NTSB Factual Report

HISTORY OF FLIGHT

On January 22, 2011, about 1357 Pacific standard time, an amphibious float-equipped, Cessna T206H airplane, N142HF, sustained substantial damage when it nosed over during landing on Lake Goodwin near Stanwood, Washington. The airplane was registered to Juneau-Tempe Asset Management LLC., Anchorage, Alaska, and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. The airline transport rated pilot was not injured and his one passenger was fatally injured. Visual meteorological conditions prevailed and no flight plan had been filed for the personal flight. The flight originated from the Arlington Municipal Airport (AWO), Arlington, Washington, about five minutes prior to the accident with an intended destination of Anacortes, Washington.

During an interview with the National Transportation Safety Board investigator-in-charge (IIC) and in written statements, the pilot reported that he departed AWO as part of a flight of three airplanes with the intention of performing one landing on Lake Goodwin prior to continuing to Anacortes. The pilot said that he was the third airplane of a flight of three and that the accident flight was his first time landing in Lake Goodwin. Following a normal takeoff from AWO, his son engaged him in conversation throughout the short duration flight. As the flight approached Lake Goodwin, he observed the other two airplanes he was following land uneventfully on Lake Goodwin and he setup for landing between both wakes created by the other airplanes. The pilot began the descent for landing thinking the airplane was properly configured for a water landing and engaged full flaps and reduced power. The pilot stated that while on short final, his son engaged him in conversation and that as he anticipated touchdown, the nose of the airplane dipped. As the pilot reached to retract the flaps and pull the yoke back, the nose of the airplane dipped a second time. Subsequently, the airplane flipped over upside-down, and became submerged within the lake.

During a follow-up interview, the pilot reported that he always used a checklist that he typically kept in the map pocket or on the dash of the instrument panel. On the day of the accident however, he did not recall raising the landing gear or verifying its position prior to landing, nor did he recall hearing the audible landing gear position warning alert.

The pilot further reported that the windshield imploded on impact, and a wave of water entered the cockpit area, submerging his head and upper body instantly. He said that with the water rapidly rising up to his chest, he had the impression that they were sinking deep into the lake. The pilot attempted to locate his son's seatbelt release as well as open the door; however, he began "gulping water." The pilot stated that he did not recall being able to feel anything with his hands, and his next conscious thought was when the second half of his body from the waist down was exiting the pilot side window. The pilot said that he did not know how he got out, and doesn't recall disconnecting his seatbelt. The pilot recalled that he remembered popping up out of the water, ripping the cord on his life vest, and observing two individuals in a boat alongside the airplane.

Multiple witnesses located near Lake Goodwin reported observing three airplanes approach and land on the lake. One witness reported that as the third airplane was approaching the lake, he observed the landing gear in an extended position. Another witness located on the lake in a boat reported that after witnessing the accident, they immediately went to the downed airplane. The witness said that another person aboard his boat jumped into the water to attempt to get the passenger out, however was unable to do so. The witness then jumped into the water, attempting to rescue the passenger. The witness stated that he was able to see the passenger, however, was unable to get him out of the airplane because he was unable to release the seatbelt.

Local law enforcement reported that prior to the diver arriving, multiple citizens attempted to gain access to the airplane in an attempt to rescue the passenger. Due to the cold water temperature and reduced underwater visibility, the first responders were only able to dive into the water once or twice before the diver arrived.

PERSONNEL INFORMATION

The pilot, age 55, held an airline transport certificate with airplane multiengine land, airplane single-engine land, airplane single-engine sea ratings. A second-class airman medical certificate was issued on November 27, 2009, with no limitations stated. Review of the pilot's logbook revealed that as of his most recent entry, dated January 26, 2011, he had accumulated 4,213.4 total flight hours, of which 474.15 hours were in the seaplane category. Within the previous 90 days to the accident, the pilot had logged 4.7 hours and 2 hours within the previous 30 days to the accident in the accident make/model airplane.

In a written statement submitted to the NTSB IIC on April 12, 2011, the pilot reported that he felt that the impact of a loss of a family member 12 days before the accident could have affected his cognitive abilities. The pilot stated that after the accident, he realized his sleep patterns had been disrupted and recalled not being able to get his day started as early as he wanted to on the day of the accident. The pilot said that he felt that he was not getting as much "good sleep" even though he spent that same amount of time in bed each night. He further stated that his "sleep deprivation became very obvious" after the accident.

AIRCRAFT INFORMATION

The two-seat, high-wing, retractable-gear amphibious float equipped airplane, serial number (S/N) T20608142, was manufactured in 1999. It was powered by a Rolls Royce 250-B17F/2 turbine engine, serial number CAE-881337, rated at 450 shaft horse power, driving a Hartzell variable pitch propeller; model HC-B3TF-7A/T10173FNK-11R, serial number EXA1450.

The airplane was equipped with two forward facing crew seats in the cockpit, a main entry door on the left side of the cockpit, and a modified entry door per Supplemental Type Certificate (STC) SA1470GL on the right side of the cockpit. A cargo door was also located on the right side of the fuselage aft of the right cockpit entry door. The left front and right front inside door latch handles have three positions, lock, close, and open. When the handle is in the lock position, the door cannot be opened from the outside, however, in the closed and open position, the door can be opened from the outside.

Review of the airplane’s maintenance records revealed that the most recent annual inspection was completed on February 17, 2010, at an airframe total time of 715.9 hours, engine total time of 132.3 hours, and a HOBBS time of 132.3 hours.

Review of the Wipaire, Inc. Pilot Operating Handbook/Airplane Flight Manual Supplement for Amphibian Operations in the Cessna C206H with Wipline Model 3450 amphibian floats revealed that in section 4, titled Checklist Procedures, Takeoff on Land, item 8, states "Landing Gear – RETRACT."

The Before Landing on Water checklist states:

1. Landing Gear – UP.

2. Landing Gear Lights – 4 BLUE (check on).

3. Landing Gear Position – CONFIRM VISUALLY.

4. Water Rudders – UP.

5. Wing Flaps – 40 Degrees.

6. Airspeed – 75-85 KIAS.

Section 7, Airplane & Systems Descriptions, subpart Amphibian, item "B" states in part "… A set of four blue lights (one for each wheel) indicates gear up position and a set of four green lights indicates gear down position. The four blue lights indicate gear up and locked. The four lights of each color are the means of identifying that the landing gear is locked in the up or down position. There are visual indicators also."

METEOROLOGICAL INFORMATION

A review of recorded data from the Arlington Municipal Airport (AWO) automated weather observation station, located 6 miles northeast of the accident site, revealed at 1355 that conditions were wind calm, visibility 10 statute miles, few clouds at 1,600 feet above ground level (agl), scattered clouds at 4,000 feet agl, temperature 9 degrees Celsius, dew point 5 degrees Celsius, and an altimeter setting of 30.39 inches of Mercury.

WRECKAGE AND IMPACT INFORMATION

Post accident examination of the accident site by a Federal Aviation Administration (FAA) Inspector revealed that the airplane was mostly submerged within waters of Lake Goodwin. According to local law enforcement, the airplane originally was located inverted on the north-northwestern side of the lake and was towed to shore after all life saving operations were finished. The FAA inspector reported that all four float main landing gears were observed in the extended position. Local law enforcement reported that shortly after the accident, the water temperature was at 41 degrees Fahrenheit.

The airplane was recovered from Lake Goodwin on January 24, 2011. To facilitate the recovery of the airplane, it was towed to a public boat dock on the southeastern side of the lake where a crane was utilized to lift it from the water. It was noted that during the removal of the airplane from the water, the empennage became partially separated from the fuselage slightly aft of the baggage compartment. During the recovery of the airplane, a strong smell consistent with jet fuel was noticed.

Examination of the airplane by the IIC revealed that the left and right wings remained attached to the fuselage. Both wings exhibited buckling throughout their entire wingspan. The left wing was bent downward slightly just outboard of the flap/aileron junction. The left and right ailerons remained attached to their respective mounts. The right aileron exhibited some downward bending/bowing about mid-span. The left and right flaps were observed in the extended position. The left and right wing lift struts remained attached to their respective attach points.

The fuselage was mostly intact. The engine remained attached to the airframe firewall via all mounts. The forward portion of the engine, including the propeller and gearbox exhibited impact damage and was partially separated. The forward windscreen was fractured throughout and partially displaced from the airframe. The left and right forward doors remained attached to the airframe via their respective attach points. The right forward door was closed and in a locked position. The left front door was in an open and unlatched position. The left door window was in a latched position; however, the forward hinge was separated. The rear right door remained attached to the airframe via its respective mounts, and appeared to be in a closed position.

The left and right float pontoons remained attached to the airframe via their respective mounts. The forward and aft main landing gear on each float was observed in the extended position. The mechanical wire landing gear indicator system, located on the top of each float displayed the gear in the "down" position.

Examination of the aircraft cabin area revealed that the power and condition levers were observed in the full forward position. The flap selector handle and indicator were in the full down position. The landing gear position switch was observed in the "down" position.

About 2 hours after the airplane was recovered from the lake, a warning horn (pulsating beeping) was heard originating from a speaker on the left side of the cabin. Along with this warning horn, the gear advisory light above the gear position switch was observed blinking. The battery switch was moved to the "OFF" position and the warning horn ceased operation.

The wreckage was recovered to a secure location for further examination

SURVIVAL FACTORS

NTSB Survival Factors Specialists assisted in documenting the recovered wreckage as well as conducted interviews with first responders.

One first responder diver, who was employed by local law enforcement, reported that upon reaching the airplane, the left door was closed and he was the first one to open it. Upon entering the airplane, he noticed that there were no air pockets in the airplane. The diver stated that during the extraction process, he grabbed the passenger lap belt near the lower retractor and cut the webbing with his knife. The diver said that the child passenger was wearing a life vest and that it was very loose and appeared much too big for him. The diver further stated that he did not know that the seat restraint was a shoulder harness integrated with the lap restraint. He did not have to remove the shoulder harness from the child when he cut the lap belt to release the child from the seat. He added that he did not have trouble initially opening the left door, and was able to just grab the handle and the door opened.

For further survival factors details, see the Survival Factors Factual Report in the public docket for this accident.

TESTS AND RESEARCH

On February 2 and 3, 2011, the airframe was examined by representatives from the NTSB, Soloy Aviation Solutions, Wipaire Inc., Federal Aviation Administration, and Cessna Aircraft under the supervision of the NTSB IIC at the facilities of AvTech Services, Auburn, Washington.

The left and right float pontoons and both wings were removed by the aircraft recovery company to facilitate wreckage transport. The floats were partially reattached to the airframe, which included the forward mounts and hydraulic system. The hydraulic pump and motor was removed from the separated portion of fuselage/empennage and reconnected to the hydraulic lines and power cables.

Power was applied to the airframe, and four green lights were observed on the landing gear positioning system. The landing gear pump circuit breaker was reset, and the hydraulic pump did not actuate. The hydraulic pump was removed, and power was applied directly to the electrical contacts on the pump from a 28 volt battery. The hydraulic pump did not actuate, and was retained for further inspection.

The emergency gear extension position handle was repositioned from the neutral position to the "up" position. The emergency gear pump was actuated numerous times with subsequent movement noted on all four landing gear. All four landing gear were retracted to their respective stops using the emergency gear hand pump. The gear position indication system displayed four blue lights, consistent with the landing gear being in the "up" position. The emergency landing gear extension position handle was placed in the "down" position and the emergency gear extension pump was actuated by hand. All four landing gear extended to the down and locked position with four green lights displayed on the gear position indication system.

During the landing gear retraction and extension, the manual gear position indicators on the left and right floats displayed the correct position of the landing gear. The audible alert for the gear warning system was not heard as a result of the airplane's avionics not functioning. The avionics/radios were water soaked, and did not illuminate when power was applied to the airplane/avionics electrical bus. The landing gear advisory system and switch were removed from the airplane for further examination. Electrical power continuity from the gear position selector switch to the electrical wiring harness contacts for the hydraulic pump was obtained.

Examination of the hydraulic pump and motor, landing gear position selector switch, and Amphibian Landing Gear Advisory System was conducted on May 4, 2011, at the facilities of Wipaire Inc., South St. Paul, Minnesota.

The hydraulic pump and motor was installed on a test bench. A slave ground wire was attached to the hydraulic pump. The hydraulic pump operated normally when the test bench gear selector was placed in the "DOWN" position. However, the hydraulic pump would not operate when the gear selector was placed in the "UP" position. The K1 relay switch was replaced and the pump operated normally when the test bench gear selector handle was placed in the "UP position. Examination of the K1 relay using an OHM meter revealed electrical continuity throughout the relay. The internal areas of the relay are not seale

NTSB Probable Cause

The pilot did not confirm retraction of the landing gear before landing on water as a result of distraction. Contributing to the accident was the pilot coping with the death of a close family member in the days before the accident, which resulted in a self-reported disruption in the quality of sleep.