GAA19CA563

NTSB accident investigation · De Havilland Beaver DHC 2 · Mountain Village, AK · September 22, 2019

Accident · No injuriesData collectionFinal report
Date
September 22, 2019, 14:50 local (22:50 UTC)
Place
Mountain Village, AK
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N77KZDe Havilland Beaver DHC 2
Defining event
Takeoff: Loss of control on ground
Weather
Visual (VMC) · Day
Status
Completed · report February 11, 2020
Report
Approved by Office Director
NTSB office
General Aviation Accidents
Parties
FAA
FAA report
20190922013449A
Case key
100325

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's improper takeoff configuration due to distraction, which resulted in the airplane’s failure to become airborne and its subsequent collision with rising terrain. Contributing to the accident was the pilot's failure to use the Before Takeoff checklist.

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.

Flight control system: lE flap control systemAircraft › Aircraft systems · Incorrect use/operationDehavilland BEAVER DHC-2: 1 caseAll aircraft: 3 casesProbable cause
Performance/control parameters: configurationAircraft › Aircraft oper/perf/capability · Incorrect use/operationDehavilland BEAVER DHC-2: 1 caseAll aircraft: 80 casesProbable cause
Use of equip/info: use of checklistPersonnel issues › Task performance · PilotDehavilland BEAVER DHC-2: 1 caseAll aircraft: 336 casesProbable cause
Terrain: rough terrainEnvironmental issues › Physical environment · Effect on operationDehavilland BEAVER DHC-2: 1 caseAll aircraft: 442 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.

Analysis

The pilot in the float-equipped airplane reported that he did not extend the flaps before he accelerated for takeoff from a lake. He added that, shortly after coming on step, he rolled the ailerons left and applied back pressure to the elevator to "become airborne." However, the airplane did not become airborne, and the floats subsequently impacted the shoreline. The airplane then bounced, skidded to a stop, impacted rising terrain, and came to rest upright. The airplane sustained substantial damage to the left elevator. The pilot reported that he had not maintained a sterile cockpit during takeoff and that he failed to complete the Before Takeoff checklist. The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation.

Factual narrative

The pilot in the float-equipped airplane reported that, he did not extend the flaps before he accelerated for takeoff. Shortly after coming on step, "I rolled the ailerons to the left and applied back pressure to the yoke to become airborne." However, the airplane did not become airborne before the floats struck the tundra, the airplane bounced and skidded to a stop, upright. The airplane sustained substantial damage to the left elevator. The pilot reported that he had not maintained a sterile cockpit during takeoff, and he failed to complete the Before Takeoff Checklist. The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation.

Aircraft

Registration
N77KZ
Reported as
De Havilland Beaver DHC 2 (No Series)
Category
Airplane
Serial number
950
Built
1955
Airframe hours
9,333.6
Engine
Pratt & Whitney R-985-AN-14B, 450 horsepower, reciprocating
Damage
Substantial damage
Flight
Part 135
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · September 14, 2019
Departed
Mountain Village, AK
Destination
Mountain Village, AK
Flight plan
Company VFR
Equipment
Unknown

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
32
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
August 29, 2019
Seat
Left
Restraint
3-point
Flight hours
2,200 total · 830 in this make and model · 2,100 as pilot in command · 250 in the last 90 days · 150 in the last 30 days · 6 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
190° at 10 knots
Visibility
10 statute miles
Lowest ceiling
3,800 ft overcast
Temperature
48 °F, dew point 39 °F
Observed at
PAMO, 10 nm away

Docket · 2

The files NTSB released with the investigation on October 18, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.8 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.