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Crash of a Pilatus PC-12 NGX in the Pacific Ocean

Date & Time: Nov 6, 2020 at 1520 LT
Type of aircraft:
Registration:
N400PW
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Santa Maria - Hilo
MSN:
2003
YOM:
2020
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2740
Captain / Total hours on type:
22.00
Circumstances:
On November 6, 2020, about 1600 Pacific standard time, a Pilatus PC-12, N400PW, was substantially damaged when it was ditched in the Pacific Ocean about 1000 miles east of Hilo, Hawaii. The two pilots sustained no injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 ferry flight. According to the pilot-in-command (PIC), who was also the ferry company owner, he and another pilot were ferrying a new airplane from California to Australia. The first transoceanic leg was planned for 10 hours from Santa Maria Airport (KSMX), Santa Maria, California to Hilo Airport (PHTO), Hilo, Hawaii. The manufacturer had an auxiliary ferry fuel line and check valve installed in the left wing before delivery. About 1 month before the trip, the pilot hired a ferry company to install an internal temporary ferry fuel system for the trip. The crew attempted the first transoceanic flight on November 2, but the ferry fuel system did not transfer properly, so the crew diverted to Merced Airport (KMCE), Merced, California. The system was modified with the addition of two 30 psi fuel transfer pumps that could overcome the ferry system check valve. The final system consisted of 2 aluminum tanks, 2 transfer pumps, transfer and tank valves, and associated fuel lines and fittings. The ferry fuel supply line was connected to the factory installed ferry fuel line fitting at the left wing bulkhead, which then fed directly to the main fuel line through a check valve and directly to the turbine engine. The installed system was ground and flight checked before the trip. According to Federal Aviation Administration automatic dependent surveillance broadcast (ADS-B) data, the airplane departed KSMX about 1000. The pilots each stated that the ferry fuel system worked as designed during the flight and they utilized the operating procedures that were supplied by the installer. About 5 hours after takeoff, approaching ETNIC intersection, the PIC climbed the airplane to flight level 280. At that time, the rear ferry fuel tank was almost empty, and the forward tank was about 1/2 full. The crew was concerned about introducing air into the engine as they emptied the rear ferry tank, so the PIC placed the ignition switch to ON. According to the copilot (CP), she went to the cabin to monitor the transparent fuel line from the transfer pumps to ensure positive fuel flow while she transferred the last of the available rear tank fuel to the main fuel line. When she determined that all of the usable fuel was transferred, and fuel still remained in the pressurized fuel line, she turned the transfer pumps to off and before she could access the transfer and tank valves, the engine surged and flamed out. The PIC stated that the crew alerting system (CAS) fuel low pressure light illuminated about 5 to 15 seconds after the transfer pumps were turned off, and then the engine lost power and the propeller auto feathered. The PIC immediately placed the fuel boost pumps from AUTO to ON. The CP went back to her crew seat and they commenced the pilot operating handbook’s emergency checklist procedures for emergency descent and then loss of engine power in flight. According to both crew members, they attempted an engine air start. The propeller unfeathered and the engine started; however, it did not reach flight idle and movement of the power control lever did not affect the engine. The crew secured the engine and attempted another air start. The engine did not restart and grinding sounds and a loud bang were heard. The propeller never unfeathered and multiple CAS warning lights illuminated, including the EPECS FAIL light (Engine and Propeller Electronic Control System). The crew performed the procedures for a restart with EPECS FAIL light and multiple other starts that were unsuccessful. There were no flames nor smoke from either exhaust pipe during the air start attempts. About 8,000 ft mean sea level, the crew committed to ditching in the ocean. About 1600, after preparing the survival gear, donning life vests, and making mayday calls on VHF 121.5, the PIC performed a full flaps gear up landing at an angle to the sea swells and into the wind. He estimated that the swells were 5 to 10 ft high with crests 20 feet apart. During the landing, the pilot held back elevator pressure for as long as possible and the airplane landed upright. The crew evacuated through the right over wing exit and boarded the 6 man covered life raft. A photograph of the airplane revealed that the bottom of the rudder was substantially damaged. The airplane remained afloat after landing. The crew utilized a satellite phone to communicate with Oakland Center. The USCG coordinated a rescue mission. About 4 hours later, a C-130 arrived on scene and coordinated with a nearby oil tanker, the M/V Ariel, for rescue of the crew. According to the pilots, during the night, many rescue attempts were made by the M/V Ariel; however, the ship was too fast for them to grab lines and the seas were too rough. After a night of high seas, the M/V Ariel attempted rescue again; however, they were unsuccessful. That afternoon, a container ship in the area, the M/V Horizon Reliance, successfully maneuvered slowly to the raft, then the ship’s crew shot rope cannons that propelled lines to the raft, and they were able to assist the survivors onboard. The pilots had been in the raft for about 22 hours. The airplane was a new 2020 production PC-12 47E with a newly designed Pratt and Whitney PT6E-67XP engine which featured an Engine and Propeller Electronic Control System. The airplane is presumed to be lost at sea.
Probable cause:
A total loss of engine power due to fuel starvation for reasons that could not be determined based on the available evidence.
Final Report:

Crash of a Cessna 414A Chancellor in Laupahoehoe: 3 killed

Date & Time: Jan 31, 2004 at 0140 LT
Type of aircraft:
Operator:
Registration:
N5637C
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Honolulu – Hilo
MSN:
414A-0118
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
8230
Captain / Total hours on type:
1037.00
Aircraft flight hours:
11899
Circumstances:
The airplane collided with trees and mountainous terrain at the 3,600-foot-level of Mauna Kea Volcano during an en route cruise descent toward the destination airport that was 21 miles east of the accident site. The flight departed Honolulu VFR at 0032 to pickup a patient in Hilo, on the Island of Hawaii. The inter island cruising altitude was 9,500 feet and the flight was obtaining VFR flight advisories. At 0113, just before the flight crossed the northwestern coast of Hawaii, the controller provided the pilot with the current Hilo weather, which was reporting a visibility of 1 3/4 miles in heavy rain and mist with ceiling 1,700 feet broken, 2,300 overcast. Recorded radar data showed that the flight crossed the coast of Hawaii at 0122, descending through 7,400 feet tracking southeast bound toward the northern slopes of Mauna Kea and Hilo beyond. The last recorded position of the aircraft was about 26 miles northwest of the accident site at a mode C reported altitude of 6,400 feet. At 0130, the controller informed the pilot that radar contact was lost and also said that at the airplane's altitude, radar coverage would not be available inbound to Hilo. The controller terminated radar services. A witness who lived in the immediate area of the accident site reported that around 0130 he heard a low flying airplane coming from the north. He alked outside his residence and observed an airplane fly over about 500 feet above ground level (agl) traveling in the direction of the accident site about 3 miles east. The witness said that light rain was falling and he could see a half moon, which he thought provided fair illumination. The area forecast in effect at the time of the flight's departure called for broken to overcast layers from 1,000 to 2,000 feet, with merging layers to 30,000 feet and isolated cumulonimbus clouds with tops to 40,000 feet. It also indicated that the visibility could temporarily go below 3 statute miles. The debris path extended about 500 feet along a magnetic bearing of 100 degrees with debris scattered both on the ground and in tree branches. Investigators found no anomalies with the airplane or engines that would have precluded normal operation. Pilots for the operator typically departed under VFR, even in night conditions or with expectations of encountering adverse weather, to preclude ground holding delays. The pilots would then pick up their instrument flight rules (IFR) clearance en route. The forecast and actual weather conditions at Hilo were below the minimums specified in the company Operations Manual for VFR operations.
Probable cause:
The pilot's disregard for an in-flight weather advisory, his likely encounter with marginal VFR or IMC weather conditions, his decision to continue flight into those conditions, and failure to maintain an adequate terrain clearance altitude resulting in an in-flight collision with trees and mountainous terrain. A contributing factor was the pilot's failure to adhere to the VFR weather minimum procedures in the company's Operations Manual.
Final Report:

Crash of a PAC 750XL in the Pacific Ocean: 1 killed

Date & Time: Dec 26, 2003 at 0601 LT
Operator:
Registration:
ZK-UAC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Hamilton – Pago Pago – Christmas Island – Kiribati – Hilo – Oakland
MSN:
103
YOM:
2003
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
16564
Captain / Total hours on type:
180.00
Aircraft flight hours:
65
Circumstances:
The pilot was ferrying the aircraft from Hamilton, New Zealand to Davis, California, via Pago Pago, American Samoa; Christmas Island, Kiribati; and Hilo, Hawaii. On the final leg, following a position report 858 nm from San Francisco, he reported a problem with his fuel system, indicating a probable ditching. Under the observation of a US Coast Guard HC-130 crew, the pilot ditched the aircraft at 1701 UTC, 341 nm from San Francisco, the aircraft nosing over on to its back as it touched down. The pilot did not emerge as expected and was later found by rescue swimmers, deceased, still in the cockpit. His body could not be recovered and was lost with the aircraft.
Probable cause:
The following findings were reported:
- The pilot was appropriately licensed, rated and experienced for the series of flights undertaken.
- The aeroplane had a valid airworthiness certificate and had been released to service.
- There was nothing (other than the item in 3.5) to suggest that the aeroplane was operating abnormally on the final flight.
- The aeroplane was being operated at 14 000 feet pressure altitude without supplementary oxygen as required by CAR 91.209 and 91.533.
- The left front fuel filler orifice was observed to be leaking fuel before departure.
- There was no attempt made to further investigate or correct this fuel leak and the pilot stated that it would stop once he departed.
- On most other aircraft this would be true, once the fuel level dropped away from the filler orifice and was no longer affected by aerodynamic suction.
- On the 750XL, the fuel system design was such that the front tanks were continuously topped up.
- The fuel loss would continue until all fuel in the rear tanks and the ferry system was consumed.
- The front fuel caps are thus critical items to be checked before flight.
- The fuel quantity uplifted at Hilo indicated that the problem had existed on the previous leg with a loss rate of up to 125 litres (33.2 US gallons) per hour.
- A comparison of the uplift figure with the expected consumption on the previous leg should have provided sufficient warning to the pilot that a problem existed.
- The existence of the problem could have been detected on the final flight by the shortened top-up intervals and by comparing fuel used by the engine with fuel remaining.
- Cumulative delays, especially including the longer than normal final refuelling time, probably influenced the pilot’s decision to depart without further checking the reason for the fuel leak or the apparent discrepancy between fuel figures.
- Cumulative fatigue, circadian rhythm and hypoxia were probably significant factors in the pilot’s failure to detect the fuel problem in flight, in time to make a safe return.
- By the time the pilot announced that he had a fuel problem, the only course of action open to him was ditching the aeroplane.
- The search and rescue facilities were activated appropriately, and had the potential to effect a successful rescue.
- The water entry impact on ditching was reasonably severe and probably incapacitated the pilot before he could vacate the cockpit.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain off Hilo: 1 killed

Date & Time: Aug 25, 2000 at 1735 LT
Operator:
Registration:
N923BA
Survivors:
Yes
Schedule:
Kona – Kona
MSN:
31-8252024
YOM:
1982
Flight number:
BIA057
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2067
Captain / Total hours on type:
465.00
Aircraft flight hours:
3492
Circumstances:
The pilot ditched the twin engine airplane in the Pacific ocean after experiencing a loss of engine power and an in-flight engine fire while in cruise flight. The flight was operating at 1,000 feet msl, when the pilot noticed a loss of engine power in the right engine. At the same time the pilot was noticing the power loss, passengers noted a fire coming from the right engine cowling. The pilot secured the right engine and feathered the propeller. He attempted to land the airplane at a nearby airport; however, when he realized that the airplane was unable to maintain altitude he elected to ditch the airplane in the ocean. Prior to executing the forced landing, the pilot instructed the passengers to don their life jackets and assume the crash position. After touchdown, all but one passenger exited the airplane through the main cabin and pilot doors. It was reported that the remaining passenger was frightened, and could not swim. One survivor saw the remaining passenger sitting in the seat with the seat belt still secured and the life vest inflated. The pilot and passengers were then rescued from the ocean via rescue helicopter and boat. Postaccident examination of the airplane revealed that the right engine's oil converter plate gasket had deteriorated and extruded from behind the converter plate, allowing oil to spray in the accessory section and resulting in the subsequent engine fire. The engine manufacturer had previously issued a mandatory service bulletin (MSB) requiring inspection of the gasket every 50 hours for evidence of gasket extrusion around the cover plate or oil leakage. Maintenance records revealed that the inspection had been conducted 18.3 hours prior to the accident. At the time of the accident, the right engine had accumulated 386.8 hours since its last overhaul, and gasket replacement. The MSB was issued one month prior to the accident, after the manufacturer received reports of certain oil filter converter plate gaskets extruding around the oil filter converter plate. The protruding or swelling of the gasket allowed oil to leak and spray from between the plate and the accessory housing. A series of tests were conducted on exemplar gaskets by submerging them in engine oil heated to 245 degrees F; after about 290 hours, the gasket material displayed signs of deterioration similar to that of the accident gasket. A subsequent investigation revealed that the engine manufacturer had recently changed gasket suppliers, which resulted in a shipment of gaskets getting into the supply chain that did not meet specifications. As a result of this accident, the engine manufacturer revised the MSB to require the replacement of the gasket every 50 hours. The FAA followed suit and issued an airworthiness directive to mandate the replacement of the gasket every 50 hours.
Probable cause:
Deterioration and failure of the oil filter converter plate gasket, which resulted in a loss of engine power and a subsequent in-flight fire.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain off Hilo

Date & Time: Apr 10, 1997 at 0706 LT
Registration:
N27659
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Hilo - Hayward
MSN:
31-7852090
YOM:
1978
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5700
Captain / Total hours on type:
15.00
Aircraft flight hours:
5074
Circumstances:
The aircraft was being operated on a trans-Pacific ferry flight. A special flight permit authorized a gross weight increase and ferry fuel tanks had been installed along with long range communication and navigation radios. The pilot reported that when 85 miles from the departure airport, the right engine failed and he was unable to restart it. Power from the remaining engine was insufficient to maintain level flight at the overweight condition and the pilot permitted the aircraft to drift down until it was necessary to ditch in the ocean 28 miles offshore. The pilot had departed and returned to Hawaii twice previously. The first time he returned due to an oil leak on the left engine, and the second time because of a loose window. A mechanic who repaired the window reported that the left engine appeared to still be leaking oil. Both pilots told the FAA inspector that the oil leak had been repaired.
Probable cause:
The loss of engine power in one engine for undetermined reasons. A factor in the accident was the aircraft's diminished single engine performance during the early portion of the overweight ferry flight.
Final Report:

Crash of a Consolidated PBY-5A Catalina in the Pacific Ocean

Date & Time: Jan 15, 1994
Type of aircraft:
Registration:
N5404J
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Los Angeles - Hilo - Papeete
MSN:
22022
YOM:
1943
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was transferred from Los Angeles to New Zealand via Hilo and Papeete, Tahiti. En route, while cruising at the altitude of 1,500 metres, the crew encountered technical problems with the left engine and decided to divert to Christmas Island. The left engine eventually failed and as the crew as unable to maintain a safe altitude because the aircraft was heavy (load of fuel to cross the Pacific), he decided to ditch the aircraft about 150 km north of Christmas Island. The aircraft sank four hours later and was lost. All eight occupants were rescued by the crew of a merchant ship eight hours later.
Probable cause:
Failure of the left engine for unknown reasons.

Crash of a Piper PA-31-310 Navajo off Hilo

Date & Time: Oct 13, 1993 at 1414 LT
Type of aircraft:
Registration:
N7079J
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Christmas Island - Hilo
MSN:
31-663
YOM:
1970
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3500
Captain / Total hours on type:
100.00
Aircraft flight hours:
4356
Circumstances:
During an oceanic ferry flight, the right engine developed magneto problems which resulted in only residual power being available. The pic increased the power on the remaining left engine, but it soon overheated. The pic elected to ditch the airplane into the pacific ocean. Both crewmembers were successfully rescued.
Probable cause:
Failure of the right engine's magnetos for undetermined reasons and the resulting overtemperature of the remaining left engine.
Final Report:

Crash of a Beechcraft E18 on Mt Haleakala: 9 killed

Date & Time: Apr 22, 1992 at 1553 LT
Type of aircraft:
Operator:
Registration:
N342E
Flight Phase:
Survivors:
No
Site:
Schedule:
Hilo - Honolulu
MSN:
BA-308
YOM:
1957
Flight number:
SAT022
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total flying hours:
2100
Captain / Total hours on type:
465.00
Aircraft flight hours:
15925
Circumstances:
During the air tour flight the pilot had radioed his intentions to FSS to overfly an area about 5 miles southwest of the island of Maui. Approximately 10 minutes later the airplane impacted mountainous terrain on the island. IMC prevailed at the time and location of the accident. The pilot did not possess the minimum hours stipulated in the company ops manual to qualify as a captain. He falsified the employment application and resume. The company did not pursue substantive pre employment background checks, nor were they required by the FAA to do so. Regulations are needed for air tour operators that will enable FAA inspectors to require, rather than merely encourage, operators to adhere to procedures that offer the safety improvements of sfar 50-2 and FAA handbook 8400.10 bulletin 92-01. All nine occupants were killed.
Probable cause:
The captain's decision to continue visual flight into instrument meteorological conditions that obscured rising mountainous terrain and his failure to properly use available navigational information to remain clear of the island of Maui. Contributing to the accident was the failure of Scenic Air Tours to conduct substantive pilot pre-employment background screening, and the failure of the Federal Aviation Administration to require commercial operators to conduct substantive pilot pre-employment screening.
Final Report:

Crash of a Beechcraft H18 in Waipio Valley: 11 killed

Date & Time: Jun 11, 1989 at 1330 LT
Type of aircraft:
Operator:
Registration:
N34AP
Flight Phase:
Survivors:
No
Site:
Schedule:
Hilo - Kahului
MSN:
BA-746
YOM:
1967
Flight number:
YR021
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
11
Captain / Total flying hours:
3500
Captain / Total hours on type:
305.00
Aircraft flight hours:
19864
Circumstances:
Scenic Air Tours flight 21 (Beech H18, N34AP) was on an air taxi, sightseeing flight from Hilo to Kahului, HI. The pilot took off at approximately 1300 hst. After takeoff, flight 21 proceeded northwest along the coastline at an altitude of about 2,000 feet. The aircraft subsequently crashed in a scenic canyon area near a waterfall in Waipio Valley, approximately 50 miles northeast of Hilo. Impact occurred at an elevation of about 2,800 feet, approximately 600 to 900 feet below the rim. No preimpact mechanical problem of the aircraft or engines was found. A passenger, who was on a previous sightseeing flight, reported the pilot had maneuvered below the rim of a canyon. Company officials reported that flying below rims of canyons was against company policy; however, the operations manual did not contain any guidance or cautions about such operations. All 11 occupants were killed.
Probable cause:
The pilot's improper in-flight planning/decision to maneuver with insufficient altitude over or in a a canyon area. Factors related to the accident were: the terrain conditions and Scenic Air Tour's lack of specific direction to its pilots concerning safety procedures for sightseeing flights.
Final Report:

Crash of a Boeing 737-297 in Kahului: 1 killed

Date & Time: Apr 28, 1988 at 1346 LT
Type of aircraft:
Operator:
Registration:
N73711
Flight Phase:
Survivors:
Yes
Schedule:
Hilo - Honolulu
MSN:
20209
YOM:
1969
Flight number:
AQ243
Location:
Crew on board:
5
Crew fatalities:
Pax on board:
90
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
8500
Captain / Total hours on type:
6700.00
Copilot / Total flying hours:
8000
Copilot / Total hours on type:
3500
Aircraft flight hours:
35496
Aircraft flight cycles:
89680
Circumstances:
On April 28, 1988, an Aloha Airline Boeing 737, N73711, was scheduled for a series of interisland flights in Hawaii. The crew flew three uneventful roundtrip flights, one each from Honolulu to Hilo (ITO), Kahului Airport, HI (OGG) on the island of Maui, and Kauai Island Airport (LIH). At 11:00, a scheduled first officer change took place for the remainder of the day. The crew flew from Honolulu to Maui and then from Maui to Hilo. At 13:25, flight 243 departed Hilo Airport en route to Honolulu. The first officer conducted the takeoff and en route climb to FL240 in VMC. As the airplane leveled at 24,000 feet, both pilots heard a loud "clap" or "whooshing" sound followed by a wind noise behind them. The first officer's head was jerked backward, and she stated that debris, including pieces of gray insulation, was floating in the cockpit. The captain observed that the cockpit entry door was missing and that "there was blue sky where the first-class ceiling had been." The captain immediately took over the controls of the airplane. He described the airplane attitude as rolling slightly left and right and that the flight controls felt "loose." Because of the decompression, both pilots and the air traffic controller in the observer seat donned their oxygen masks. The captain began an emergency descent. He stated that he extended the speed brakes and descended at an indicated airspeed (IAS) of 280 to 290 knots. Because of ambient noise, the pilots initially used hand signals to communicate. The first officer stated that she observed a rate of descent of 4,100 feet per minute at some point during the emergency descent. The captain also stated that he actuated the passenger oxygen switch. The passenger oxygen manual tee handle was not actuated. When the decompression occurred, all the passengers were seated and the seat belt sign was illuminated. The No. 1 flight attendant reportedly was standing at seat row 5. According to passenger observations, the flight attendant was immediately swept out of the cabin through a hole in the left side of the fuselage. The No. 2 flight attendant, standing by row 15/16, was thrown to the floor and sustained minor bruises. She was subsequently able to crawl up and down the aisle to render assistance and calm the passengers. The No. 3 flight attendant, standing at row 2, was struck in the head by debris and thrown to the floor. She suffered serious injuries. The first officer tuned the transponder to emergency code 7700 and attempted to notify Honolulu Air Route Traffic Control Center (ARTCC) that the flight was diverting to Maui. Because of the cockpit noise level, she could not hear any radio transmissions, and she was not sure if the Honolulu ARTCC heard the communication. Although Honolulu ARTCC did not receive the first officer's initial communication, the controller working flight 243 observed an emergency code 7700 transponder return about 23 nautical miles south-southeast of the Kahalui Airport, Maui. Starting at 13:48:15, the controller attempted to communicate with the flight several times without success. When the airplane descended through 14,000 feet, the first officer switched the radio to the Maui Tower frequency. At 13:48:35, she informed the tower of the rapid decompression, declared an emergency, and stated the need for emergency equipment. The local controller instructed flight 243 to change to the Maui Sector transponder code to identify the flight and indicate to surrounding air traffic control (ATC) facilities that the flight was being handled by the Maui ATC facility. The first officer changed the transponder as requested. At 13:50:58, the local controller requested the flight to switch frequencies to approach control because the flight was outside radar coverage for the local controller. Although the request was acknowledged, Flight 243 continued to transmit on the local controller frequency. At 13:53:44, the first officer informed the local controller, "We're going to need assistance. We cannot communicate with the flight attendants. We'll need assistance for the passengers when we land." An ambulance request was not initiated as a result of this radio call. The captain stated that he began slowing the airplane as the flight approached 10,000 feet msl. He retracted the speed brakes, removed his oxygen mask, and began a gradual turn toward Maui's runway 02. At 210 knots IAS, the flightcrew could communicate verbally. Initially flaps 1 were selected, then flaps 5. When attempting to extend beyond flaps 5, the airplane became less controllable, and the captain decided to return to flaps 5 for the landing. Because the captain found the airplane becoming less controllable below 170 knots IAS, he elected to use 170 knots IAS for the approach and landing. Using the public address (PA) system and on-board interphone, the first officer attempted to communicate with the flight attendants; however, there was no response. At the command of the captain, the first officer lowered the landing gear at the normal point in the approach pattern. The main gear indicated down and locked; however, the nose gear position indicator light did not illuminate. Manual nose gear extension was selected and still the green indicator light did not illuminate; however, the red landing gear unsafe indicator light was not illuminated. After another manual attempt, the handle was placed down to complete the manual gear extension procedure. The captain said no attempt was made to use the nose gear downlock viewer because the center jumpseat was occupied and the captain believed it was urgent to land the airplane immediately. At 13:55:05, the first officer advised the tower, "We won't have a nose gear," and at 13:56:14, the crew advised the tower, "We'll need all the equipment you've got." While advancing the power levers to maneuver for the approach, the captain sensed a yawing motion and determined that the No.1 (left) engine had failed. At 170 to 200 knots IAS, he placed the No. 1 engine start switch to the "flight" position in an attempt to start the engine; there was no response. A normal descent profile was established 4 miles out on the final approach. The captain said that the airplane was "shaking a little, rocking slightly and felt springy." Flight 243 landed on runway 02 at Maui's Kahului Airport at 13:58:45. The captain said that he was able to make a normal touchdown and landing rollout. He used the No. 2 engine thrust reverser and brakes to stop the airplane. During the latter part of the rollout, the flaps were extended to 40° as required for an evacuation. An emergency evacuation was then accomplished on the runway.
Probable cause:
The failure of the Aloha Airlines maintenance program to detect the presence of significant disbonding and fatigue damage, which ultimately led to failure of the lap joint at S-10L and the separation of the fuselage upper lobe. Contributing to the accident were the failure of Aloha Airlines management to supervise properly its maintenance force as well as the failure of the FAA to evaluate properly the Aloha Airlines maintenance program and to assess the airline's inspection and quality control deficiencies. Also contributing to the accident were the failure of the FAA to require Airworthiness Directive 87-21-08 inspection of all the lap joints proposed by Boeing Alert Service Bulletin SB 737-53A1039 and the lack of a complete terminating action (neither generated by Boeing nor required by the FAA) after the discovery of early production difficulties in the 737 cold bond lap joint, which resulted in low bond durability, corrosion and premature fatigue cracking.
Final Report: