De Havilland DHC-2 Safety Record

The failure of both pilots to see and avoid the other airplane. Contributing to the accident were (1) the PA-12 pilot’s decision to fly with a known severe vision deficiency that had resulted in denial of his most recent application for medical certification and (2) the Federal Aviation Administration’s absence of a requirement for airborne traffic advisory systems with aural alerting among operators who carry passengers for hire.

The inherent limitations of the see-and-avoid concept, which prevented the two pilots from seeing the other airplane before the collision, and the absence of visual and aural alerts from both airplanes’ traffic display systems, while operating in a geographic area with a high concentration of air tour activity. Contributing to the accident were (1) the Federal Aviation Administration’s provision of new transceivers that lacked alerting capability to Capstone Program operators without adequately mitigating the increased risk associated with the consequent loss of the previously available alerting capability and (2) the absence of a requirement for airborne traffic advisory systems with aural alerting among operators who carry passengers for hire.

Impact with terrain for reasons that could not be determined because the airplane was not recovered due to the inaccessible nature of the accident site.

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.

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.

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.

The pilot's decision to continue under visual flight rules into an area of instrument metrological conditions. Contributing to the accident was the pilot's inadequate weather evaluation, and the FAA's inadequate surveillance of the commercial air tour operator.

The pilot's failure to maintain adequate airspeed while maneuvering to reverse direction, which resulted in an inadvertent stall and an uncontrolled descent. Factors associated with the accident were the inadvertent stall and wind gusts.

The pilot's continued VFR flight into instrument meteorological conditions, which resulted in an in-flight collision with mountainous terrain. A factor associated with the accident was a low cloud ceiling.

The pilot's failure to use a checklist to ensure the airplane was in the proper landing configuration, which precipitated an inadvertent water landing on amphibious floats with the wheels extended. A factor contributing to the accident was the pilot's failure to secure the cargo in the aft cabin.

The pilot's failure to maintain clearance from terrain while maneuvering inside a box/blind canyon, resulting in an in-flight collision with terrain. A factor contributing to the accident was the box/blind canyon.

The pilot's failure to ensure attainment of adequate airspeed prior to initiating a steep turn at low altitude, resulting in an accelerated stall. A factor contributing to the occurrence of the accident was the aircraft's low altitude. Factors contributing to the severity of the accident included a water impact, and jammed/restricted doors due to impact damage resulting in degraded aircraft evacuation capability.

The pilot's failure to maintain adequate airspeed which resulted in an inadvertent stall. Factors associated with this accident were the pilot's unfamiliarity with the geographic area, the low clouds, his becoming disoriented, and the blind canyon into which he flew. An additional factor was the intentionally disabled stall warning system.

The pilot's inadequate procedures/directives when he allowed a passenger to exit the cabin area while the propeller was still turning, and the passenger's failure to follow the pilot's instructions to stay away from the propeller. A factor associated with the accident is the passenger's unfamiliarity with aircraft.

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.

a loss of engine power due to the fatigue failure of the no.1 exhaust push rod. Factors contributing to the accident were: insufficient information on pushrod inspection and overhaul from the manufacturer, unsuitable terrain available for landing, and the pilot's failure to maintain airspeed during the approach which led to an inadvertent stall.

the pilot's inadequate compensation for wind conditions, and failure to maintain adequate airspeed, which resulted in an inadvertent stall and collision with terrain (water). A factor associated with the accident was the gusty wind condition.

continued flight by the pilot into adverse weather condition, and his failure to maintain adequate altitude/clearance from mountainous terrain. Factors related to the accident were the high/mountainous terrain, and weather conditions that included low ceilings.

The pilot's decision to continue VFR flight into instrument meteorological conditions, and his failure to maintain adequate clearance from rising terrain. Factors associated with the accident were the rising terrain and clouds.

IMPROPER IN-FLIGHT PLANNING/DECISION BY THE PILOT, AND HIS FAILURE TO REMAIN CLEAR OF MOUNTAINOUS TERRAIN. THE BOX/BLIND CANYON AND PROXIMITY OF MOUNTAINOUS TERRAIN WERE RELATED FACTORS.

THE PILOT OF THE VFR ONLY FLIGHT INTENTIONALLY ENTERED INSTRUMENT METEOROLOGICAL CONDITIONS. FACTORS IN THE ACCIDENT WERE THE INADEQUATE PROCEDURES/DIRECTIVES BY THE COMPANY/OPERATOR MANAGEMENT CONCERNING CONTINUED VFR FLIGHT IN MARGINAL WEATHER CONDITIONS AND THE FOG.

THE PILOT'S FAILURE TO MAINTAIN AIRSPEED RESULTING IN AN INADVERTENT STALL. A FACTOR IN THE ACCIDENT WAS THE INADEQUATE RECURRENT TRAINING OF THE PILOT BY THE OPERATOR/MANAGEMENT.

THE PILOT'S DELAYED DECISION IN REVERSING COURSE AND HIS FAILURE TO MAINTAIN AIRSPEED DURING THE MANEUVER. FACTORS RELATED TO THE ACCIDENT WERE: MOUNTAINOUS TERRAIN AND A LOW CEILING.