Ketchikan International Airport
Aircraft Accident/Incident Report

Ketchikan, Alaska 99901
Monday, September 29, 1997 17:47 AKD

NTSB Narrative Summary Released at Completion of Accident

The float equipped airplane was observed taking off in light winds and calm water, and obtaining a steep climb and nose high attitude. Witnesses described hearing no reduction of engine noise from takeoff power to climb power. The airplane entered a steep left bank about 200 feet above the water, then rolled rapidly to the right and impacted at a steep angle into the water. The airplane had been modified with a Short Take Off and Landing (STOL) kit. Certification flight tests had determined that this modification eliminated aerodynamic warning of impending stalls, and therefore required an audible stall warning. Test results also required the addition of both a ventral fin, and horizontal stabilizer finlets, to meet directional stability certification. These tests determined that the least stable condition was in the takeoff flap configuration, during climb. The Supplemental Type Certificate (STC) for the modification required the ventral fin, and an audible stall warning system be installed. The manufacturer provided a marketing video, produced prior to the STC approval, which stated the stall warning system was not required in the U.S. The company indicated this tape was used for training, and was a basis for pilots routinely disabling the stall warning horn by pulling the circuit breaker. At the time of the accident, the airplane did not have the ventral fin installed, a takeoff flaps setting was selected, and the audible stall warning circuit breaker was in the pulled (disabled) position. The local FAA Flight Standards Office had inspected the accident airplane 14 times in the previous 29 months, and made no mention of the ventral fin not being installed.

NTSB Probable Cause Narrative

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.

Event Information

Type of Event Accident
Event Date 9/29/1997
Event Day of the Week Monday
Time of Event 1747
Event Time Zone --
Event City KETCHIKAN
Event State ALASKA
Event Country --
Zipcode of the event site 99901
Event Date Year 1997
Event Date Month 9
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude
Event Location Longitude
Event Location Airport KETCHIKAN INTERNATIONAL
Event Location Nearest Airport ID KTN
Indicates whether the acc/inc occurred off or on an airport On Airport
Distance from airport in statute miles 1
Degrees magnetic from airport 310
Airport Elevation 0
Weather Briefing Completeness Not pertinent
Investigator's weather source Weather Observation Facility
Time of the weather observation 1753 Atlantic Daylight Time
Direction of event from weather observation facility (degrees) 270
Weather Observation Facility ID KTN
Elevation of weather observation facility 10
Distance of event from weather observation facility (units?) 1
Time Zone of the weather observation ADT
Lighting Conditions Day
Lowest Ceiling Height 0
Lowest Non-Ceiling Height 0
Sky/Lowest/Cloud Conditions Clear
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) 0
Visibility Runway Visual Value (Statute Miles) 0
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 10
Dew Point at event time (in degress fahrenheit) 6
Wind Direction (degrees magnetic) 300
Variable Wind Indicator Unknown
Wind Speed (knots) 5
Wind Velocity Indicator Unknown
Wind Gust Indicator Not Gusting
Wind Gust (knots) 0
Altimeter Setting at event time (in. Hg) 29
Density Altitude (feet) --
Intensity of Precipitation Unknown
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries 0
On Ground, Minor Injuries 0
On Ground, Serious Injuries 0
Injury Total Fatal 1
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 1
Investigating Agency NTSB
NTSB Docket Number (internal use) 1588
NTSB Notification Source --
NTSB Notification Date Sep 29 1997 12:00AM
NTSB Notification Time 1800
Fiche Number and/or location -used to find docket information IMAGE
Date of most recent change to record Dec 8 2000 12:32PM
User who most recently changed record dbo
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N4787C
NTSB Number ANC97FA159
Missing Aircraft Indicator N
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed Company VFR
Flight plan Was Activated? --
Damage Destroyed
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name de Havilland
Aircraft Model DHC-2
Aircraft Series Identifier DHC-2
Aircraft Serial Number 1330
Certified Max Gross Weight 5370
Aircraft Category Airplane
Aircraft Registration Class U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 8
Number of Engines 1
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection 100 Hour
Date of Last Inspection Sep 17 1997 12:00AM
Airframe hours since last inspection 32
Airframe Hours 24267
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site Unknown
ELT Type --
Aircraft Owner Name KEVIN HACK
Aircraft Owner Street Address 1515 TONGASS HIGHWAY
Aircraft Owner City KETCHKIKAN
Aircraft Owner State AK
Aircraft Owner Country
Aircraft Owner Zipcode 99901
Operator is an individual? --
Operator Name PROMECH AIR, INC.
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address
Operator City
Operator State
Operator Country
Operator Zip code
Operator Code PJMA
Owner has at least one certificate Yes - certificate holder
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation Unknown
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Positioning
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code KTN
Departure City KETCHIKAN IAP
Departure State AK
Departure Country
Departure Time 1745
Departure Time Zone ADT
Destination Same as Local Flt --
Destination Airport Code 5KE
Destination City KETCHIKAN HARBR
Destination State AK
Destination Country
Specific Phase of Flight Takeoff
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jan 2 2001 10:34AM
User who most recently changed record dbo
Since inspection or accident --
Event Location Runway Number and Location 29
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --