# NTSB GAA19CA563: De Havilland Beaver DHC 2, N77KZ, Mountain Village, AK, September 22, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: September 22, 2019, 14:50 local (22:50 UTC) - Place: Mountain Village, AK - Coordinates: 61.934722, -163.664169 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=61.9347&lon=-163.6642&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed, report February 11, 2020 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 100325 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA19CA563 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100325/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100325 - Page: https://openairdocs.org/ntsb/GAA19CA563 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Dehavilland BEAVER DHC-2, 1 case](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=2800108), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Attention/monitoring: attention](https://openairdocs.org/ntsb-findings/02021510): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Dehavilland BEAVER DHC-2, 1 case](https://openairdocs.org/ntsb-findings/02021510/cases.md?model=2800108), [All aircraft, 226 cases](https://openairdocs.org/ntsb-findings/02021510/cases.md) - [Flight control system: lE flap control system](https://openairdocs.org/ntsb-findings/01022780): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Dehavilland BEAVER DHC-2, 1 case](https://openairdocs.org/ntsb-findings/01022780/cases.md?model=2800108), [All aircraft, 3 cases](https://openairdocs.org/ntsb-findings/01022780/cases.md) - [Performance/control parameters: configuration](https://openairdocs.org/ntsb-findings/01062017): Aircraft › Aircraft oper/perf/capability · Incorrect use/operation (probable cause); cases with it: [Dehavilland BEAVER DHC-2, 1 case](https://openairdocs.org/ntsb-findings/01062017/cases.md?model=2800108), [All aircraft, 80 cases](https://openairdocs.org/ntsb-findings/01062017/cases.md) - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Dehavilland BEAVER DHC-2, 1 case](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=2800108), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md) - [Terrain: rough terrain](https://openairdocs.org/ntsb-findings/03021015): Environmental issues › Physical environment · Effect on operation; cases with it: [Dehavilland BEAVER DHC-2, 1 case](https://openairdocs.org/ntsb-findings/03021015/cases.md?model=2800108), [All aircraft, 442 cases](https://openairdocs.org/ntsb-findings/03021015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Dehavilland BEAVER DHC-2, 1 case](https://openairdocs.org/ntsb-events/900/sequence.md?model=2800108), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Dehavilland BEAVER DHC-2, 5 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=2800108), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Takeoff: Abnormal runway contact](https://openairdocs.org/ntsb-events/090); cases with it: [Dehavilland BEAVER DHC-2, 1 case](https://openairdocs.org/ntsb-events/090/sequence.md?model=2800108), [All aircraft, 1,506 cases](https://openairdocs.org/ntsb-events/090/sequence.md) - [Takeoff: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Dehavilland BEAVER DHC-2, 5 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2800108), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/aircraft/N77KZ), registered now, S/N 950, built 1955 (OpenAirDocs) - Reported make and model: De Havilland BEAVER DHC 2 (No Series) - Registry model: [Dehavilland BEAVER DHC-2](https://openairdocs.org/model/dehavilland-beaver-dhc-2) (registry code 2800108) (OpenAirDocs) - Registry engine: [Pratt & Whitney R-985-AN-14B](https://openairdocs.org/engine/pratt-whitney-r-985-an-14b) (registry code 51654, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 950 - Year built: 1955 - Airframe hours: 9333.6 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 32; injuries: none; 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 ## 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 20190922013449A](https://openairdocs.org/incident/20190922013449A), Sep 22, 2019: Dehavilland BEAVER DHC-2, Mountain Villag, AK, Substantial damage. Pre takeoff pilot failed to deploy flaps to takeoff setting. Aircraft did not become airborne, slid across tundra, came to stop about .25 miles from lake. Ac… ## Docket (2 files) The files NTSB released with the investigation on October 18, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100325. 3.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476881&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Photo (item 2, .PDF, 1 photo, 132 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476882&FileExtension=.PDF&FileName=Photo-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.