1 fatality

1997-09-29: De Havilland DHC-2 Beaver (N4787C) — Promech Air — Ketchikan, United States of America

Ketchikan, United States of AmericaTakeoff (climb)

On September 29, 1997, a De Havilland DHC-2 Beaver (registration N4787C) operated by Promech Air was involved in an aviation accident near Ketchikan, United States of America during takeoff. One person was killed. Investigators recorded the probable cause as: 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. This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A); 4 related events involving the same aircraft type or operator are linked below.

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781205777Data APIEditorial standards

A float-equipped airplane modified with a STOL kit experienced a stall after a steep climb and left bank, then rolled right and impacted water. Witnesses noted no reduction in engine noise. The aircraft lacked a required ventral fin and had a disabled stall warning system.

Accident Sequence

The float-equipped airplane initiated takeoff in light winds and calm water conditions. Witnesses observed the airplane achieving a steep climb with a nose-high attitude. Throughout the climb, no reduction in engine noise from takeoff power to climb power was heard. At approximately 200 feet above the water, the airplane entered a steep left bank, then rapidly rolled to the right and descended at a steep angle, impacting the water.

Aircraft Modifications

The airplane had been modified via a Short Take Off and Landing (STOL) kit. Certification flight tests for this modification determined that it eliminated aerodynamic warning cues for impending stalls, thus requiring installation of an audible stall warning system. The tests also mandated addition of a ventral fin and horizontal stabilizer finlets to meet directional stability certification. The least stable configuration identified during testing was the takeoff flap configuration during climb.

Certification Requirements

The Supplemental Type Certificate (STC) for the modification specified that both a ventral fin and an audible stall warning system must be installed. However, the manufacturer produced a marketing video prior to STC approval claiming the stall warning system was not required in the U.S. The company stated that this tape was used for training and served as a basis for pilots to routinely disable the stall warning horn by pulling the circuit breaker.

Investigation Findings

At the time of the accident, the airplane lacked the required ventral fin. The flaps were set to the takeoff position, and the audible stall warning circuit breaker was found in the pulled (disabled) position. The local FAA Flight Standards Office had conducted 14 inspections of the accident airplane in the preceding 29 months, yet none referenced the missing ventral fin.

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.