Accident Details
Probable Cause and Findings
The operator's failure to determine the actual cargo weight, leading to the loading and operation of the airplane outside of the weight and center of gravity limits contained in the airplane flight manual, which resulted in an aerodynamic stall. Contributing to the accident was the Federal Aviation Administration's failure to require weight and balance documentation for each flight in 14 Code of Federal Regulations Part 135 single-engine operations.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHTOn July 7, 2013, about 1120 Alaska daylight time, a deHavilland DHC-3 Otter airplane, N93PC, collided with terrain shortly after takeoff from Soldotna Airport, Soldotna, Alaska. The commercial pilot and nine passengers died, and the airplane was destroyed. The airplane was registered to Rediske Family Limited Partnership, Nikiski, Alaska, and was operated by Rediske Air, Nikiski, Alaska, under the provisions of 14 Code of Federal Regulations (CFR) Part 135 as an on-demand charter flight. Visual meteorological conditions prevailed, and no flight plan was filed for the flight, which was destined to Bear Mountain Lodge, about 90 miles southwest of Soldotna.
On the day of the accident, the pilot was in Nikiski and was scheduled to fly a different trip with the accident airplane, but shortly before the planned departure time, the trip was canceled. The group of nine passengers on board the accident flight had been scheduled to go to the lodge in two of the operator's smaller airplanes; however, the pilot decided to use the Otter after his previous flight was canceled so that the group could fly together on one plane.
The lodge operator, who was in Nikiski before the departure, requested that a load of groceries and lodge supplies be flown with the group and brought the supplies to Rediske Air's base of operations. The lodge operator estimated the cargo weighed about 300 lbs. After the pilot unloaded the cargo from the canceled flight, he and the lodge owner loaded the groceries and lodge supplies on the accident airplane.
Rediske Air did not keep fueling records for each flight. A witness who was present during the fueling operations at Nikiski reported that he saw the pilot top off the forward tank then begin fueling the center tank. The witness later returned to the fuel supply tank to fuel his helicopter and thought he noticed 56 gallons on the fuel reader. He said that he and the accident pilot would have been the only people to use the fuel tank.
The first leg of the trip was a positioning flight from Nikiski to Soldotna, where the passengers were to be picked up. The flight was completed uneventfully.
According to witnesses at Soldotna Airport, after loading the passengers and their baggage, the pilot taxied to runway 25 for departure. There were no witnesses to the accident sequence. The airplane impacted the ground about 2,320 ft from the threshold of runway 25 and about 154 feet right of the runway centerline. Impact signatures were consistent with a nose-low, right-wing-low attitude at impact. PERSONNEL INFORMATIONThe pilot, age 42, held a commercial pilot certificate with an airplane single-engine land, multiengine land, and instrument ratings. His most recent second-class airman medical certificate was issued July 11, 2012, and contained no limitations. On April 24, 2012, the pilot was approved as a check airman in single-engine land airplanes flown by Rediske Air.
A review of Rediske Air's training records showed that the pilot's initial ground training in the Otter was completed on June 28, 2011. The pilot's most recent 14 CFR Part 135 competency check in the Otter was accomplished on June 15, 2012, and his most recent recurrent ground training in the airplane was completed on the same date. The pilot received Part 135 competency and line checks in a Cessna 206 airplane on May 15, 2013.
Personal flight logbooks for the pilot were not located, but his most recent insurance application, dated April 23, 2013, showed a total flight time of 7,765 hours with a total time in DHC-3 airplanes of 105 hours. The insurance form for the previous year indicated a total time in DHC-3 airplanes of 155 hours. His total flying time in the last 12 months was listed as 350 hours.
A review of company flight and duty time records for the pilot found no entries after June 23, 2013. Company personnel attempted to recreate a record of the pilot's flights between that date and the day of the accident but were unable to create a complete log because company flight records did not indicate pilots' names for each flight. According to the records that could be recreated, the pilot flew 1.9 hours the day before the accident and 6.1 hours in the 72 hours before the accident.
The pilot's spouse reported that, 2 days before the accident, the pilot went to work about 0600. She recalled that they took their children to a movie that started at 1920 and that they returned home between 2100 and 2130. She stated that the day before the accident was a normal workday for the pilot and that he left for work by 0830. She stated that he returned home and had dinner about 1830 to 1900. She reported that the pilot fell asleep between 2100 and 2130. On the day of the accident, she did not talk to the pilot before he left for work and did not know the time that he left but recalled that it was light outside. AIRCRAFT INFORMATIONThe accident airplane, serial number 280, was manufactured in 1958 by the deHavilland Aircraft Company of Canada and was a single-engine, propeller-driven, single-pilot, high-wing short takeoff and landing (STOL) airplane. It was modified with a Honeywell TPE 331-10R-511C turboprop engine per a Texas Turbine Conversions, Inc. supplemental type certificate (STC). It was equipped with a Hartzell model HC-B4TN-5NL four-blade propeller. The airplane was also modified with a Baron STOL kit per an STC to improve its performance. The airplane was configured to carry 10 passengers and cargo and had a maximum gross weight of 8,000 lbs.
Airplane maintenance records indicated that STCs for cargo net installation and for installation of shoulder harnesses had been installed. The cargo compartment on the original airplane had a load limit of 650 pounds. The cargo net STC stated that the aft cargo area had a load limit of 750 pounds. Information from the STC holder substantiated the increased load limit in the cargo area due to the increased size of the compartment.
In July 2010, the previous owner sent the airplane to Recon Air Corporation in Geraldton, Ontario, Canada, for a major overhaul and the conversion to a turbine-powered airplane at an airplane total time of 22,536.5 hours. In addition to the Baron STOL kit STC, a pulse light control system STC and an extended range fuel system STC were installed. The STC approval pages for these STCs were contained in the permanent maintenance records and were dated July 12, 2010.
Recon also performed all required inspections and complied with all applicable airworthiness directives (AD) during the overhaul. On July 9, 2010, the airplane was removed from the Canadian Civil Aircraft Register and placed on the US registry as N93PC. At this time, the airplane received an FAA standard airworthiness certificate in the Normal category.
Following the Recon conversion, in August 2010, three additional STCs were incorporated by Peninsula Aero Technology in Kenai, Alaska, to install updated avionics in the airplane at an airplane total time of 22,566.2 hours.
The Rediske Family Limited Partnership purchased the airplane in October 2010. The airplane was maintained under an Approved Airplane Inspection Program (AAIP) dated February 11, 2011, that was approved by the FAA on March 9, 2011. The AAIP was used for maintaining the accident airplane in lieu of conventional 100-hour and annual inspections. The AAIP divided the maintenance of the airplane into four consecutive phase inspections to be performed every 50 hours of flight time. There was a special note in the AAIP that required accomplishment of all four phase inspections within each 12 months even if the airplane hour requirements were not met. The AAIP had provisions for a 10-hour grace period on all of the phase inspections. All special inspection items, calendar time inspections, ADs, and service bulletins (SB) outside the scope of the phase inspections were to be tracked and complied with under the AAIP. Rediske Air, Inc. documented all of the requirements of the AAIP in the aircraft inspection record maintained at the company headquarters.
On June 17, 2011, an inspection of the airplane in accordance with annual, 800-hour, phases 1-4, and all calendar and special inspection items was completed at an airframe total time of 22,611.8 hours, and the airplane was placed on the AAIP. At this time, the engine and propeller had accumulated 75.3 hours and 26 cycles since the conversion. The records indicated that all applicable ADs were complied with at this time.
The most recent inspection of the airplane incorporated phases 2, 3, and 4 on June 13, 2013, at an airplane total time of 22,831.8 hours and engine and propeller times of 295.3 hours since overhaul and installation on the airplane. Ten discrepancies were recorded during the most recent inspections and all were rectified. None of the discrepancies were notable in terms of major repairs to the airplane.
Weight and Balance
The weight and balance information for the airplane was contained in the aircraft inspection record. As part of the Recon overhaul, the airplane was physically weighed on July 7, 2010, with the cargo net, ELT, turbine engine conversion, STOL kit, extended range fuel system, and pulse light system listed as installed equipment. The empty weight, as weighed, was 4,259.00 lbs with a center of gravity (CG) at 132.66 in. The notes stated that the airplane had residual fuel, full oil, and full hydraulic fluid for this weighing. In August 2010, the weight and balance was recalculated after the installation of the updated avionics. The new empty weight, as calculated, was 4,283.09 lbs with a CG at 132.66 in.
The NTSB calculated the airplane's weight and balance based on the data from the August 2010 paperwork. The total moment of removed equipment was calculated to be 138 lb-in greater than that in the paperwork. The data for the total installed equipment was also calculated to be different than that in the paperwork. The total installed weight was ...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# DCA13MA121