Lihue Airport
Aircraft Accident/Incident Report

Lihue, Hawaii 96766
Monday, January 14, 2008 5:08 HST

NTSB Narrative Summary Released at Completion of Accident

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.

NTSB Probable Cause Narrative

The pilot's spatial disorientation and loss of situational awareness. Contributing to the accident were the dark night and the task requirements of simultaneously monitoring the cockpit instruments and the other airplane.

Event Information

Type of Event Accident
Event Date 1/14/2008
Event Day of the Week Monday
Time of Event 508
Event Time Zone Hawaii Standard Time
Event City Lihue
Event State HAWAII
Event Country --
Zipcode of the event site 96766
Event Date Year 2008
Event Date Month 1
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 215102N
Event Location Longitude 1591927W
Event Location Airport Lihue
Event Location Nearest Airport ID LIH
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 453 Hawaii Standard Time
Direction of event from weather observation facility (degrees) 180
Weather Observation Facility ID HLI
Elevation of weather observation facility 153
Distance of event from weather observation facility (units?) 7
Time Zone of the weather observation HST
Lighting Conditions Night/Dark
Lowest Ceiling Height 5500
Lowest Non-Ceiling Height 4100
Sky/Lowest/Cloud Conditions Scattered
Sky Condition for Lowest Ceiling Overcast
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 20
Dew Point at event time (in degress fahrenheit) 13
Wind Direction (degrees magnetic) 30
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 23
Wind Velocity Indicator --
Wind Gust Indicator Gusting
Wind Gust (knots) 27
Altimeter Setting at event time (in. Hg) 30.13
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 1
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 1
Investigating Agency NTSB
NTSB Docket Number (internal use) 25123
NTSB Notification Source WP-AWP-Operations Center
NTSB Notification Date Jan 14 2008 12:00AM
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Apr 23 2009 11:53AM
User who most recently changed record broda
Basic weather conditions Visual Meteorological Cond
FAA District Office WP-HNL-FSDO

Aircraft Involved

Aircraft #1

Aircraft Registration Number N410UB
NTSB Number SEA08FA062
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 135: Air Taxi & Commuter
Type of Flight Plan filed IFR
Flight plan Was Activated? Yes
Damage Destroyed
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Hawker Beechcraft Corporation
Aircraft Model 1900C
Aircraft Series Identifier --
Aircraft Serial Number UC-70
Certified Max Gross Weight 16600
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 2
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Continuous Airworthiness
Date of Last Inspection Nov 1 2007 12:00AM
Airframe hours since last inspection 73
Airframe Hours 19123.9
ELT Installed Yes
ELT Activated Yes
ELT Aided Location of Event Site No
ELT Type C91
Aircraft Owner Name Alpine Aviation Inc.
Aircraft Owner Street Address 1177 Alpine Air Way
Aircraft Owner City Provo
Aircraft Owner State UT
Aircraft Owner Country USA
Aircraft Owner Zipcode 84601
Operator is an individual? No
Operator Name --
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address --
Operator City --
Operator State --
Operator Country USA
Operator Zip code --
Operator Code TIMA
Owner has at least one certificate Yes - certificate holder
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not Non-scheduled
Indicates Domestic or International Flight Domestic
Operator carrying Pax/Cargo/Mail Mail
Type of Flying (Per_Bus / Primary) --
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 443
Departure Time Zone HST
Destination Same as Local Flt --
Destination Airport Code LIH
Destination City Lihue
Destination State HI
Destination Country USA
Specific Phase of Flight Landing
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Feb 18 2009 9:18AM
User who most recently changed record dunk
Since inspection or accident Last Inspection
Event Location Runway Number and Location N/A
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --