · PDF · 5 pages · 384 KBOperational factors - attachment 7 west isle air flight operations manual [excerpts]Item 38 · PDF · 9 pages · 857 KBOperational factors - attachment 8 west isle air flight training manual [excerpts]Item 39 · PDF · 5 pages · 6.4 MBOperational factors - attachment 9 see gee calculator and instructions - DHC-3Item 40 · PDF · 4 pages · 1.5 MBOperational factors - attachment 10 fueling information - N725THItem 41 · PDF · 2 pages · 95 KBOperational factors - attachment 11 pilot training record summaryItem 42 · PDF · 3 pages · 4.3 MBOperational factors - attachment 12 - statement of party representatives to NTSB investigationItem 43 · PDF · 3 pages · 3.0 MBOperational factual attachment 13 - email from west isle air chief pilot re training datesItem 44 · PDF · 3 pages · 187 KBMaintenance recordsItem 45 · PDF · 28 pages · 289 KBMaintenance records - errataItem 46 · PDF · 2 pages · 70 KBLubrication intervals diagramItem 47 · PDF · 1 page · 2.0 MB100 Hour / annual inspection checklistItem 48 · PDF · 4 pages · 2.0 MBExcerpt from maintenance manual - supplemental inspection and corriosion control programItem 49 · PDF · 3 pages · 96 KBAirworthiness factual reportItem 50 · PDF · 26 pages · 11 photos · 2.0 MBPhotographs - wreckage layout - generalItem 51 · PDF · 6 pages · 5 photos · 1.8 MBMaterials laboratory factual report 23-020 actuator - exemplarItem 52 · PDF · 22 pages · 1.2 MBMaterials laboratory factual report 23-019 actuator - accidentItem 53 · PDF · 25 pages · 1.2 MBMoisture seal position descriptionItem 54 · PDF · 8 pages · 2.7 MBMaterials laboratory factual report 23-021 experimentsItem 55 · PDF · 22 pages · 260 KBVideo demo 1 - lock ring seating testItem 56 · MOV · 108 MBVideo demo 2 - lock ring seating testItem 57 · MOV · 130 MBVideo demo 3 - lock ring seating testItem 58 · MOV · 134 MBMaterials laboratory factual report 23-022 elevatorItem 59 · PDF · 17 pages · 1.1 MBMaterials laboratory factual report 22-023 bottom panelItem 60 · PDF · 7 pages · 290 KB
All 66 files on NTSB’s docket

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.