Crash of a De Havilland DHC-2 Beaver in Ketchikan: 5 killed

Date & Time: Jul 24, 2007 at 1405 LT
Type of aircraft:
Operator:
Registration:
N995WA
Flight Phase:
Survivors:
No
Schedule:
Ketchikan - Ketchikan
MSN:
1100
YOM:
1957
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
5273
Captain / Total hours on type:
178.00
Aircraft flight hours:
17356
Circumstances:
The air taxi float-equipped airplane was the second of three airplanes on an air tour flight over a remote scenic area in southeast Alaska. As the flight of three airplanes flew into mountainous terrain, the first pilot reported low clouds, with rain and fog, which required him to descend to 700 feet msl to maintain VFR flight conditions. The pilot of the third tour airplane, which was about 5 minutes behind the accident airplane, stated that as he approached the area around the accident site, he encountered "a wall of weather" which blocked his intended flight route, and he turned around. The accident airplane's fragmented wreckage was discovered in an area of steep, tree-covered terrain, about 2,500 feet msl, near the area where the third airplane turned around. The NTSB discovered no mechanical problems with the airplane during postaccident inspections. An NTSB weather study revealed instrument meteorological conditions in the area at the time of the accident. Photographs recovered from a passenger's camera depicted deteriorating weather conditions as the flight progressed. A charter boat captain, who had seen numerous float-equipped tour airplanes operating in adverse weather conditions, called the local FAA Flight Standards District Office (FSDO) 9 days before the accident, to report his sightings. According to the FAA, no specific tour operator could be identified during their ensuing investigation, and no enforcement actions or additional surveillance of any operators was initiated. According to the FSDO manager, the local FSDO had lost inspectors due to downsizing. He reported they had not attempted to observe operators' adherence to weather minimums via ground-based viewing locations along the heavily traveled tour routes, and noted that FAA inspectors used to purchase air tour tickets to provide en route, on-board surveillance, but had not done so for approximately the last 10 years. He noted that additional inspector assistance from other FAA offices was not requested
Probable cause:
The pilot's decision to continue under visual flight rules into an area of instrument metrological conditions. Contributing to the accident was the pilot's inadequate weather evaluation, and the FAA's inadequate surveillance of the commercial air tour operator.
Final Report:

Crash of a De Havilland DHC-2 Beaver off Ketchikan: 1 killed

Date & Time: Sep 29, 1997 at 1747 LT
Type of aircraft:
Operator:
Registration:
N4787C
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Ketchikan - Ketchikan
MSN:
1330
YOM:
1959
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2071
Captain / Total hours on type:
1200.00
Aircraft flight hours:
24267
Circumstances:
The float equipped airplane was observed taking off in light winds and calm water, and obtaining a steep climb and nose high attitude. Witnesses described hearing no reduction of engine noise from takeoff power to climb power. The airplane entered a steep left bank about 200 feet above the water, then rolled rapidly to the right and impacted at a steep angle into the water. The airplane had been modified with a Short Take Off and Landing (STOL) kit. Certification flight tests had determined that this modification eliminated aerodynamic warning of impending stalls, and therefore required an audible stall warning. Test results also required the addition of both a ventral fin, and horizontal stabilizer finlets, to meet directional stability certification. These tests determined that the least stable condition was in the takeoff flap configuration, during climb. The Supplemental Type Certificate (STC) for the modification required the ventral fin, and an audible stall warning system be installed. The manufacturer provided a marketing video, produced prior to the STC approval, which stated the stall warning system was not required in the U.S. The company indicated this tape was used for training, and was a basis for pilots routinely disabling the stall warning horn by pulling the circuit breaker. At the time of the accident, the airplane did not have the ventral fin installed, a takeoff flaps setting was selected, and the audible stall warning circuit breaker was in the pulled (disabled) position. The local FAA Flight Standards Office had inspected the accident airplane 14 times in the previous 29 months, and made no mention of the ventral fin not being installed.
Probable cause:
The pilot's excessive climb and turning maneuver at low altitude, the pilot's inadvertent stall, and the intentional operation of the airplane with the required stall warning system disabled. Factors associated with this accident were the pilot's overconfidence in the modified airplane's ability, the uninstalled ventral fin, inadequate compliance with the STC by the company, unclear information by the manufacturer, and inadequate surveillance by the FAA.
Final Report:

Crash of a Rockwell Aero Commander 500A in Ketchikan: 2 killed

Date & Time: Sep 6, 1997 at 1300 LT
Registration:
N543AN
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Wrangell – Everett
MSN:
500-908-17
YOM:
1960
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2577
Captain / Total hours on type:
81.00
Aircraft flight hours:
6679
Circumstances:
The aircraft had an in-flight breakup when the left wing and tail section separated. Post accident inspection revealed a right engine main fuel supply line progressive rupture, only trace amounts of fuel in the fuel lines, and no rotational damage to the right engine. Pre accident, long term, fuel leak evidence surrounded the ruptured line. The right propeller was not feathered. The left wing D-tube rib at station 127 exhibited compressive buckling. Left wing fractures were upward, and horizontal stabilizer deformation was downward. During an actual loss of engine power in the airplane 17 months before this accident, the pilot had feathered the incorrect propeller. Both a mechanic, and an FAA safety counselor, who were familiar with the pilot, described him as able to be disoriented, and reliant on GPS for navigation. He had stated five months before the accident that he did not feel his instrument flying skills were proficient, and desired training. On the day of the accident, weather was visual meteorological conditions, with layered clouds above 2,200 feet mean sea level. The pilot stated to the FAA weather briefer that he wanted to make the flight under visual conditions. The flight route and altitude was unknown.
Probable cause:
The rupture of the right engine fuel supply line as a result of inadequate inspection by the pilot/mechanic, and the pilot's excessive pull up which resulted in exceeding the design stress limits of the airplane. Factors were the improper emergency procedures and failure to feather the propeller.
Final Report:

Crash of a De Havilland DHC-2 Beaver I in Port Johnson: 1 killed

Date & Time: Dec 12, 1996 at 0905 LT
Type of aircraft:
Operator:
Registration:
N67694
Flight Phase:
Survivors:
Yes
Schedule:
Port Johnson – Ketchikan
MSN:
924
YOM:
1956
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
17800
Captain / Total hours on type:
8500.00
Aircraft flight hours:
20640
Circumstances:
According to the passenger, he and the pilot had just taken off, and as they were climbing out over an open water portion of a bay, the pilot said, 'here comes a gust.' Reportedly, the pilot added engine power, and the airplane began descending. The right wing started to dip, and the nose started to drop. The pilot had the control yoke turned all the way to the left, then yelled that they were going in. The airplane crashed in the water, and the passenger exited the airplane through the windshield. He did not see the pilot. The deceased pilot was found still strapped in his seat several days later, when a portion of the wreckage was recovered.
Probable cause:
The pilot's inadequate compensation for wind conditions, and failure to maintain adequate airspeed, which resulted in an inadvertent stall and collision with terrain (water). A factor associated with the accident was the gusty wind condition.
Final Report:

Crash of a De Havilland DHC-2 Beaver near Ketchikan: 3 killed

Date & Time: Oct 13, 1996 at 1455 LT
Type of aircraft:
Registration:
N64276
Flight Phase:
Survivors:
No
Site:
Schedule:
Ketchikan - Rowena Lake
MSN:
1025
YOM:
1957
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
17000
Captain / Total hours on type:
8500.00
Aircraft flight hours:
12475
Circumstances:
The pilot and two passengers departed for a remote area on an on-demand charter flight in a float-equipped airplane. An emergency locator transmitter signal was heard in the area of the intended destination about 55 minutes after departure. The flight was reported overdue and search personnel located the wreckage at an elevation of about 2,850 feet in mountainous terrain about 2 and 1/2 hours after departure. The airplane collided with terrain below the top of a steep ridge. Search personnel reported the weather conditions in the area included low ceilings. The conditions deteriorated during subsequent rescue operations. The area forecast included an AIRMET for marginal VFR conditions with mountain obscuration due to clouds and precipitation.
Probable cause:
Continued flight by the pilot into adverse weather condition, and his failure to maintain adequate altitude/clearance from mountainous terrain. Factors related to the accident were the high/mountainous terrain, and weather conditions that included low ceilings.
Final Report:

Crash of a Cessna T207A Turbo Stationair 8 in Ketchikan

Date & Time: Mar 10, 1995 at 0745 LT
Registration:
N6478H
Flight Phase:
Survivors:
Yes
Schedule:
Ketchikan - Wrangell
MSN:
207-0538
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1352
Captain / Total hours on type:
750.00
Aircraft flight hours:
16116
Circumstances:
Prior to departing on a scheduled air taxi flight with two passengers, the pilot obtained a weather briefing that included airmets for mountain obscuration, IFR and icing conditions. VFR flight was not recommended. A company flight that departed before the accident flight, returned to the company base due to low ceilings, after the accident flight departed. The flight departed on a VFR flight plan and encountered low ceilings in the area of mountainous terrain. The pilot began maneuvering around the terrain and during a period of obscuration, collided with several trees. The company operations manual specifies that the pilot is responsible for the conduct of the flight; however, procedures are included that detail the dispatch responsibilities, dissemination of weather information, and the director of operations responsibility to monitor and cancel flights if necessary.
Probable cause:
The pilot's continued visual flight rules (VFR) flight into instrument meteorological conditions (IMC). Factors in the accident were fog and low ceilings, and a failure of the operator to follow their procedures specified in the company operations manual.
Final Report:

Crash of a De Havilland DHC-3 Otter off Thorne Bay

Date & Time: Nov 10, 1993
Type of aircraft:
Registration:
N98AT
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Thorne Bay - Ketchikan
MSN:
181
YOM:
1956
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine airplane was returning to its base in Ketchikan following maintenance in Thorne Bay. Shortly after takeoff, while climbing, the engine lost power, forcing the pilot to attempt an emergency landing. While landing on water, a control wire snapped, causing the airplane to nose down in the water, coming to rest upside down. All three occupants were rescued by coastguard 20 minutes later and the aircraft sank.
Probable cause:
Loss of engine power on climb out for unknown reasons.

Crash of a Britten-Norman BN-2A-26 Islander near Ketchikan: 4 killed

Date & Time: Aug 20, 1991 at 1315 LT
Type of aircraft:
Operator:
Registration:
N68HA
Flight Phase:
Survivors:
No
Site:
Schedule:
Ketchikan - Wrangell
MSN:
2009
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
5107
Captain / Total hours on type:
740.00
Aircraft flight hours:
16395
Circumstances:
Approximately 3/4 of an hour after departing for Wrangell, Alaska, the pilot of the regularly scheduled commuter flight contacted company dispatch approximately 30 miles from Ketchikan, and reported that he was returning due to weather. Shortly thereafter, the pilot communicated with another company pilot flying in the same vicinity and both pilots described the weather at their respective locations as 'marginal'. Weather conditions at the Ketchikan International Airport (18 nautical miles from the crash site) at the time of the accident were characterized by low ceilings, multiple cloud layers and reduced (3 mile) visibilities with light rain. The aircraft collided with trees/rising terrain at 800 feet msl while in a near level flight path headed east southeast. Right wingtip impact signatures indicated a very shallow right wing down/nose up attitude at the initial tree impacts. All four occupants were killed.
Probable cause:
The pilot's attempting to operate vfr in instrument meteorological conditions. Factors contributing to the accident were upsloping terrain in the aircraft's flight path as well as weather conditions resulting in an obscuration of the terrain.
Final Report:

Crash of a Douglas C-47A-65-DL off Petersburg

Date & Time: Jun 26, 1989 at 1105 LT
Registration:
N8042X
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Petersburg - Ketchikan
MSN:
19041
YOM:
1943
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9500
Captain / Total hours on type:
4000.00
Aircraft flight hours:
10762
Circumstances:
Immediately after takeoff at 200-300 feet agl, a portion of fabric separated from the right aileron. While maneuvering the aircraft the pilot's control wheel became free, and he elected to ditch using full rudder and differential power. Examination of the pilot's control wheel aileron control chain revealed that the chain failed due to overload. The right seat was occupied by a mechanic employed by the operator and held a private pilot certificate with single and multi engine rating. He stated that he suggested to the pilot that his controls were functioning normally, but the pilot disagreed and proceeded to ditch the aircraft. Examination of the right control yoke revealed aileron movement in the correct direction.
Probable cause:
The pilot's improper decision to ditch the aircraft when it could have been flown back to the airport using the right seat controls. Contributing factor(s) was: the failure and separation of a portion of the right aileron fabric, and the pilot's excessive force applied to the control wheel which resulted in overstressing the aileron control chain.
Final Report:

Crash of a De Havilland DHC-3 Otter in Ketchikan: 2 killed

Date & Time: Jan 15, 1989 at 0810 LT
Type of aircraft:
Operator:
Registration:
N11250
Flight Phase:
Survivors:
No
Schedule:
Ketchikan - Klawock
MSN:
171
YOM:
1956
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1470
Captain / Total hours on type:
150.00
Aircraft flight hours:
10366
Circumstances:
After departing the floatplane base on a company VFR flight plan, the scheduled commuter flight proceeded northwest along a saltwater strait at a low altitude above water. Two miles northwest of the airport the aircraft entered a snow squall and the pilot attempted a steep turn to reverse course. During the turn the aircraft impacted and sank in 167 feet deep water. Search and rescue efforts were suspended after 4 days.
Probable cause:
The pilot's inadvertent flight into IFR conditions and the stall which occurred during the turn to reverse course. Contributing to the accident were the snow conditions encountered.
Occurrence #1: in flight encounter with weather
Phase of operation: cruise
Findings
1. (f) weather condition - snow
2. (c) vfr flight into imc - inadvertent - pilot in command
3. (c) weather evaluation - poor - pilot in command
----------
Occurrence #2: loss of control - in flight
Phase of operation: maneuvering - turn to reverse direction
Findings
4. Maneuver - excessive - pilot in command
5. (c) stall - inadvertent
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report: