Accident Details
Probable Cause and Findings
The pilot's exceedance of the airplane's critical angle of attack during departure climb, which resulted in an aerodynamic stall. Contributing to the accident was the pilot's improper decision to load the airplane beyond its allowable gross weight and center of gravity limits, coupled with his lack of operational experience in the airplane make, model, and configuration.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHTOn July 18, 2018, about 1900 Alaska daylight time, a float-equipped De Havilland DHC-2 (Beaver) airplane, N9878R, was destroyed when it was involved in an accident near Willow, Alaska. The pilot sustained fatal injuries and the two passengers sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 135 on-demand air taxi flight.
The director of operations (DO) for Regal Air reported that the flight was chartered by the Alaska Medicaid Travel Office to provide roundtrip transportation for two passengers from a private residence at a remote lake, to the Willow Seaplane Base (2X2) and then return them home 2 days later. A different company pilot flew the passengers (a woman and her 2.5-year-old son) from their home to Willow Seaplane Base on July 16, and the accident flight was the return trip. The accident pilot had not flown out of Willow Lake as a company pilot-in-command or to the destination lake before, so the DO reviewed the lakes, route, and fuel load with him before the flight. The company vice president called the passenger before the flight and obtained an expected cargo load of 600 lbs.
A review of Federal Aviation Administration radar and automatic dependent surveillance-broadcast (ADS-B) track data, revealed the airplane departed Lake Hood Seaplane Base (LHD), the operator's home base, about 1755 and arrived at Willow Seaplane Base at 1817.
Witnesses reported that after arriving at the Willow Seaplane Base, the pilot loaded the passenger's cargo. According to the passenger, the cargo consisted of 800 lbs of masonry mortar bags, three totes full of food and stores, two propane tanks, a utility sink, and miscellaneous baggage and supplies. No one witnessed the pilot weighing or loading the cargo; therefore, it is unknown where items were stowed or the exact calculated weight and balance. The passenger stated that the bags of mortar were piled up on the floor behind the pilot in the second-row, and she was seated in the second-row right seat with her son on her lap. Two witnesses helped push the airplane off the shore after loading because the floats were deep and stuck on the lake bottom. They stated that the airplane appeared very deep and heavy, especially the aft end of the floats. The pilot stated to the witnesses that he planned on offloading some "cement bricks" if he could not takeoff.
Other lakeside witnesses observed the airplane maneuvering on the lake. A review of various witness videos and statements revealed that the pilot made one take-off attempt to the south-southeast. The airplane then taxied back to the north end of the lake, with the aft end of the floats deep under water in almost a plow taxi, then he step taxied (taxied fast on-plane) around the center portion of the lake with the flaps up, and finally performed a step taxi takeoff with the flaps in the takeoff position, heading south-southeast. One witness stated that the pilot did not use the entire length of the lake for takeoff but rather started the takeoff with 1,300 ft of waterway behind the airplane at the north end of the lake.
According to the witnesses, the airplane slowly lifted off and attained a nose high attitude as it barely climbed over trees at the southeast end of the lake (see figure 1). The passenger stated that after takeoff, as the airplane turned left in the direction of the destination, it rolled left and crashed. After the impact, she noted that the pilot was unresponsive as the airplane became engulfed in fire, and she immediately evacuated with her son.
Figure 1. Willow Lake with approximate water and flight tracks based on witness videos.
A home surveillance video camera near the accident site captured the seconds before impact as the airplane flew east-southeast. The National Transportation Safety Board performed a video study that revealed that 3 seconds before ground impact the airplane's altitude was estimated at 115 ft above ground level (agl) and about 56 knots (64.4 miles per hour) groundspeed, in a 25° left turn. The airplane then rolled rapidly left through 90° as it descended in a nose-down attitude. The engine speed was estimated, using propeller sound spectrum analysis, at a constant 2235 rpm up until ground impact, which was slightly above maximum continuous power. A copy of the video and sound spectrum study is included in the public docket for this accident.
About 1900, multiple residents in a neighborhood southeast of Willow Lake heard a loud impact and witnessed smoke rising above the site. A neighbor responded and discovered the passenger walking with her son in her arms outside of the airplane which was nose down and engulfed in flames. The Willow Fire Department, Alaska State Troopers, and personnel from the Alaska Rescue Coordination Center responded. PERSONNEL INFORMATIONThe pilot worked for multiple operators in Anchorage. He was a part time pilot for Regal Air and Fly Denali, and also worked full time for Corvus Airlines (doing business as Ravn Alaska.) On the day of the accident, the pilot reported for duty at Ravn Alaska at 0615 as a first officer on a DHC-8 at the Anchorage base. He flew 6 legs and was released from duty at 1551. The DO described him as a real "go-get-getter" and remarked that he seemed well rested the day of the accident. The pilot had flown a total of 137.28 hours for Ravn in June and July.
The pilot also worked part time for Fly Denali as a pilot-in-command of a DHC-2T "turbine Beaver" on wheels. He had accumulated over 320 DHC-2T flight hours, and his last flight was June 29, 2018.
A review of Regal Air personnel records indicated that the pilot was a part-time pilot who was recently hired. He completed initial company training (both land and sea initial flight training and proficiency checkrides were in Cessna 206 airplanes) and was assigned as pilot-in-command (PIC) for single-engine wheeled airplanes on May 5, 2018, and single-engine seaplanes May 17, 2018. Examination of pilot records revealed the pilot received 3 hours of DHC-2 "transition-floats" flight training on June 16 and he flew his first DHC-2 float plane commercial flight the week before the accident. He had no proficiency check ride in the DHC-2, nor was he required to by regulation. He had accumulated 12.9 flight hours and 13 sea landings/takeoffs in the DHC-2 since he was hired.
A review of the pilot's personal logbook revealed he had experience in many different airplanes. He had accumulated a total of 216.6 hours of airplane single-engine sea flight time, and about 4 of those hours were in a DHC-2 many years before working for Regal Air. His initial seaplane training was conducted at Willow Lake. He was known by company personnel to be a professional and highly competent pilot. His family members stated that he loved flying and had no health issues. AIRCRAFT INFORMATIONThe accident airplane was equipped with Aerocet model 5850 floats and had a Wipaire 5600 lb gross weight increase kit installed, which increased the maximum takeoff weight to 5,600 lbs.
The Viking DHC-2 AFM, section 4.6.1, stated stall speed with the flaps up was 60 mph indicated airspeed and with landing flaps (50°) stall speed was 45 mph indicated airspeed. No stall speed for takeoff flaps (35°) was provided.
Weight and Balance
The estimated weight and balance at the time of the accident was calculated using the company's documented preflight fuel quantities, reported weights of the passengers, actual weights of recreated passenger purchased items (from receipts), estimated weights of miscellaneous items, likely load placement and company weight and balance figures. The operator recorded 70 gallons of fuel (35 gallons in the forward tank and 35 gallons in the center tank) before the pilot's initial departure from LHD. The flight to Willow Lake was about 25 minutes, and according to the Viking DHC-2 Airplane Flight Manual (AFM), about 15 gallons would have been used.
Using the calculated values, the gross weight of the airplane at the time of the accident was estimated to be 5,675.8 lbs, which was 75.8 lbs over the maximum gross takeoff weight for the airplane. The estimated center of gravity arm at the time of the accident was 107.76 inches, which was 1.76 inches aft of the rear limit.
Performance
The AFM operating data chart for seaplanes was used to calculate the takeoff distance required to climb above a 50-ft obstacle had the airplane been operating within takeoff limits. The Aerocet Supplement indicated that an additional 90% of the calculated distance should be added to the distance. Using the maximum gross weight and ambient conditions, the takeoff distance required was 1,670 ft without the Aerocet floats, and the Aerocet adjustment resulted in 3,173 ft of required distance.
The AFM section II Normal Procedures, paragraph 2.9 stated that after takeoff, "…climb at 65 mph. As soon as safe height has been attained, reduce power to 33.5 inches manifold pressure and 2200 rpm if fully loaded. Slowly increase airspeed from 65 mph to 80 mph and retrim. At an altitude of 500 ft- flaps to CLIMB and retrim." The best angle of climb is listed as 80 mph. METEOROLOGICAL INFORMATIONA review of the witness videos revealed that at the time of the takeoff, the wind was calm on the west side of the lake, and light and gusting from the southwest at the east side of the lake. Witnesses reported that the outside air temperature was much warmer than usual. The calculated density altitude at the time of the accident was 976 ft. AIRPORT INFORMATIONThe accident airplane was equipped with Aerocet model 5850 floats and had a Wipaire 5600 lb gross weight increase kit installed, which increased the maximum takeoff weight to 5,600 lbs.
The Viking DHC-2 AFM, section 4.6.1, stated stall speed with the flaps up was 60 mph indicated airspeed and with landing flaps (50°) stall speed was 45 mph indicated airspeed. No stall speed for takeoff flaps (3...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ANC18FA055