ANC23LA023

NTSB accident investigation · Cessna P337H · Kona, HI · February 14, 2023

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
February 14, 2023, 08:00 local (18:00 UTC)
Place
Kona, HI · Runway overrun area
Injuries
1 minor, 4 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N5KRCessna P337H
Defining event
Takeoff: Unknown or undetermined
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Alaska Regional Office
Parties
FAA
FAA report
20230214002279A
Case key
106742

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The failure of the pilot to recognize that the rear engine was not operating during takeoff, which resulted in an attempted single-engine takeoff and the airplane’s subsequent descent and impact with terrain. Contributing to the accident was a loss of rear engine power for reasons that could not be determined.

Findings · 6

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Power plantAircraft › Aircraft power plant · Unknown/Not determinedCessna P337H: 1 caseAll aircraft: 198 casesProbable cause
Use of equip/info: use of available resourcesPersonnel issues › Task performance · PilotCessna P337H: 1 caseAll aircraft: 41 casesProbable cause
Performance/control parameters: powerplant parametersAircraft › Aircraft oper/perf/capability · Capability exceededCessna P337H: 1 caseAll aircraft: 81 casesProbable cause
Use of equip/info: use of policy/procedurePersonnel issues › Task performance · PilotCessna P337H: 1 caseAll aircraft: 191 casesProbable cause
Action: incorrect action sequencePersonnel issues › Action/decision · PilotCessna P337H: 1 caseAll aircraft: 77 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot reported that during the preflight inspection and engine run-up, he noted no anomalies with the airplane. Then, on departure, the airplane lost partial power. The pilot performed an emergency landing to the runway overrun area with the landing gear retracted, and the airplane sustained substantial damage to the fuselage. Postaccident examination of the engines revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. During the examination the rear engine started normally, accelerated smoothly, and ran continuously without interruption. Review of recorded engine monitoring data revealed that the rear engine lost total engine power during the engine run-up. Although the reason for the rear engine’s total loss of power during the engine run-up could not be determined, the pilot should have recognized that the rear engine was not operating during the takeoff roll and aborted the takeoff. Placards on the instrument panel and the owner’s manual stated, “Do not initiate single engine take-off,” The continuation of the takeoff in this condition resulted in the airplane’s inability to climb and its subsequent descent and impact with terrain.

Factual narrative

On February 14, 2023, about 0800 Hawaii-Aleutian standard time, a Cessna C337H airplane, N5KR, sustained substantial damage when it was involved in an accident in Kona, Hawaii. The pilot had minor injuries and four passengers were not injured. The airplane was operated by the pilot as a Title 14 Code of Federal Regulations Part 135 sightseeing flight. The pilot completed the preflight inspection and engine run-up with no anomalies noted. The airplane departed from runway 35 at the Kona International Airport (KOA), Kona, Hawaii. During takeoff, after an indicated positive rate of climb, the pilot retracted the landing gear. As the landing gear retracted, the airplane had significantly less performance. The pilot performed an emergency landing to the runway overrun area with the landing gear retracted. The airplane sustained substantial damage to the fuselage. The operator’s weight and balance for the flight showed a takeoff weight of 4,681.5 lbs. with an allowable maximum gross weight of 4,700 lbs. An engine examination was performed by Federal Aviation Administration inspectors after the accident. The rear engine started normally, accelerated smoothly, and ran continuously without interruption. The front engine spark plugs were removed from the engine and no anomalies were observed with their electrodes. The crankshaft was rotated by hand and valvetrain continuity was confirmed to the rear accessory section. Thumb compression was attained on all cylinders. Magnetos were checked and timing was correct and both magnetos were operational. The examination of both engines revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Review of recorded engine monitoring data revealed that, about 4 minutes after both engines were started, the rear engine’s cylinder head temperatures (CHT) and exhaust gas temperatures (EGT) began to decrease, the engine oil pressure dropped from 69 psi to 1 psi, the fuel flow rate dropped to 0 gph, fuel pressure decreased from 6.9 psi to 1.3 psi, and the horsepower dropped from 32% to 0%. About 7 minutes after both engines were started, the front engine rpm increased and the airplane began to takeoff. Placards on the instrument panel stated, “Do not initiate single engine take-off” and, “Lead with rear engine power check RPM and fuel flow.” The owner’s manual indicated that, during takeoff, it was recommended to advance the rear engine throttle ahead of the front engine throttle and to periodically monitor fuel flow and rpm throughout the takeoff. If either of these indicators was below normal, the takeoff should be discontinued immediately while sufficient runway remained. The owner’s manual also indicated that full throttle checks on the ground were not recommended. The owner’s manual stated that the airplane drag with the landing gear doors opened and the gear partially extended is greater than the drag with the landing gear fully extended. Correspondingrate-of-climb penalties are 240 fpm and 110 fpm, respectively. Therefore, since there is a drag increase with the initiation of gear retraction, it should not be attempted unless adequate airspeed and altitude margins exist for sustained flight. This is especially important under the conditions of weight, altitude, and temperature that result in little or no single-engine climb.

Aircraft

Registration
N5KR
Reported as
Cessna P337H
Category
Airplane
Serial number
P3370335
Built
1979
Airframe hours
2,118
Engines
Continental TSIO-360-CB3B, 225 horsepower, reciprocatingContinental TSIO-360-CB4B, 225 horsepower, reciprocating
Damage
Substantial damage
Flight
Business · Part 135
Operator
Big Island Air, INC, doing business as Big Island Air
Registered owner
Hana Like II LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · November 28, 2022 · 28.2 hours before
Destination
Same as departure
Flight plan
Company VFR
Airport
KOA · Ellison Onizuka Kona International at Keahole, runway 35, 11,000 × 150 ft, asphalt
Equipment
Electronic primary flight display, Electronic multifunction display, Auto-pilot, ADS-B, Stall warning system

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
62
Injuries
Minor
Certificates
Commercial, Airline transport
Airplane ratings
Multi-engine land, Single-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
July 25, 2022
Seat
Left
Restraint
3-point
Flight hours
4,116 total · 122 in this make and model · 3,841 as pilot in command · 104 in the last 90 days · 36 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
360° at 12 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
79 °F, dew point 57 °F
Altimeter
29.96 inHg
Observed at
PHKO, 1 nm away
METAR
PHKO 141844Z 36012KT 10SM CLR 26/14 A2996 RMK AO2 T02560144

Docket · 10

The files NTSB released with the investigation on August 1, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.