# NTSB ANC19LA046: Cessna 208B, N879MA, Lahaina, HI, August 18, 2019

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Class 3 · Limited · Final report
- Date: August 18, 2019, 10:37 local (20:37 UTC)
- Place: Lahaina, HI
- Coordinates: 20.969722, -156.669174 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=20.9697&lon=-156.6692&mi=10
- Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping)
- Defining event: [Landing: Landing area overshoot](https://openairdocs.org/ntsb-events/380)
- Highest injury: No injuries
- Injuries: 10 uninjured
- Status: Completed
- Report: Approved by Office Director
- Investigation class: Class 3
- NTSB office: Alaska Regional Office
- Parties: Textron Aviation, Transportation Safety Board of Canada, Hatzell Propeller, Pratt & Whitney Canada Corp., FAA
- NTSB case key (mKey): 100077
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC19LA046
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100077/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100077
- Page: https://openairdocs.org/ntsb/ANC19LA046

## Probable cause

The pilots’ failure to maintain a proper approach speed and their decision to continue the approach for landing, which resulted in the airplane landing long and a subsequent runway overrun.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 208B, 18 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2073701), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md)
- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Copilot (probable cause); cases with it: [Cessna 208B, 19 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2073701), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)
- [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 208B, 5 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=2073701), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md)
- [Performance/control parameters: landing flare](https://openairdocs.org/ntsb-findings/01062041): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 208B, 6 cases](https://openairdocs.org/ntsb-findings/01062041/cases.md?model=2073701), [All aircraft, 1,285 cases](https://openairdocs.org/ntsb-findings/01062041/cases.md)
- [Propeller system: propeller feather/reversing](https://openairdocs.org/ntsb-findings/01046123): Aircraft › Aircraft propeller/rotor · Not specified (probable cause); cases with it: [Cessna 208B, 2 cases](https://openairdocs.org/ntsb-findings/01046123/cases.md?model=2073701), [All aircraft, 26 cases](https://openairdocs.org/ntsb-findings/01046123/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Approach: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Cessna 208B, 5 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=2073701), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md)
- [Landing: Landing area overshoot](https://openairdocs.org/ntsb-events/380) (defining event); cases with it: [Cessna 208B, 2 cases](https://openairdocs.org/ntsb-events/380/sequence.md?model=2073701), [All aircraft, 400 cases](https://openairdocs.org/ntsb-events/380/sequence.md)
- [Landing: Abnormal runway contact](https://openairdocs.org/ntsb-events/090); cases with it: [Cessna 208B, 6 cases](https://openairdocs.org/ntsb-events/090/sequence.md?model=2073701), [All aircraft, 1,506 cases](https://openairdocs.org/ntsb-events/090/sequence.md)
- [Landing: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Cessna 208B, 5 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=2073701), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md)
- [Landing: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340); cases with it: [Cessna 208B, 3 cases](https://openairdocs.org/ntsb-events/340/sequence.md?model=2073701), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md)
- [Landing: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Cessna 208B, 8 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=2073701), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md)
- [Landing: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Cessna 208B, 3 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=2073701), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md)
- [Landing: Abrupt maneuver](https://openairdocs.org/ntsb-events/270); cases with it: [Cessna 208B, 6 cases](https://openairdocs.org/ntsb-events/270/sequence.md?model=2073701), [All aircraft, 346 cases](https://openairdocs.org/ntsb-events/270/sequence.md)

## Analysis

The captain reported that, due to the wind conditions at the destination airport, he and the first officer, who was the pilot flying, decided to fly the approach for landing at 95 knots indicated airspeed (KIAS) and use less than full flaps. The captain stated, and onboard data confirmed, that the airplane crossed the threshold of the 3,000 ft-long-runway at 115 KIAS. The airplane touched down about 2,000 ft down the runway at about 96 knots KIAS. Despite the pilots’ application of reverse thrust and full braking, the airplane continued off the end of the runway, where it impacted a fence and trees and came to rest in a ditch, resulting in substantial damage. The pilots and eight passengers egressed the airplane with no injuries. A complete examination of the thrust reverse system was not performed, as the airplane had been disassembled before the examination could take place. However, given the airplane’s touchdown point, there was insufficient runway remaining on which to stop the airplane even if the pilots had utilized a short field landing technique, which required an approach speed of 78 KIAS and full landing flaps. The pilots’ failure to maintain the predetermined approach speed and their decision to continue the approach despite the airplane’s excessive speed resulted in the airplane landing long and a subsequent runway overrun.

## Factual narrative

On August 18, 2019, about 1037 Hawaii-Aleutian standard time, a Cessna 208B-EX airplane, N879MA, sustained substantial damage when it was involved in an accident near Lahaina, Hawaii. The eight passengers and two pilots were not injured. The airplane was operated by Mokulele Airlines as a Title 14 Code of Federal Regulations Part 135 scheduled passenger flight. The captain reported that the accident occurred while landing during the second flight of the day. The first officer was the pilot flying, and the captain was the pilot monitoring. He and the first officer briefed the approach and chose to fly a speed of 95 knots with an approach flap setting due to the wind conditions. The captain noted that the airplane’s speed on final approach was 115 knots and that the airplane touched down "a little longer than normal." After touchdown, the first officer applied reverse thrust (beta range). He added that, "something didn't feel right" and that the airplane was not decelerating. The captain took control of the airplane and applied the thrust lever to full reverse, but the airplane did not slow down; he applied brakes, but the tires skipped with the brakes locked and had limited effect. The airplane exited the runway, impacted the airport boundary fence, trees, and a ditch, and sustained substantial damage to the left aileron. The first officer reported that, during the approach, the airplane was "a little fast" and floated longer down the runway than normal. He was not sure of the exact touchdown point but noted that he did not hear any loud noise typically associated with the application of reverse thrust. The captain then took the flight controls and applied full reverse thrust with no change or deceleration. The captain then applied full brakes, but the airplane exited the runway. All crew and passengers evacuated through the main door without further incident. One of the passengers, who was also a pilot for the company, reported that, before departure, he observed and heard the reverse thrust operation of the airplane function properly. He added that, during the landing, the airplane touched down about halfway down the runway. He was not able to confirm that the pilots were applying reverse thrust during the landing roll; however, he did feel the brakes being applied. He noted that he did not hear or smell the brakes being locked up and that, after the accident, no tire skid marks were present on the runway or in the grass near where the airplane exited the runway. A review of the Garmin 1000 data indicated that the airplane crossed over the runway numbers at an indicated airspeed of about 115 knots (kts) and landed about 2,000 ft down the 3,000-ft-long runway. The touchdown was registered at approximately 1037:49, with the indicated airspeed of about 96 knots and a ground speed of about 89 knots, as shown in the following figure. Figure: Approximate touchdown of the airplane at JHM According to the pilots operating handbook (POH), the airplane’sestimated landing ground roll distance using a short field landing technique was about 1,070 ft; however, this assumed full flap extension and an approach speed of 78 knots indicated airspeed. The airplane was reported to have an airframe total time of 8,820.5 hrs at the time of the accident. Review of maintenance records revealed that, the month before the accident, the propeller control lever was adjusted because the propeller could not be brought to the feather stop. The propeller received a 100-hour inspection about 56 flight hours before the accident. Examination revealed that the propeller and gearcase section had been displaced from the engine and came to rest on the ground in front of the airplane. Proper rigging of the propeller controls could not be confirmed, as the airplane was dismantled before the examination could take place.

## Aircraft

- Registration: [N879MA](https://openairdocs.org/deregistered/N879MA-2021-04-08), registration cancelled 2021-04-08, S/N 208B5019, built 2013 (OpenAirDocs)
- Reported make and model: Cessna 208B
- Registry model: [Cessna 208B](https://openairdocs.org/model/cessna-208b) (registry code 2073701) (OpenAirDocs)
- Registry engine: [Pratt & Whitney Canada PT6A-140](https://openairdocs.org/engine/pratt-whitney-canada-pt6a-140) (registry code 51499, turbo-prop) (OpenAirDocs)
- Category: Airplane
- Serial number: 208B5019
- Year built: 2013
- Airframe hours: 8820.5
- Engines: Pratt & Whitney Canada PT6A-140 867 horsepower turbo prop
- Damage: Substantial damage
- Flight: Part 135
- Operator: Mokulele Airlines, doing business as Mokulele Airlines
- Registered owner: Mokulele Flight Service Inc
- Airworthiness certificate: Standard, Normal
- Departed: HNL, Honolulu, HI
- Destination: JHM, Kapalua, HI
- Flight plan: IFR
- Airport: JHM, Kapalua, runway 02, 3,000 × 100 ft, asphalt
- Equipment: Stall warning system, Auto-pilot, Electronic flight bag or handheld device

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 64; injuries: none; commercial, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review March 28, 2019; seat: left; restraint: 5-point; flight hours: 9,374 total, 1,288 in this make and model, 7,045 as pilot in command, 212 in the last 90 days, 66 in the last 30 days
- Co-pilot; age 29; injuries: none; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review April 18, 2019; seat: right; restraint: 5-point; flight hours: 566 total, 294 in this make and model, 184 as pilot in command, 252 in the last 90 days, 89 in the last 30 days, 7 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 50° at 12 knots
- Visibility: 10 statute miles
- Temperature: 88 °F, dew point 64 °F
- Altimeter: 30.01 inHg
- Observed at: PHJH, 1 nm away

## FAA reports on this event (1)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Accident 20190818017809A](https://openairdocs.org/incident/20190818017809A), Aug 18, 2019: Cessna 208B, Kapalua, HI, Substantial damage. After touch down, pilot reported that the aircraft did not go into "beta" mode and reported no reverse action once applied. NTSB and Textron will be going to…

## Docket (15 files)

The files NTSB released with the investigation on November 4, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100077. 8.0 MB in all.

- Airplane performance study (item 1, PDF, 15 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9628530&FileExtension=pdf&FileName=ANC19LA046_airplane_performance_study_v3-Rel.pdf
- Pilot/operator aircraft accident report, NTSB form 6120.1 (item 2, PDF, 9 pages, 451 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8449997&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf
- Captain statement (item 3, PDF, 2 pages, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8448073&FileExtension=pdf&FileName=Richard%20Morgan%20MHO%20504%20Report-Rel.pdf
- Captain roc (item 4, PDF, 1 page, 139 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9788907&FileExtension=pdf&FileName=INTERVIEW%20SUMMARY%20Captain_Redacted-Rel.pdf
- First officer statement (item 5, PDF, 1 page, 19 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8448897&FileExtension=pdf&FileName=Accident%20Report%20MHO%20504%20Josh%20Parker-Rel.pdf
- First officer roc (item 6, PDF, 1 page, 138 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9788916&FileExtension=pdf&FileName=INTERVIEW%20SUMMARY%20FO_Redacted-Rel.pdf
- Second report - richard morgan (item 7, PDF, 4 pages, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8927799&FileExtension=pdf&FileName=Ammendments%20to%20AR-Rel.pdf
- Second report - joshua parker (item 8, PDF, 2 pages, 94 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8927730&FileExtension=pdf&FileName=Accident%20Report%20Revision%201-Rel.pdf
- Passenger/pilot statement (item 9, PDF, 2 pages, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8451020&FileExtension=pdf&FileName=Statement%20of%20Timothy%20J_Redacted-Rel.pdf
- Cessna 208 manual (item 10, PDF, 4 pages, 281 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9757093&FileExtension=pdf&FileName=Cessna%20208%20Manual-Rel.pdf
- Airplane records (item 11, PDF, 7 pages, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9809237&FileExtension=pdf&FileName=Airframe%20record%20pgs_Redacted-Rel.pdf
- Statement of party representatives to NTSB investigation (pratt and whitney Canada corp.) (item 12, PDF, 1 page, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9756464&FileExtension=pdf&FileName=Certification%20of%20Party%20Representative%20Pratt%20and%20Whitney%20Canada%20Corp_Redacted-Rel.pdf
- Statement of party representatives to NTSB investigation (hartzell) (item 13, PDF, 1 page, 184 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8448915&FileExtension=pdf&FileName=ANC19LA046%20Hartzell%20Party%20Form_Redacted-Rel.pdf
- Statement of party representatives to NTSB investigation (Textron) (item 14, PDF, 1 page, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8449524&FileExtension=pdf&FileName=Textron%20Form_Redacted-Rel.pdf
- Accident pictures (item 15, PDF, 4 pages, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8450256&FileExtension=pdf&FileName=Accident%20Pictures-Rel.pdf

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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