What happened
On June 10, 2024, a privately operated De Havilland DHC-2 aircraft, registration LN-NCC, was performing a water landing near Rytterholmene in the Kragerø archipelago. The flight originated from Nesøya, heading toward Rytterholmene to pick up a passenger after a technical inspection at Sandefjord Airport Torp.
During the climb following departure from Torp, the pilot encountered a gear warning and moved the landing gear lever to a middle position to resolve the alert. While the pilot focused on monitoring engine performance—suspecting a lack of manifold pressure—the landing gear remained extended. During the approach to the water, the pilot performed a memorized checklist but failed to verify the gear position via the cockpit indicators. Upon touchdown, the extended wheels created significant drag, causing the aircraft to decelerate violently and eventually capsize onto its back.
Despite the aircraft being upside down and the cockpit filling with water, the pilot successfully evacuated the aircraft after waiting for the internal and external water pressure to equalize.
The investigation
The Norwegian Safety Investigation Authority (NSIA) examined the aircraft, the cockpit instrumentation, and the pilot's procedures. The investigation focused on the configuration of the amphibious floats, the functionality of the landing gear warning system, and the pilot's use of checklists. The NSIA also reviewed the pilot's adherence to Threat and Error Management (TEM) principles and the effectiveness of the aircraft's automated warnings.
Findings
Several contributing factors led to the accident:
- Channelized attention: The pilot was heavily focused on investigating a suspected engine power issue, which distracted him from confirming the aircraft's configuration.
- Improper checklist usage: The pilot relied on a memorized "GUMPS" checklist rather than a physical written list. He also relied on visual inspections in the wing mirrors, which led to a confirmation bias where he perceived the gear to be up when it was actually down.
- Ineffective technical barriers: The existing landing gear warning system was prone to nuisance alerts, which may have led to the pilot ignoring or failing to react to the gear status. The system did not trigger the appropriate warning for a water landing.
- Failure to verify gear position: The pilot did not physically touch or verify the position of the gear lever or the cockpit indicator lights during the landing sequence.
Safety action
The NSIA recommends that private pilots familiarize themselves with Threat and Error Management (TEM) to better identify risks during configuration changes. Additionally, the authority recommends that all pilots operating on water in Norway undergo specialized water evacuation training, noting that the pilot's prior training was instrumental in his safe escape.