Kalaupapa

The airline transport pilot was conducting an air taxi commuter flight between two Hawaiian islands with eight passengers on board. Several passengers stated that the pilot did not provide a safety briefing before the flight. One passenger stated that the pilot asked how many of the passengers had flown over that morning and then said, “you know the procedures.” The pilot reported that, shortly after takeoff and passing through about 500 ft over the water, he heard a loud “bang,” followed by a total loss of engine power. The pilot attempted to return to the airport; however, he realized that the airplane would not be able to reach land, and he subsequently ditched the airplane in the ocean. All of the passengers and the pilot exited the airplane uneventfully. One passenger swam to shore, and rescue personnel recovered the pilot and the other seven passengers from the water about 80 minutes after the ditching. However, one of these passengers died before the rescue personnel arrived. Postaccident examination of the recovered engine revealed that multiple compressor turbine (CT) blades were fractured and exhibited thermal damage. In addition, the CT shroud exhibited evidence of high-energy impact marks consistent with the liberation of one or more of the CT blades. The thermal damage to the CT blades likely occurred secondary to the initial blade fractures and resulted from a rapid increase in fuel flow by the engine fuel control in response to the sudden loss of compressor speed due to the blade fractures. The extent of the secondary thermal damage to the CT blades precluded a determination of the cause of the initial fractures. Review of airframe and engine logbooks revealed that, about 1 1/2 years before the accident, the engine had reached its manufacturer-recommended time between overhaul (TBO) of 3,600 hours; however, the operator obtained a factory-authorized, 200-hour TBO increase. Subsequently, at an engine total time since new of 3,752.3 hours, the engine was placed under the Maintenance on Reliable Engines (MORE) Supplemental Type Certificate (STC) inspection program, which allowed an immediate increase in the manufacturer recommended TBO from 3,600 to 8,000 hours. The MORE STC inspection program documents stated that the MORE STC was meant to supplement, not replace, the engine manufacturer’s Instructions for Continued Airworthiness and its maintenance program. Although the MORE STC inspection program required more frequent borescope inspections of the hot section, periodic inspections of the compressor and exhaust duct areas, and periodic power plant adjustment/tests, it did not require a compressor blade metallurgical evaluation of two compressor turbine blades; however, this evaluation was contained in the engine maintenance manual and an engine manufacturer service bulletin (SB). The review of the airframe and engine maintenance logbooks revealed no evidence that a compressor turbine metallurgical evaluation of two blades had been conducted. The operator reported that the combined guidance documentation was confusing, and, as a result, the operator did not think that the compressor turbine blade evaluation was necessary. It is likely that, if the SB had been complied with or specifically required as part of the MORE STC inspection program, possible metal creep or abnormalities in the turbine compressor blades might have been discovered and the accident prevented. The passenger who died before the first responders arrived was found wearing a partially inflated infant life vest. The autopsy of the passenger did not reveal any significant traumatic injuries, and the autopsy report noted that her cause of death was “acute cardiac arrhythmia due to hyperventilation.” Another passenger reported that he also inadvertently used an infant life vest, which he said seemed “small or tight” but “worked fine.” If the pilot had provided a safety briefing, as required by Federal Aviation Administration regulations, to the passengers that included the ditching procedures and location and usage of floatation equipment, the passengers might have been able to find and use the correct size floatation device.

The aircraft crashed off the end of runway 23 during an attempted go-around after touchdown. The pilot stated that after the aircraft touched down approximately 300 feet down the 2,760 foot runway he raised the flaps along with the nose of the aircraft to slow down. Brakes were applied and the left main gear skidded 2/3 the way down the runway at which time full power was applied to go-around. The aircraft mushed off the end of the runway where it contacted a rock pile and was destroyed by impact and post crash fire. The pilot reported winds from 270° at 10 knots when the accident occurred.

On final approach to Kalaupapa in good weather conditions, the crew failed to realize his altitude was insufficient when the airplane struck the ground 38 feet short of runway threshold. On impact, the undercarriage were torn off and the airplane came to rest on its belly. All 13 occupants were injured, four of them seriously. The aircraft was written off.

The aircraft was engaged in a sightseeing flight from Kalaupapa – Lihue, carrying 11 passengers and two pilots. En route, the left engine lost power. Unable to maintain flying speed, the crew attempted an emergency landing when the airplane struck trees and crashed in a wooded area. A passenger was killed while 12 other occupants were injured, some of them seriously.