WPR16LA189

NTSB accident investigation · Dehavilland Beaver DHC 2 MK.1 · Lopez Island, WA · September 30, 2016

Accident · Serious injuriesLimited investigationFinal report
Date
September 30, 2016, 08:37 local (15:37 UTC)
Place
Lopez Island, WA
Injuries
2 serious, 2 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N6781LDehavilland Beaver DHC 2 MK.1
Defining event
Enroute-descent: VFR encounter with IMC
Weather
Instrument (IMC) · Day
Status
Completed · report July 5, 2018
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20160930013799A
Case key
94049

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 decision to land in an area of low visibility and ground fog, which resulted in collision with water.

Findings · 4

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.

Performance/control parameters: altitudeAircraft › Aircraft oper/perf/capability · Not attained/maintainedDehavilland BEAVER DHC-2 MK.1: 1 caseAll aircraft: 1,310 casesProbable cause
Ceiling/visibility/precip: low visibilityEnvironmental issues › Conditions/weather/phenomena · Effect on operationDehavilland BEAVER DHC-2 MK.1: 1 caseAll aircraft: 175 casesProbable cause

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

While maneuvering at low altitude for a water landing, the commercial pilot of the float-equipped airplane encountered low visibility due to ground fog. The pilot initiated a go-around, but the airplane impacted the water, bounced, and impacted the water a second time before coming to rest upright. The airplane subsequently sank and was not recovered. The pilot reported that there were no mechanical anomalies with the airplane that would have precluded normal operation. The operator further reported that other company pilots who were flying on the day of the accident stated that the low visibility conditions were easily avoided by a slight course deviation.

Factual narrative

On September 30, 2016, at 0837 Pacific daylight time (PDT), a Dehavilland, Beaver DHC-2 MK1, N6781L, unintentionally impacted the water near Lopez Island, Washington, while descending through a break in a cloud layer. The airplane was registered to and operated by Kenmore Air Seaplanes under the provisions of 14 Code of Federal Regulations Part 135. The commercial pilot, and one passenger sustained minor injuries, two passengers sustained serious injuries. The airplane sustained substantial damage during the accident sequence, and subsequently sunk. The scheduled commuter flight departed Kenmore Air Harbor Seaplane Base (W55), Seattle, Washington, about 0800, with a planned destination of Fisherman Bay (81W), Washington. Visual and instrument meteorological conditions prevailed along the route of flight, and a company visual flight rules (VFR) flight plan had been filed. In a statement submitted to the NTSB investigator-in-charge, the pilot reported that he departed W55 with three passengers, and that his first planned stop was 81W. As he initiated his descent just south of Cattle Pass at 2,000 ft, he observed breaks in the undercast north of the pass. The pilot stated that he could see the water at all times during the descent, and that he could see the destination "all the way down." The pilot further stated that he then completed the landing checklist, except for flaps, and at a certain point, before turning final to land north at 81W, he lost sight of the water. The pilot reported that when he realized the approach was no longer practical, he added go-around power, raised the nose, and initiated a go-around. Shortly thereafter, the airplane impacted the water, bounced, then impacted the water again. The pilot stated that after the airplane came to rest in an upright position, water began to enter the [cabin/cockpit areas]. The pilot mentioned that after he and his three passengers had successfully egressed the airplane and been in the water from between 35 to 45 minutes, they were rescued by a motor trawler and a local Sheriff's boat. The airplane sank and was not recovered. The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. Air Airmen's Meteorological Information (AIRMET) SIERRA advisory for instrument flight rules (IFR) conditions, which was applicable for the accident site, was issued at 0745 PDT. It advised of ceilings below 1,000 ft above ground level (agl), visibility below 3 statute miles, mist and fog. At 0753, the Automated Surface Observing System (ASOS) located at Friday Harbor Airport (FHR), Friday Harbor Washington, about 3.5 nm northwest of the accident location, reported wind calm, visibility 6 miles, mist, ceiling overcast at 300 ft agl, temperature 10° C, dew point 8° C, and an altimeter setting of 30.03 inches of mercury. At 0853, the FHR weather reporting facility indicated wind 080° at 3 knots, visibility 9 miles, ceiling overcast 400 ft agl,temperature 10° C, dew point 8° C, and an altimeter setting of 30.06 inches of mercury. (Refer to the NTSB's Meteorological Specialist's report, which is appended to the docket for this accident.) In the RECOMMENDATION section of the NTSB 6120.1 report, the operator opined that the accident occurred because of the pilot's decision to operate in an area in which there was at least some ground fog present in some areas, including at the accident site itself. According to other [company] pilots flying that morning, this area was easily avoidable with a slight flight path deviation to the west, where ceiling and visibility remained unrestricted. The operator further stated that any recommendations for prevention, therefore, must address the pilot's decision to operate where he did. Additionally, the operator referenced the Federal Aviation Administration's Risk Management Handbook (FAA-H-8083-2), stating, "...this addresses this need well, and would be the template followed for training."

Aircraft

Registration
N6781L
Reported as
Dehavilland Beaver DHC 2 MK.1 (MARKI)
Category
Airplane
Serial number
788
Built
1953
Airframe hours
7,395.1
Engine
Pratt & Whitney R985AN/14B, 450 horsepower, reciprocating
Damage
Substantial damage
Flight
Part 135
Operator
Kenmore Air Harbor Inc
Registered owner
Kenmore Air Harbor Inc
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · September 28, 2016
Departed
W55 · Seattle, WA
Destination
81W · Lopez, WA
Airport
81W · Fishermans Bay
Equipment
Handheld GPS

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
69
Injuries
Minor
Certificates
Commercial, Airline transport
Airplane ratings
Multi-engine land, Single-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
April 11, 2016
Seat
Left
Restraint
3-point
Flight hours
25,000 total · 1,630 in this make and model · 15,000 as pilot in command · 202 in the last 90 days · 51 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
80° at 3 knots
Visibility
7 statute miles
Lowest ceiling
400 ft overcast
Temperature
50 °F, dew point 46 °F
Altimeter
30.05 inHg
Observed at
KFHR, 4 nm away

Docket · 4

The files NTSB released with the investigation on January 8, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.5 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.

Other investigations on N6781L · 1

Matched to the same aircraft by N-number and date.