# NTSB WPR16LA189: Dehavilland Beaver DHC 2 MK.1, N6781L, Lopez Island, WA, September 30, 2016 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: September 30, 2016, 08:37 local (15:37 UTC) - Place: Lopez Island, WA - Coordinates: 48.464168, -122.95333 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=48.4642&lon=-122.9533&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-descent: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401) - Highest injury: Serious injuries - Injuries: 2 serious, 2 minor - Status: Completed, report July 5, 2018 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 94049 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR16LA189 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94049/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94049 - Page: https://openairdocs.org/ntsb/WPR16LA189 ## Probable cause The pilot's decision to land in an area of low visibility and ground fog, which resulted in collision with water. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Dehavilland BEAVER DHC-2 MK.1, 8 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2800102), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Attention/monitoring: monitoring environment](https://openairdocs.org/ntsb-findings/02021545): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Dehavilland BEAVER DHC-2 MK.1, 4 cases](https://openairdocs.org/ntsb-findings/02021545/cases.md?model=2800102), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/02021545/cases.md) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Dehavilland BEAVER DHC-2 MK.1, 1 case](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=2800102), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Ceiling/visibility/precip: low visibility](https://openairdocs.org/ntsb-findings/03035015): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Dehavilland BEAVER DHC-2 MK.1, 1 case](https://openairdocs.org/ntsb-findings/03035015/cases.md?model=2800102), [All aircraft, 175 cases](https://openairdocs.org/ntsb-findings/03035015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-descent: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401) (defining event); cases with it: [Dehavilland BEAVER DHC-2 MK.1, 1 case](https://openairdocs.org/ntsb-events/401/sequence.md?model=2800102), [All aircraft, 392 cases](https://openairdocs.org/ntsb-events/401/sequence.md) - [Approach-VFR go-around: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Dehavilland BEAVER DHC-2 MK.1, 9 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2800102), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N6781L-2019-07-08), registration cancelled 2019-07-08, S/N 788, built 1953 (OpenAirDocs) - Reported make and model: DEHAVILLAND BEAVER DHC 2 MK.1 (MARKI) - Registry model: [Dehavilland BEAVER DHC-2 MK.1](https://openairdocs.org/model/dehavilland-beaver-dhc-2-mk-1) (registry code 2800102) (OpenAirDocs) - Registry engine: [NONE](https://openairdocs.org/engine/none) (registry code 00000, none) (OpenAirDocs) - Category: Airplane - Serial number: 788 - Year built: 1953 - Airframe hours: 7395.1 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 69; injuries: minor; 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 ## 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 20160930013799A](https://openairdocs.org/incident/20160930013799A), Sep 30, 2016: Dehavilland BEAVER DHC-2 MK.1, Lopez, WA, Destroyed. Pilot departed on a CFR 135 flight from kenmore air harbor seaplane base (W55) to fisherman's bay seaplane base (81W). The nearest reported weather was from… ## Other investigations on N6781L (1) 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. - [NTSB SEA01LA081](https://openairdocs.org/ntsb/SEA01LA081), Apr 30, 2001: de Havilland DHC-2 (N6781L), Seattle, WA, substantial damage. Probable cause: The high wind conditions encountered as the aircraft began its takeoff roll. Contributing factors were the variable and gusty wind conditions. ## Docket (4 files) The files NTSB released with the investigation on January 8, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94049. 5.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459264&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Weather Study (item 2, .PDF, 882 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459267&FileExtension=.PDF&FileName=Weather%20Study-Master.PDF - Accident Location Map (item 3, .PDF, 166 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459270&FileExtension=.PDF&FileName=Accident%20Location%20Map-Master.PDF - ICAO Notificatin and Response (item 4, .PDF, 643 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459271&FileExtension=.PDF&FileName=ICAO%20Notificatin%20and%20Response-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.