Crash of a Beechcraft H18 in Lanai

Date & Time: Feb 14, 1992 at 0815 LT
Type of aircraft:
Registration:
N33AP
Flight Type:
Survivors:
Yes
Schedule:
Honolulu - Lanai
MSN:
BA-748
YOM:
1967
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1571
Captain / Total hours on type:
464.00
Circumstances:
The pilot said that the approach to the airport was normal, with a 100 knot indicated airspeed. The pilot said the winds were about 110° at 10 knots during the approach; however, on short final he encountered a very strong gust from the right. The pilot corrected for the wind gust then it stopped and the aircraft suddenly dropped hard to the runway without warning. The pilot said he suspected a windshear encounter was responsible for the accident. Witnesses said the approach seemed normal when the aircraft suddenly dropped to the runway and bounced. The witnesses said that a thunderstorm had passed through the area just prior to the aircraft's approach.
Probable cause:
Failure of the pilot to compensate for an encounter with a windshear phenomena. Contributing to the accident was the lack of a low level windshear warning system or a system for the collection and dissemination of weather advisories.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 in Molokai: 20 killed

Date & Time: Oct 28, 1989 at 1837 LT
Operator:
Registration:
N707PV
Survivors:
No
Site:
Schedule:
Kahului - Molokai
MSN:
400
YOM:
1973
Flight number:
WP1712
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
20
Captain / Total flying hours:
3542
Captain / Total hours on type:
1668.00
Copilot / Total flying hours:
425
Copilot / Total hours on type:
189
Aircraft flight hours:
19875
Aircraft flight cycles:
30139
Circumstances:
De Havilland DHC-6, N707PV (Aloha Islandair flight 1712), collided with mountainous/hilly terrain near Halawa Bay, HI, while en route on a scheduled passenger flight at night from Maui to Molokai, HI. Impact occurred at an elevation of about 500 feet, shortly after the aircraft had descended over water, then crossed the shoreline. There was evidence that the captain had made a navigational error and mistakenly believed that he was circumnavigating the northern portion of Molokai Island. The aircraft crashed while on a heading that was parallel with the island's northern shoreline. Low clouds obscured the mountain tops in the area of the accident. There was also evidence of inadequate supervision of personnel, training and operations by Aloha Islandair management and insufficient oversight of Aloha Islandair by the FAA during a period of Aloha Islandair's rapid operational expansion. All 20 occupants were killed.
Probable cause:
The airplane's controlled flight into terrain as a result of the decision of the captain to continue flight under visual flight rules at night into instrument meteorological conditions (IMC), which obscured rising mountainous terrain. Contributing to the accident was: the inadequate supervision of personnel, training, and operations by aloha islandair management and insufficient oversight of Aloha Islandair by the Federal Aviation Administration particularly during a period of rapid operational expansion.
Final Report:

Crash of a Rockwell Grand Commander 680FLP in Kona: 1 killed

Date & Time: Sep 10, 1989 at 1518 LT
Registration:
N22LR
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Kona - Honolulu
MSN:
680-1503-18
YOM:
1965
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
203
Captain / Total hours on type:
23.00
Aircraft flight hours:
4790
Circumstances:
As the aircraft was departing from runway 17, smoke was observed coming from the right engine. The pilot confirmed a loss of power and made a right turn back toward the runway, then reported he had 'lost both engines.' The aircraft was extensively damaged during a landing on rough, rocky terrain about 1/4 mile southwest of the runway threshold. Investigation revealed the aircraft had just changed ownership. During pre-purchase inspection in Florida, metal particles were found in the oil screens of both engines. Oil was changed and flushed, but metal particles were found after another engine run. In May 1989, the right engine was replaced with an engine from another aircraft. The aircraft was flown to Oakland, CA, where it was painted and new interior was installed. A local mechanic noted metal particles in both eng oil screens and recommended oil analysis, but ferrying pilot refused. After flight to Hawaii, no oil stain noted on fuselage before flight on 9/9/89. Exam of wreckage revealed both engines failed from detonation. Heavy oil streaks found behind right engine, some streaks of oil found behind left engine. Right engine crankshaft/rod bearing surface was 0.010' under standard, but rod bearings were standard size. While the passenger was seriously injured, the pilot was killed.
Probable cause:
Inadequate maintenance, and operation by the pilot with known deficiencies in the aircraft. Factors related to the accident were: excessive wear in both engines, improper use of powerplant controls by the pilot, subsequent overtemperature/detonation in both engines, improper emergency procedures by the pilot (including premature gear extension and/or failure to properly reduce drag on the aircraft after loss of engine power), and the pilot's lack of experience in multi engine and this make and model of aircraft.
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:

Crash of a Piper PA-31-350 Navajo Chieftain off Molokai: 8 killed

Date & Time: Dec 23, 1987 at 1853 LT
Operator:
Registration:
N712AN
Flight Phase:
Survivors:
No
Site:
Schedule:
Honolulu – Molokai
MSN:
31-7652151
YOM:
1976
Flight number:
PV082
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
2987
Captain / Total hours on type:
617.00
Aircraft flight hours:
6516
Circumstances:
The flight was to be flown across a 22 mile channel between islands on an overcast night with no moon and no ground reference lights. The aircraft disappeared from radar and, after extensive searches, could not be found. A three dimensional flight track was reconstructed using recorded radar data. The data indicated that in the last 60 seconds the aircraft slowed from 170 to 95 knots, gained 500 feet in altitude, and turned left 190° before abruptly disappearing from radar. Flight tests indicated that the movements of the aircraft in the last 60 seconds of the flight were consistent with a loss of the left engine, without compensation by the pilot. The operator's training program did not provide for night or instrument flight conditions. The last documented instrument time for the pilot was 15 months prior during a checkride. The pilot flew sporadic night flights. The pilot had previously flown during the day and was on his thirteenth hour of duty. The wreckage and all eight occupants were never found. However it is believed it crashed about 13 miles northwest of Maunaloa, on Molokai Island.
Probable cause:
Occurrence #1: loss of engine power
Phase of operation: cruise - normal
Findings
1. (f) 1 engine - undetermined
----------
Occurrence #2: loss of control - in flight
Phase of operation: cruise - normal
Findings
2. (f) light condition - dark night
3. (c) aircraft control - not maintained - pilot in command
4. (f) spatial disorientation - pilot in command
5. (c) airspeed (vmc) - not maintained - pilot in command
6. (f) fatigue (flight and ground schedule) - pilot in command
7. (f) lack of recent instrument time - pilot in command
8. (f) inadequate training - company/operator management
9. (c) stall/spin - inadvertent - pilot in command
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Honolulu

Date & Time: Nov 20, 1987 at 1124 LT
Operator:
Registration:
N27512
Survivors:
Yes
Schedule:
Kona - Honolulu
MSN:
31-7852035
YOM:
1978
Flight number:
PV084
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4190
Captain / Total hours on type:
1685.00
Aircraft flight hours:
6315
Circumstances:
The pilot estimated that the aircraft's reduced fuel quantity was adequate for the flight during his preflight inspection. As the aircraft descended for the traffic pattern near the destination airport both engines failed. After the loss of power the pilot executed a forced landing into a park with the landing gear not fully extended. The aircraft impacted the terrain and slid into a fence before coming to a stop.
Probable cause:
Occurrence #1: loss of engine power (total) - nonmechanical
Phase of operation: descent - normal
Findings
1. (c) fluid, fuel - exhaustion
2. (c) fuel consumption calculations - inaccurate - pilot in command
3. (f) preflight planning/preparation - inadequate - pilot in command
----------
Occurrence #2: forced landing
Phase of operation: descent - emergency
----------
Occurrence #3: on ground/water collision with object
Phase of operation: landing
Findings
4. (f) object - fence
5. Gear extension - not attained - pilot in command
Final Report:

Crash of a Cessna 402A in Kahului

Date & Time: Apr 29, 1987 at 0854 LT
Type of aircraft:
Registration:
N4588Q
Flight Type:
Survivors:
Yes
Schedule:
Kahului - Lanai
MSN:
402A-0088
YOM:
1969
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6650
Circumstances:
Shortly after takeoff, the pilot requested an 'immediate downwind' to return to the airport and was cleared to land. When asked if equipment was needed, he replied, 'negative, sir, a little matter of fuel.' A witness said the aircraft appeared very low on final approach with both props turning. The aircraft crash landed short of the runway, went thru a perimeter fence and came to rest on an incline about 10 feet short of the runway. The pilot received a head injury and couldn't remember many details of the occurrence. In an early interview, he induced there was a partial power loss and the aircraft yawed, but he couldn't remember which engine 'cut out first.' Later, he was unable to recall losing power. Six gallons of fuel was found in the left main tank, about 1.5 gallon was in the right main tank. The left fuel selector was found in the 'main' position, but due to damage and rescue activities, the position of the right fuel selector was not determined. Both auxiliary pump switches were in the 'off' position. The left propeller control was in the feather position, but neither propeller had feathered. Each main tank held one gallon of unusable fuel. A test of the pilot's blood showed 0,45‰ alcohol.
Probable cause:
Occurrence #1: loss of engine power (partial) - nonmechanical
Phase of operation: approach
Findings
1. (c) preflight planning/preparation - inadequate - pilot in command
2. (f) refueling - not performed - pilot in command
3. (f) fluid, fuel - low level
4. Precautionary landing - initiated
5. (c) fluid, fuel - starvation
6. (c) fuel supply - inadequate - pilot in command
7. (f) impairment (alcohol) - pilot in command
----------
Occurrence #2: forced landing
Phase of operation: descent - emergency
Findings
8. (c) planning/decision - improper - pilot in command
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: landing
Findings
9. (f) terrain condition - rough/uneven
----------
Occurrence #4: on ground/water collision with object
Phase of operation: landing
Findings
10. (f) object - fence
Final Report:

Crash of a Consolidated PBY-5A Catalina off Kahului

Date & Time: Apr 14, 1986
Type of aircraft:
Registration:
C-FSAT
Flight Type:
Survivors:
Yes
MSN:
21986
YOM:
1943
Location:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After being stores for almost a year, the seaplane was engaged in a local test flight in the region of Kahului. Upon landing on sea, it collided with reef and came to rest. There were no casualties but the aircraft was damaged beyond repair.
Probable cause:
Collision with reef upon landing.

Crash of a Beechcraft E18S in Kalaupapa

Date & Time: Feb 13, 1986 at 0900 LT
Type of aircraft:
Registration:
N30Y
Flight Type:
Survivors:
Yes
Schedule:
Honolulu - Kalaupapa
MSN:
BA-93
YOM:
1955
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1328
Captain / Total hours on type:
775.00
Aircraft flight hours:
5589
Circumstances:
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.
Probable cause:
Occurrence #1: overrun
Phase of operation: landing
Findings
1. Weather condition - crosswind
2. (f) all available runway - not used - pilot in command
3. (f) planned approach - misjudged - pilot in command
4. (c) go-around - delayed - pilot in command
----------
Occurrence #2: loss of control - in flight
Phase of operation: go-around (vfr)
Findings
5. (c) airspeed (vmc) - not attained - pilot in command
6. (c) stall/mush - inadvertent - pilot in command
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: go-around (vfr)
Final Report: