Hawaii

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.

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.

The airplane collided with mountainous terrain after the flight crew terminated the instrument approach and proceeded visually at night. The flight crew failed to brief or review the instrument approach procedure prior to takeoff and exhibited various cognitive task deficiencies during the approach. These cognitive task deficiencies included selection of the wrong frequency for pilot controlled lighting, concluding that the airport was obscured by clouds despite weather information to the contrary, stating inaccurate information regarding instrument approach headings and descent altitudes, and descending below appropriate altitudes during the approach. This resulted in the crew's lack of awareness regarding terrain in the approach path. Pilots approaching a runway over a dark featureless terrain may experience an illusion that the airplane is at a higher altitude that it actually is. In response to this illusion, referred to as the featureless terrain illusion or black hole phenomenon, a pilot may fly a lower than normal approach potentially compromising terrain clearance requirements. The dark visual scene on the approach path and the absence of a visual glideslope indicator were conducive to producing a false perception that the airplane was at a higher altitude. A ground proximity warning device may have alerted the crew prior to impact. However, the amount of advanced warning that may have been provided by such a device was not determined. Although the flight crew's performance was consistent with fatigue-related impairment, based on available information, the Safety Board staff was unable to determine to what extent the cognitive task deficiencies exhibited by the flight crew were attributable to fatigue and decreased alertness.

On September 25, 1999, about 1726 Hawaiian standard time, Big Island Air flight 58, a Piper PA-31-350 (Chieftain), N411WL, crashed on the northeast slope of the Mauna Loa volcano near Volcano, Hawaii. The pilot and all nine passengers on board were killed, and the airplane was destroyed by impact forces and a postimpact fire. The sightseeing tour flight was operating under 14 Code of Federal Regulations Part 135 as an on-demand air taxi operation. A visual flight rules flight plan was filed, and visual meteorological conditions existed at the Keahole-Kona International Airport, Kona, Hawaii, from which the airplane departed about 1622. The investigation determined that instrument meteorological conditions prevailed in the vicinity of the accident site.

Following the 12th sport parachute jump of the day, which occurred after sunset, ground witnesses observed the airplane descend into the ocean in a left wing low, nose down attitude. They did not hear the engines sputtering or popping, or see the airplane make any erratic movements during its descent. Skydivers indicated that the two previous flights had been conducted at altitudes of at least 18,000 feet, and the accident flight and subsequent jump were made at 20,000 feet. During this final jump flight, one of the skydivers stated he had a hard time breathing and felt nauseous. The skydivers also noted that the pilot was unable to maintain a steady course and did not respond well to minor course corrections. No supplemental oxygen was found onboard the airplane during the recovery or subsequent inspection phases of the investigation. No skydiver observed the pilot using supplemental oxygen. The airplane manufacturer noted that the pressurization system would have been rendered inoperable due to a non-sealed cockpit door. Hypoxia is defined as a physiological condition where a person is bereft of needed oxygen. Judgment is poor and reaction time delayed. Total incapacitation coupled with a loss of consciousness can occur with little or no warning. The airframe, engines, and propellers were examined with no preexisting impact anomalies found.

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.

The airplane was loaded with mail & freight within 57 lbs of its max takeoff weight limit. No malfunction was noted during start or taxi. The pilot made a near-midfield intersection departure from runway 08L at 0622:35 local time. Seconds earlier, a Boeing 747 had completed its landing roll-out on runway 4R, which crossed runway 8L near its departure end. Winds were from 285° at 2 kts. The pilot and loader (a private pilot) said nothing unusual occurred during takeoff until the aircraft climbed to 100 feet agl, then 'suddenly the airplane yawed to the left as though the left engine had lost power.' Despite use of full right rudder, directional control was lost, and the pilot decreased the pitch attitude because of 'severe yawing and rolling tendencies.' The airplane's left wing tip impacted the right side of the runway, the tricycle gear collapsed, and the airplane slid to a stop and was consumed by fire. Due to fire damage and lack of accurate records, neither the total fuel load, the freight's actual weight, the cargo's preimpact location within the aircraft, nor the adequacy of the cargo tie down system could be validated. Weight and balance documents filed with the FAA were at variance with 'duplicate' documents held by the operator. Exam of the engines did not reveal evidence of a preimpact failure. Propeller ground scars on the runway indicated both engines were operating during impact. The accident occurred during the pilot's last flight as an employee with the company.

The aircraft departed at night from runway 4R on a flight to transport mail. The pilot-in-command (PIC) was in the left seat, a pilot-rated cargo loader was in the right seat, and another cargo loader was aboard the aircraft, but was not in a seat. During takeoff, the aircraft entered a turn and flew into gradually rising terrain. The initial impact point was about 15 feet higher than the runway elevation and about 0.3 miles abeam the departure end of the runway. Investigation revealed that the company allowed pilot-rated cargo loaders to fly the aircraft from the right seat during positioning and ferry flight segments (to build multiengine flight time) as part of their compensation. There was evidence that at the time of the accident, the aircraft was being piloted on this flight from the copilot's position. The right side of the instrument panel was equipped with only EGT gauges (no flight instruments on the copilot's side). There were cloud layers in the vicinity, no moon illumination, and no visible ground lighting in the direction of flight. No preimpact mechanical malfunction or failure was identified during the investigation. Except at the pilot and copilot positions, the airplane had no other seat and/or restraint system. The operator stated that the pilot was not authorized to carry company personnel or passengers without the required seating.

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.

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.