Aircraft Accident/Incident Report

Laupahoehoe, Hawaii 96764
Saturday, January 31, 2004 1:40 HST

NTSB Narrative Summary Released at Completion of Accident

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 walked 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 pickup 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.

NTSB Probable Cause Narrative

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.

Event Information

Type of Event Accident
Event Date 1/31/2004
Event Day of the Week Saturday
Time of Event 140
Event Time Zone Hawaii Standard Time
Event City Laupahoehoe
Event State HAWAII
Event Country --
Zipcode of the event site 96764
Event Date Year 2004
Event Date Month 1
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 195724N
Event Location Longitude 1551950W
Event Location Airport --
Event Location Nearest Airport ID --
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles 24
Degrees magnetic from airport --
Airport Elevation 38
Weather Briefing Completeness Full
Investigator's weather source Weather Observation Facility
Time of the weather observation 131 Hawaii Standard Time
Direction of event from weather observation facility (degrees) 117
Weather Observation Facility ID PHTO
Elevation of weather observation facility 38
Distance of event from weather observation facility (units?) 21
Time Zone of the weather observation HST
Lighting Conditions Night
Lowest Ceiling Height 1800
Lowest Non-Ceiling Height 1300
Sky/Lowest/Cloud Conditions Scattered
Sky Condition for Lowest Ceiling Broken
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 2.5
Air Temperature at event time (in degrees celsius) 19
Dew Point at event time (in degress fahrenheit) 18
Wind Direction (degrees magnetic) 260
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 8
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 30.03
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal 3
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 3
Investigating Agency NTSB
NTSB Docket Number (internal use) 19363
NTSB Notification Source FAA
NTSB Notification Date Jan 31 2004 12:00AM
NTSB Notification Time 645
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Mar 28 2006 1:55PM
User who most recently changed record NTSB\JOHB
Basic weather conditions Instrument Meteorological Cond
FAA District Office WP-HNL-FSDO

Aircraft Involved

Aircraft #1

Aircraft Registration Number N5637C
NTSB Number LAX04FA113
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed VFR
Flight plan Was Activated? Yes
Damage Destroyed
Aircraft Fire Ground
Aircraft Explosion None
Aircraft Manufacturer's Full Name Cessna
Aircraft Model 414A
Aircraft Series Identifier --
Aircraft Serial Number 414A0118
Certified Max Gross Weight 7085
Aircraft Category Airplane
Aircraft Registration Class U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 6
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection AAIP
Date of Last Inspection Jan 1 2004 12:00AM
Airframe hours since last inspection 39
Airframe Hours 11899
ELT Installed Yes
ELT Activated Yes
ELT Aided Location of Event Site Yes
ELT Type --
Aircraft Owner Name Pacific Air Ambulance
Aircraft Owner Street Address 70 Mitchell Blvd, Suite 202
Aircraft Owner City San Jose
Aircraft Owner State CA
Aircraft Owner Country USA
Aircraft Owner Zipcode 94903
Operator is an individual? No
Operator Name Hawaii Air Ambulance
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address PO Box 30242
Operator City Honolulu
Operator State HI
Operator Country USA
Operator Zip code --
Operator Code H48A
Owner has at least one certificate --
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Positioning
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code HNL
Departure City Honolulu
Departure State HI
Departure Country USA
Departure Time 32
Departure Time Zone HST
Destination Same as Local Flt --
Destination Airport Code ITO
Destination City Hilo
Destination State HI
Destination Country USA
Specific Phase of Flight Cruise
Report sent to ICAO? No
Evacuation occurred No
Date of most recent change to record Jan 11 2006 3:37PM
User who most recently changed record COOS
Since inspection or accident Last Inspection
Event Location Runway Number and Location NA
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight Yes
Medical Flight --