Crash of a De Havilland DHC-2 Beaver in La Grande: 2 killed

Date & Time: Jul 24, 2010 at 1053 LT
Type of aircraft:
Operator:
Registration:
C-FGYK
Flight Phase:
Survivors:
Yes
Schedule:
La Grande - Lac Eau Claire
MSN:
123
YOM:
1951
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3800
Captain / Total hours on type:
1000.00
Aircraft flight hours:
23808
Circumstances:
At approximately 1053 Eastern Daylight Time, de Havilland DHC-2 Mk. 1 amphibious floatplane (registration C-FGYK, serial number 123), operated by Nordair Québec 2000 Inc., took off from runway 31 at La Grande-Rivière Airport, Quebec, for a visual flight rules flight to l’Eau Claire Lake, Quebec, about 190 nautical miles to the north. The take-off run was longer than usual. The aircraft became airborne but was unable to gain altitude. At the runway end, at approximately 50 feet above ground level, the aircraft pitched up and banked left. It then nosed down and crashed in a small shallow lake. The pilot and 1 front-seat passenger were fatally injured and the 3 rear-seat passengers sustained serious injuries. The aircraft broke up on impact, and the forward part of the cockpit was partly submerged. The emergency locator transmitter activated on impact.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The aircraft was overloaded and its centre of gravity was beyond the aft limit. The aircraft pitched up and stalled at an altitude that did not allow the pilot to execute the stall recovery manoeuvre.
2. The baggage was not secured. Shifting of the baggage caused the triple seat to pivot forward, propelling the 3 rear-seat passengers against the pilot and front-seat passenger during impact.
3. Although the design of the triple seat met aviation standards, it separated from the floor at the time of impact, principally due to the fact that the heavy cargo shifted.
4. The action taken by TC did not have the desired outcomes to ensure regulatory compliance; consequently, unsafe practices persisted.
Finding as to Risk:
1. Operating an aircraft outside the limits and conditions under which a permit is issued can increase the risk of an accident
Final Report:

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

Date & Time: Jul 23, 2010 at 0727 LT
Type of aircraft:
Operator:
Registration:
N9290Z
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Thorne Bay - Ketchikan
MSN:
1387
YOM:
1959
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5300
Captain / Total hours on type:
4500.00
Aircraft flight hours:
21065
Circumstances:
The pilot had been advised by the Federal Aviation Administration flight service station (FSS) specialist to remain clear of the destination airport until the specialist could issue a special visual flight rules clearance. Instrument meteorological conditions prevailed at the airport, with a strong southeasterly wind. About 8 minutes after initial contact, the FSS specialist attempted to contact the pilot to issue the clearance but received no response. A witness about 0.5 mile southeast of the accident site said he saw the accident airplane flying very low over the treetops. He said the weather conditions consisted of low clouds, rain, and gusty southeasterly wind estimated at 30 to 40 knots. He said that, as the airplane passed overhead, it turned sharply to the left. As he watched the airplane, the wings rocked violently from side to side, and the nose pitched up and down. As the airplane passed low over hilly, tree-covered terrain, it rolled to the right, the right wing struck a large tree and separated, and the airplane descended behind a stand of trees. Pilots flying in the accident area reported strong wind with significant downdrafts and turbulence. A postaccident examination of the airplane did not disclose any preimpact mechanical malfunctions. Given the lack of mechanical deficiencies and the reports of turbulence and downdrafts, as well as the witness’ account of the airplane’s physical movements, it is likely that the pilot encountered significant terrain-induced turbulence and downdrafts while flying at low altitude. The area surrounding the accident site and portions of the pilot's earlier flight path were bordered by large areas of open and protected water, several of which were suitable for landing the float-equipped airplane.
Probable cause:
The pilot’s decision to continue the flight toward his destination in significant turbulence and downdrafts, and his subsequent failure to maintain control of the airplane while flying low over rising terrain.
Final Report:

Crash of a De Havilland DHC-2 Beaver near Chute des Passes: 4 killed

Date & Time: Jul 16, 2010 at 1117 LT
Type of aircraft:
Operator:
Registration:
C-GAXL
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Lac des Quatre - Lac Margane
MSN:
1032
YOM:
1957
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
11500
Captain / Total hours on type:
9000.00
Aircraft flight hours:
17204
Circumstances:
The float-equipped de Havilland Beaver DHC-2 Mk.I (registration number C-GAXL, serial number 1032), operated by Air Saguenay (1980) Inc., was flying under visual flight rules from Lac des Quatre to Lac Margane, Quebec, with 1 pilot and 5 passengers on board. A few minutes after take-off, the pilot reported intentions of making a precautionary landing due to adverse weather conditions. At approximately 1117, Eastern Daylight Time, the aircraft hit a mountain, 12 nautical miles west-south-west of the southern part of Lac Péribonka. The aircraft was destroyed and partly consumed by the fire that broke out after the impact. The pilot and 3 passengers were killed; 1 passenger sustained serious injuries and 1 passenger sustained minor injuries. No ELT signal was received.
Probable cause:
Causes and Contributing Factors:
1. The pilot took off in weather conditions that were below the minimum for visual flight rules, and continued the flight in those conditions.
2. After a late decision to carry out a precautionary alighting, the pilot wound up in instrument meteorological conditions (IMC). Consequently, the visual references were reduced to the point of leading the aircraft to controlled flight into terrain (CFIT).
3. The passenger at the rear of the aircraft was not seated on a seat compliant with aeronautical standards. The passenger was ejected from the plane at the moment of impact, which diminished his chances of survival.
Findings as to Risk:
1. The lack of training on pilot decision-making (PDM) for air taxi operators exposes pilots and passengers to increased risk when flying in adverse weather conditions.
2. In view of the absence of an ELT signal and the operator’s delay in calling, search efforts were initiated more than 3 ½ hours after the accident. That additional time lag can influence the seriousness of injuries and the survival of the occupants.
Final Report:

Crash of a De Havilland DHC-2 Beaver in Kukaklek Lake

Date & Time: Jun 27, 2010 at 1730 LT
Type of aircraft:
Operator:
Registration:
N9RW
Flight Phase:
Survivors:
Yes
Schedule:
Kukaklek Lake - Kukaklek Lake
MSN:
1095
YOM:
1957
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5000
Captain / Total hours on type:
2000.00
Circumstances:
The commercial pilot was taking off on a passenger flight in conjunction with a remote lodge operation under Title 14, CFR Part 91. The pilot said he picked up passengers in the float-equipped airplane on a beach, and water-taxied out into the lake for takeoff. He said he taxied out about 1,200 feet, reversed course into the wind, and initiated a takeoff. He said when the airplane reached his predetermined abort point, the airplane was still on the water, and might not lift off in time to avoid the terrain ahead. The pilot said rather than abort the takeoff he elected to apply full power and continue the takeoff. He said the airplane collided with the bank, and nosed over. The pilot said there were no preaccident mechanical anomalies with the airplane. The owner of the company said the lake was about 1 mile wide where the pilot elected to takeoff. He said the airplane received substantial damage to the wings and fuselage. He also said the passengers related to him that the engine sounded fine, but they did not think the pilot taxied out very far into the lake.
Probable cause:
The pilot's decision to use only a portion of the available takeoff area, which resulted in a collision with terrain during takeoff.
Final Report:

Crash of a De Havilland DHC-2 Beaver off Lyall Haarbour: 6 killed

Date & Time: Nov 28, 2009 at 1603 LT
Type of aircraft:
Operator:
Registration:
C-GTMC
Flight Phase:
Survivors:
Yes
Schedule:
Vancouver - Mayne Island - Pender Island - Lyall Harbour - Vancouver
MSN:
1171
YOM:
1958
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
2800
Captain / Total hours on type:
2350.00
Circumstances:
The Seair Seaplanes Beaver was departing Lyall Harbour, Saturna Island, for the water aerodrome at the Vancouver International Airport, British Columbia. After an unsuccessful attempt at taking off downwind, the pilot took off into the wind towards Lyall Harbour. At approximately 1603 Pacific Standard Time, the aircraft became airborne, but remained below the surrounding terrain. The aircraft turned left, then descended and collided with the water. Persons nearby responded immediately; however, by the time they arrived at the aircraft, the cabin was below the surface of the water. There were 8 persons on board; the pilot and an adult passenger survived and suffered serious injuries. No signal from the emergency locator transmitter was heard.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The combined effects of the atmospheric conditions and bank angle increased the load factor, causing an aerodynamic stall.
2. Due to the absence of a functioning stall warning system, in addition to the benign stalling characteristics of the Beaver, the pilot was not warned of the impending stall.
3. Because the aircraft was loaded in a manner that exceeded the aft CG limit, full stall recovery was compromised.
4. The altitude from which recovery was attempted was insufficient to arrest descent, causing the aircraft to strike the water.
5. Impact damage jammed 2 of the 4 doors, restricting egress from the sinking aircraft.
6. The pilot’s seat failed and he was unrestrained, contributing to the seriousness of his injuries and limiting his ability to assist passengers.
Findings as to Risk:
1. There is a risk that pilots will inadvertently stall aircraft if the stall warning system is unserviceable or if the audio warnings have been modified to reduce noise levels.
2. Pilots who do not undergo underwater egress training are at greater risk of not escaping submerged aircraft.
3. The lack of alternate emergency exits, such as jettisonable windows, increases the risk that passengers and pilots will be unable to escape a submerged aircraft due to structural damage to primary exits following an impact with the water.
4. If passengers are not provided with explicit safety briefings on how to egress the aircraft when submerged, there is increased risk that they will be unable to escape following an impact with the water.
5. Passengers and pilots not wearing some type of flotation device prior to an impact with the water are at increased risk of drowning once they have escaped the aircraft.
Final Report:

Crash of a De Havilland DHC-2 Beaver in Anchorage

Date & Time: Jun 7, 2009 at 1350 LT
Type of aircraft:
Operator:
Registration:
N915RC
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Anchorage - Bulchitna Lake
MSN:
70
YOM:
1950
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
512
Captain / Total hours on type:
21.00
Aircraft flight hours:
2350
Circumstances:
The private pilot was taking off in the float plane from the lake's west waterway. The airplane was on step, gaining airspeed, and the takeoff run seemed normal to the pilot. The airplane was nearing takeoff speed, and proceeding directly down the waterway, when it encountered a right quartering tailwind gust that lifted up the right wing and float. The airplane veered to the left toward a steep bank, and the pilot was unable to correct the deviation with the rudder. He did not feel that he could reduce power as he would slam into the bank. The airplane lifted off, but the float collided with the top of the bank. The airplane cartwheeled about 160 degrees to the left before coming to rest on its right side. It sustained substantial damage to the wings, fuselage, and floats. The pilot reported that there were no mechanical malfunctions or failures. Reported wind at the airport approximately 3 minutes after the accident was from 020 degrees magnetic at 3 knots, with no recorded gusts.
Probable cause:
The pilot’s failure to maintain directional control during takeoff.
Final Report:

Crash of a De Havilland DHC-2 Beaver near Kenai

Date & Time: Feb 20, 2009 at 1515 LT
Type of aircraft:
Operator:
Registration:
N5342G
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Kenai - Kenai
MSN:
854
YOM:
1956
Location:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14300
Captain / Total hours on type:
9000.00
Copilot / Total flying hours:
799
Copilot / Total hours on type:
30
Aircraft flight hours:
9483
Circumstances:
The certificated flight instructor was familiarizing the second pilot with ski operations in a ski-equipped airplane during an instructional flight. The flight instructor reported that he took the flight controls from the second pilot to demonstrate a touch-and-go landing on a frozen, snow-covered lake. After landing to the east, the instructor said that he kept the tail of the airplane up and the airspeed just below flying speed in order to make ski tracks on the lake to check the snow conditions. About midway along the lake the instructor added full engine power and the airplane became airborne but failed to climb sufficiently to avoid colliding with an area of rising, tree-covered terrain at the departure end of the lake. The airplane sustained substantial damage to the wings, fuselage, and empennage. Postaccident examination revealed no preaccident mechanical anomalies. The instructor noted that after the accident he noticed occasional strong gusts of wind from the west.
Probable cause:
The flight instructor’s decision to attempt a touch-and-go landing toward rising terrain and with a tailwind, resulting in an in-flight collision with terrain during takeoff.
Final Report:

Crash of a De Havilland DHC-2 Beaver in Crossroads Lake

Date & Time: Jul 14, 2008 at 0816 LT
Type of aircraft:
Operator:
Registration:
C-FPQC
Flight Phase:
Survivors:
Yes
Schedule:
Crossroads Lake - Schefferville
MSN:
873
YOM:
1956
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7885
Captain / Total hours on type:
1000.00
Circumstances:
The Labrador Air Safari (1984) Inc. float-equipped de Havilland DHC-2 (Beaver) aircraft (registration C-FPQC, serial number 873) departed Crossroads Lake, Newfoundland and Labrador, at approximately 0813 Atlantic daylight time with the pilot and six passengers on board. About three minutes after take-off as the aircraft continued in the climb-out, the engine failed abruptly. When the engine failed, the aircraft was about 350 feet above ground with a ground speed of about 85 miles per hour. The pilot initiated a left turn and, shortly after, the aircraft crashed in a bog. The pilot and four of the occupants were seriously injured; two occupants received minor injuries. The aircraft was substantially damaged, but there was no post-impact fire. The impact forces activated the onboard emergency locator transmitter.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The linkpin plugs had not been installed in the recently overhauled engine, causing inadequate lubrication to the linkpin bushings, increased heat, and eventually an abrupt engine failure.
2. Immediately following the engine failure, while the pilot manoeuvred the aircraft for a forced landing, the aircraft entered an aerodynamic stall at a height from which recovery was not possible.
Finding as to Risk:
1. The failure to utilize available shoulder harnesses increases the risk and severity of injury.
Final Report:

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

Date & Time: May 17, 2008 at 1645 LT
Type of aircraft:
Operator:
Registration:
N9558Q
Survivors:
Yes
Schedule:
Chelan - Stehekin
MSN:
1151
YOM:
1958
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5747
Captain / Total hours on type:
637.00
Aircraft flight hours:
12070
Circumstances:
The amphibious-float-equipped airplane departed from a paved runway for the 40-nautical mile flight to its destination, where a water landing on a lake was to be made. The pilot did not raise the landing gear after takeoff. During the flight, the air was bumpy and turbulent, and this resulted in the gear advisory system activating numerous times. The purpose of the system is to alert the pilot of the landing gear position--up for a water landing or down for a runway landing--when the airspeed decreased below a set threshold value. The pilot disabled the system by pulling its circuit breaker because the alerts were becoming a nuisance; he intended to reset the breaker during descent, but did not do so. Upon reaching the destination, the pilot set up a 150- to 200-feet-per-minute rate of descent for a glassy water landing on the lake. With the landing gear in the down position, the airplane contacted the water and abruptly nosed over. The airplane came to rest floating inverted, suspended by the floats. The pilot reported that the day of the accident was his nineteenth consecutive duty day, including office duty and flight duty. He stated that he feels the lack of days off during the previous 19 days was a contributing factor to this accident. When asked what would have prevented the accident, the pilot suggested consistency in using the checklist. On two flights earlier in the day he had used a written checklist; on the accident flight he did not.
Probable cause:
The pilot's failure to retract the landing gear wheels prior to performing a water landing. Contributing to the accident were the pilot's disabling of the landing gear warning/advisory system and possible fatigue due to his work schedule.
Final Report:

Crash of a De Havilland DHC-2 Beaver I in Traitor's Cove: 6 killed

Date & Time: Aug 16, 2007 at 1730 LT
Type of aircraft:
Registration:
N345KA
Flight Phase:
Survivors:
Yes
Schedule:
Traitor's Cove - Ketchikan
MSN:
1306
YOM:
1959
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
17000
Captain / Total hours on type:
7000.00
Aircraft flight hours:
22409
Circumstances:
The float-equipped airplane was departing from a remote bay 20 miles north of Ketchikan, Alaska, to return air taxi passengers to Ketchikan after a ground tour. The accident pilot, who reported that he had 17,000 flight hours and 7,000 hours in the make and model of the accident airplane, said that southeasterly winds had begun to increase while he was waiting at the bay for the passengers to return from the tour. He said that, unlike when he had landed about 2.5 hours earlier, it was no longer “nice and calm” when the passengers returned. The pilot noticed choppy waves in parts of a nearby cove. To avoid some of the wind and waves, the pilot elected to take off toward the interior of the bay, in the direction of rising terrain. The pilot said that he had never taken off in that direction before. The pilot also said that he had intended to make a shallow, right-climbing turn toward the mouth of the bay and away from the terrain, but shortly after takeoff, he saw numerous choppy waves concentrated along his proposed departure flightpath, which he said indicated to him that strong winds were likely along that path. The pilot decided to change his plan and continue flying straight temporarily, away from the waves, and to make a left, 180-degree turn inside the bay, which was surrounded by high terrain. The pilot indicated that when the turn was initiated, the airplane was about 400 feet above the water, and he did not recall the indicated airspeed. The attempted 180-degree turn was within the airplane’s performance capabilities but placed it closer to rising terrain. While attempting this turn, the pilot encountered a downdraft, was unable to climb above the terrain, and stalled the airplane about 60 feet above the ground. The downdraft likely made it more difficult to avoid descending into the rising terrain. A weather study by the National Transportation Safety Board confirmed that there was a gust front in the area and an abrupt wind change about the time of the accident. Pilots flying nearby also reported low-level windshear, strong winds, and turbulence. No mechanical anomalies were discovered during postaccident inspections by the Safety Board. Five passengers including two children were killed. A month later, one of the survivor died from his injuries.
Probable cause:
An inadvertent aerodynamic stall resulting from the pilot's poor decision-making and inadequate planning and execution when he took off toward nearby rising terrain, in strong winds, under circumstances where his options for maneuvering were severely limited and where his safety margin was, thus, insufficient.
Final Report: