Hawaii

The medical transport flight was en route to pick up a patient on a neighboring island on an instrument flight rules (IFR) flight plan in dark night conditions over the ocean. About 13 minutes after departure, at 13,000 ft mean sea level (msl), the airplane’s vertical gyro failed, which subsequently failed the pilot’s Electric Attitude Director Indicator (EADI), which also caused the autopilot to disconnect. The failure of the EADI and autopilot disconnect required the pilot to manually fly the airplane using the copilot’s attitude gyro for his horizon information (bank angle and pitch attitude) for the duration of the flight. The pilot did not declare an emergency, nor did he inform air traffic control (ATC) that his electric attitude indicator had failed and that his autopilot had disengaged. After the instrumentation failure and autopilot disconnect, the airplane entered a series of right banks before being brought back to level, followed by a left turn, and then subsequent right banks. ATC asked the pilot to change course and the pilot agreed. The copilot attitude indicator indicated that the airplane entered a descending, steep right bank turn. Over the next 5 minutes, ATC issued varying instructions to the pilot. During this time, the airplane entered several right- and left-hand banks and rolls and descended 1,000 ft per minute (fpm), which increased to -3,500 fpm as the airplane’s airspeed increased. About 7 minutes after the instrumentation failure, the airplane was in a 65° bank angle when ATC asked the pilot to verify his heading. As the pilot responded, the airplane bank angle increased to 90° and the airspeed exceeded 260 knots. The bank angle and airspeed continued to increase; a loud metallic bang was recorded that was consistent with an in-flight separation of the empennage from the fuselage before impacting with the water. After an extensive underwater search, the main wreckage was located on the seabed at a depth of about 6,420 ft. The wreckage was recovered and transported to a facility for examination.

Transair flight 810, a Title 14 Code of Federal Regulations Part 121 cargo flight, experienced a partial loss of power involving the right engine shortly after takeoff and a water ditching in the
Pacific Ocean about 11.5 minutes later. This analysis summarizes the accident and evaluates (1) the right engine partial loss of power, (2) the captain's communications with air traffic control (ATC) and the first officer's left and right engine thrust reductions, (3) the first officer's misidentification of the affected engine and the captain's failure to verify the information, (4) checklist performance, and (5) survival factors. Maintenance was not a factor in this accident. The flight data recorder (FDR) showed that, when the initial thrust was set for takeoff, the engine pressure ratios (EPR) for the left and right engines were 2.00 and 1.97, respectively. Shortly after rotation, the cockpit voice recorder (CVR) recorded a “thud” and the sound of a low-frequency vibration. The captain (the pilot monitoring at the time) and the first officer (the pilot flying) reported that they heard a “whoosh” and a “pop,” respectively, at that time. As the airplane climbed through an altitude of about 390 ft while at an airspeed of 155 knots, the right EPR decreased to 1.43 during a 2-second period. The airplane then yawed to the right; the first officer countered the yaw with appropriate left rudder pedal inputs. The CVR showed that the captain and the first officer correctly determined that the No. 2 (right) engine had lost thrust within 5 seconds of hearing the thud sound. After moving the flaps to the UP position, the captain reduced thrust to maximum continuous thrust, causing the left EPR to decrease from 1.96 to 1.91 while the airplane was in a climb. (The right EPR remained at 1.43). The captain reported that he did not move the thrust levers again until after he became the pilot flying. The first officer stated that, after the airplane leveled off at an altitude of about 2,000 ft, he reduced thrust on both engines. FDR data showed that thrust was incrementally reduced to near flight idle (1.05 EPR on the left engine and then 1.09 EPR on the right engine) and that airspeed decreased from about 250 to 210 knots. (A decrease in airspeed to 210 knots was consistent with the operator’s simulator guide procedures for a single-engine failure after the takeoff decision speed [V1]. The simulator guide, which supplemented information in the company’s flight crew training manual, contained the most recent operator guidance for single-engine failure training at the time of the accident.) The captain was unaware of the first officer’s thrust changes because he was busy contacting the controller about the emergency. The captain told the controller, “we’ve lost an engine,” but he had declared the emergency to the controller twice before this point, as discussed later in this analysis. The captain instructed the first officer to maintain a target speed of 220 knots (which the captain thought would be “easy on the running engine”), a target altitude of 2,000 ft, and a target heading of 240°. (About 52 seconds earlier, the controller had issued the 240° heading instruction to another airplane on the same radio frequency.) About 3 minutes 14 seconds after the right engine loss of thrust occurred, the captain assumed control of the airplane; at that time, the airplane’s airspeed was 224 knots and heading was 242°, but the airplane’s altitude had decreased from about 2,100 ft (the maximum altitude that the airplane reached during the flight) to 1,690 ft. The captain increased the airplane’s pitch to 9°; the airplane’s altitude then increased to 1,878 ft, but the airspeed decreased to 196 knots. The captain subsequently stated, “let’s see what is the problem...which one...what's going on with the gauges,” and “who has the E-G-T [exhaust gas temperature]?” The first officer stated that the left engine was “gone” and “so we have number two” (the right engine), thus misidentifying the affected engine. The captain accepted the first officer’s assessment and did not take action to verify the information. Afterward, the EPR level on the right engine began to increase in response to the captain advancing the right thrust lever so that the airplane could maintain airspeed and altitude. Right EPR increased and decreased several times during the rest of the flight (coinciding with crew comments regarding the EGT on the right engine and low airspeed) while the left EPR remained near flight idle. The first officer asked the captain if they “should head back toward the airport” before the airplane traveled “too far away,” and the captain responded that the airplane would stay within 15 miles of the airport. During a postaccident interview, the captain stated that, because there was no fire and an engine “was running,” he intended to have the airplane climb to 2,000 ft and stay within 15 miles of the airport to avoid traffic and have time to address the engine issue. The captain also stated that he had been criticized by the company chief pilot for returning to the airport without completing the required abnormal checklist for a previous in-flight emergency. Although the captain’s decision resulted in the accident airplane flying farther away from the airport and farther over the ocean at night, the captain’s decision was reasonable for a single-engine failure event. The captain directed the first officer to begin the Engine Failure or Shutdown checklist and stated that he would continue handling the radios. The first officer began to read aloud the conditions for executing the Engine Failure or Shutdown checklist but then stopped to tell the captain that the right EGT was at the “red line” and that thrust should be reduced on the right engine. The captain then decided that the airplane should return to the airport and contacted the controller to request vectors. The flight crew continued to express concern about the right engine. The first officer stated, “just have to watch this though…the number two.” The captain asked the first officer to check the EGT for the right engine, and the first officer responded that it was “beyond max.” Afterward, the captain told the first officer to continue with the Engine Failure or Shutdown checklist and finish as much as possible. The first officer resumed reading aloud the conditions for performing the checklist but then stopped to state, “we have to fly the airplane though,” because the airplane was continuing to lose altitude and airspeed. The captain replied “okay.” As a result, the flight crew did not perform key steps of the checklist, including identifying, confirming, and shutting down the affected (right) engine. The first officer told the captain that the airplane was losing altitude; at that time, the airplane’s altitude was 592 ft, and its airspeed was 160 knots. The captain agreed to select flaps 1 (which the first officer had previously suggested likely because the airplane was slowing). The CVR then recorded the first enhanced ground proximity warning system (EGPWS) annunciation (500 ft above ground level); various EGPWS callouts and alerts continued to be annunciated through the remainder of the flight. The captain then told the controller that “we’ve lost number one [left] engine…there’s a chance we’re gonna lose the other engine too it’s running very hot….we’re pretty low on the speed it doesn't look good out here.” Also, the captain mentioned that the controller should notify the US Coast Guard (USCG) because he was anticipating a water ditching in the Pacific Ocean. Because of the high temperature readings on the right engine, the flight crew thought, at this point in the flight, that a dual-engine failure was imminent. During a postaccident interview, the captain stated that his priority at that time was figuring out how the airplane could stay in the air and return safely to the airport. The captain also stated that he attempted to resolve the airplane’s deteriorating energy state by advancing the right engine thrust lever. However, with the left engine remaining near flight idle, the right engine was not producing sufficient thrust to enable the airplane to maintain altitude or climb. The captain’s communication with the controller continued, and the first officer stated, “fly the airplane please.” The controller asked if the airport was in sight, and the captain then asked the first officer whether he could see the airport. The first officer responded “pull up we’re low” to the captain and “negative” to the controller; the captain was likely unable to respond to the controller because he was trying to control the airplane. The captain asked the first officer about the EGT for the right engine; the first officer replied “hot…way over.” The captain then asked about, and the controller responded by providing, the location of the closest airport. Afterward, the CVR recorded a sound similar to the stick shaker, which continued intermittently through the rest of the flight. The CVR then recorded sounds consistent with water impact. The airplane came down into the Pacific Ocean about two miles offshore and sank. Both crew members were rescued, one was slightly injured and a second was seriously injured. The wreckage was later recovered for investigation purposes.

On June 21, 2019, about 1822 Hawaii-Aleutian standard time, a Beech King Air 65-A90 airplane, N256TA, impacted terrain after takeoff from Dillingham Airfield (HDH), Mokuleia, Hawaii. The pilot and 10 passengers were fatally injured, and the airplane was destroyed. The airplane was owned by N80896 LLC and was operated by Oahu Parachute Center (OPC) LLC under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91 as a local parachute jump (skydiving) flight. Visual meteorological conditions prevailed at the time of the accident. OPC had scheduled five parachute jump flights on the day of the accident and referred to the third through fifth flights of the day as “sunset” flights because they occurred during the late afternoon and early evening. The accident occurred during the fourth flight. The accident pilot was the pilot-in-command (PIC) for each of the OPC flights that departed on the day of the accident. The pilot and 8 of the 10 passengers initially boarded the airplane. These eight passengers comprised three OPC tandem parachute instructors, three passenger parachutists, and two OPC parachutists performing camera operator functions. The pilot began to taxi the airplane from OPC’s location on the airport. According to a witness (an OPC tandem instructor who was not aboard the accident flight), the two other passengers—solo parachutists who had been on the previous skydiving flight and were late additions to the accident flight—“ran out to the airplane and were loaded up at the last minute.” The pilot taxied the airplane to runway 8 about 1820, and the airplane departed about 1822. According to multiple witnesses, after the airplane lifted off, it banked to the left, rolled inverted, and descended to the ground. One witness stated that, before impact, the airplane appeared to be intact and that there were no unusual noises or smoke coming from the airplane. A security camera video showed that the airplane was inverted in a 45° nose-down attitude at the time of impact. The airplane impacted a grass and dirt area about 630 ft northeast of the departure end of the runway, and a postcrash fire ensued. The airplane was not equipped, and was not required to be equipped, with a cockpit voice recorder or a flight data recorder. The accident flight was not detected by radar at the Federal Aviation Administration’s (FAA) Hawaii Control Facility, which was the air traffic control (ATC) facility with jurisdiction of the airspace over HDH. The FAA found no audio communications between the accident airplane and ATC on the day of the accident.

The pilot stated that the flight was conducted at night and he used his GPS track to align with the runway. When the pilot activated the runway lights, the airplane was about 1/4 mile to the left of the runway and 1/2 mile from the approach end. The pilot made an aggressive right turn then hard left turn to make the runway for landing. While maneuvering on short final, at 50 feet above ground level (agl), the airplane's right wing impacted the tops of a number of trees that lined the southeast side of the runway. The airplane descended rapidly and landed hard, collapsing the landing gear and spinning the airplane around 180 degrees laterally, where it came to rest against some trees. The right wing's impact with trees and the hard landing resulted in substantial damage. The pilot reported no preimpact mechanical failures or malfunctions with the airplane that would have precluded normal operation.

The airplane departed during dark (moonless) night conditions over remote terrain with few ground-based light sources to provide visual cues. Weather reports indicated strong gusting wind from the northeast. According to a surviving passenger, shortly after takeoff, the pilot started a right turn; the bank angle continued to increase, and the airplane impacted terrain in a steep right bank. The accident site was about 1 mile from the airport at a location consistent with the airplane departing to the northeast and turning right about 180 degrees before ground impact. The operator's chief pilot reported that the pilot likely turned right after takeoff to fly direct to the navigational aid located southwest of the airport in order to escape the terrain induced turbulence (downdrafts) near the mountain range northeast of the airport. Examination of the airplane wreckage revealed damage and ground scars consistent with a high-energy, low-angle impact during a right turn. No evidence was found of preimpact mechanical malfunctions or failures that would have precluded normal operation. It is likely that the pilot became spatially disoriented during the right turn. Although visual meteorological conditions prevailed, no natural horizon and few external visual references were available during the departure. This increased the importance for the pilot to monitor the airplane's flight instruments to maintain awareness of its attitude and altitude. During the turn, the pilot was likely performing the additional task of engaging the autopilot, which was located on the center console below the throttle quadrant. The combination of conducting a turn with few visual references in gusting wind conditions while engaging the autopilot left the pilot vulnerable to visual and vestibular illusions and reduced his awareness of the airplane's attitude, altitude, and trajectory. Based on toxicology findings, the pilot most likely had symptoms of an upper respiratory infection but the investigation was unable to determine what effects these symptoms may have had on his performance. A therapeutic level of doxylamine, a sedating antihistamine, was detected, and impairment by doxylamine most likely contributed to the development of spatial disorientation.

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 pilot was flying a night, single-pilot, cargo flight over water between two islands. He had routine contact with air traffic control, and was advised by the controller to maintain 6,000 feet at 0501 hours when the airplane was 11 miles from the destination airport. Two minutes later the flight was cleared for a visual approach to follow a preceding Boeing 737 and advised to switch to the common traffic advisory frequency at the airport. The destination airport was equipped with an air traffic control tower but it was closed overnight. The accident flight's radar-derived flight path showed that the pilot altered his flight course to the west, most likely for spacing from the airplane ahead, and descended into the water as he began a turn back toward the airport. The majority of the wreckage sank in 4,800 feet of water and was not recovered, so examinations and testing could not be performed. As a result, the functionality of the altitude and attitude instruments in the cockpit could not be determined. A performance study showed, however, that the airspeed, pitch, rates of descent, and bank angles of the airplane during the approach were within expected normal ranges, and the pilot did not make any transmissions during the approach that indicated he was having any problems. In fact, another cargo flight crew that landed just prior to the accident airplane and an airport employee reported that the pilot transmitted that he was landing on the active runway, and was 7 miles from landing. Radar data showed that when the airplane was 6.5 miles from the airport, at the location of the last recorded radar return, the radar target's mode C altitude report showed an altitude of minus 100 feet mean sea level. The pilot most likely descended into the ocean because he became spatially disoriented. Although visual meteorological conditions prevailed, no natural horizon and few external visual references were available during the visual approach. This increased the importance of monitoring flight instruments to maintain awareness of the airplane attitude and altitude. The pilot's tasks during the approach, however, included maintaining visual separation from the airplane ahead and lining up with the destination runway. These tasks required visual attention outside the cockpit. These competing tasks probably created shifting visual frames of reference, left the pilot vulnerable to common visual and vestibular illusions, and reduced his awareness of the airplane's attitude, altitude and trajectory.

The airplane descended into terrain during the takeoff initial climb from a private airstrip in dark night conditions. The four passengers had been flown to the departure airport earlier in the day. After several hours at the destination, the pilot and passengers boarded the airplane and waited for two other airplanes to depart. During the initial climb, the pilot banked the airplane to the right, due to the upsloping terrain in the opposite direction (left) and noise abatement concerns; this maneuver was a standard departure procedure. The airplane collided with the gradually upsloping terrain, coming to rest upright. The pilot did not believe that he had experienced a loss of power. The accident occurred in dark night conditions, about 1 hour after sunset. In his written report, the pilot said he only had 10 hours of total night flying experience.

The twin-engine medical transport airplane was on a positioning flight when the pilot reported a loss of power affecting one engine before impacting terrain 0.6 miles west of the approach end of the runway. The airplane was at 2,600 feet and in a shallow descent approximately 8 miles northwest of the airport when the pilot checked in with the tower and requested landing. Three and a half minutes later, the pilot reported that he had lost an engine and was in a righthand turn. Radar data indicated that the airplane was 2 miles southwest of the airport at 1,200 feet msl. The radar track continued to depict the airplane in a descent and in a right-hand turn, approximately 1.9 miles west of the approach end of the runway. The altitude fluctuated between 400 and 600 feet, the track turned right again, and stabilized on an approximate 100- degree magnetic heading, which put the airplane on a left base for the runway. The track entered a third right-hand turn at 500 feet. The pilot's last transmission indicated that one engine was not producing power. The last radar return was 6 seconds later at 200 feet, in the direct vicinity of where the wreckage was located. Using the radar track data, the average ground speed calculations showed a steady decrease from 134 knots at the time of the pilot's initial report of a problem, to 76 knots immediately before the airplane impacted terrain. The documented minimum controllable airspeed (VMC) for this airplane is 68 knots. The zero bank angle stall speed varied from 78 knots at a cruise configuration to 70 knots with the gear and flaps down. A sound spectrum study using recorded air traffic control communications concluded that one engine was operating at 2,630 rpm, and one engine was operating at 1,320 rpm. Propeller damage was consistent with the right engine operating at much higher power than the left engine at the time of impact, and both propellers were at or near the low pitch stops (not feathered). Examination and teardown of both engines did not reveal any evidence of mechanical malfunction. Investigators found that the landing gear was down and the flaps were fully deployed at impact. In this configuration, performance calculations showed that level flight was not possible with one engine inoperative, and that once the airspeed had decreased below minimum controllable airspeed (VMC), the airplane could stall, roll in the direction of the inoperative engine, and enter an uncontrolled descent. The pilot had been trained and had demonstrated a satisfactory ability to operate the airplane in slow flight and single engine landings. However, flight at minimum controllable airspeed with one engine inoperative was not practiced during training. The operator's training manual stated that during single engine training an objective was to ensure the pilot reduced drag; however, there was no procedure to accomplish this objective, and the ground training syllabus did not specifically address engine out airplane configuration performance as a dedicated topic of instruction. The operator's emergency procedures checklist and manufacturer's information manual clearly addressed the performance penalties of configuring the airplane with an inoperative engine, propeller unfeathered, the landing gear down, and/or the flaps deployed. The engine failure during flight procedure checklist and the engine inoperative go-around checklist, if followed, configure the airplane for level single engine flight by feathering the propeller, raising the flaps, and retracting the landing gear.

The airplane collided with terrain 200 yards short of the runway during an emergency landing following a loss of engine power. The pilot was on an intermediate leg of a ferry trip. Approximately 300 miles from land, the fuel flow and boost pump lights illuminated. Then, the right engine failed. The pilot flew back to the nearest airport; however, approximately 200 yards from the runway, the airplane stalled and the right wing dropped and collided with the ground. The fuel system had been modified a few months prior to the accident to allow for a ferry fuel tank installation. Post accident examination of the airplane could not find a reason for the power loss.