# NTSB ANC23LA023: Cessna P337H, N5KR, Kona, HI, February 14, 2023

- Type: NTSB accident investigation
- Classification: Accident · Minor injuries · Class 3 · Limited · Final report
- Date: February 14, 2023, 08:00 local (18:00 UTC)
- Place: Kona, HI · Runway overrun area
- Coordinates: 19.756336, -156.04473 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=19.7563&lon=-156.0447&mi=10
- Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping)
- Defining event: [Takeoff: Unknown or undetermined](https://openairdocs.org/ntsb-events/000)
- Highest injury: Minor injuries
- Injuries: 1 minor, 4 uninjured
- Status: Completed
- Report: Approved by Office Director
- Investigation class: Class 3
- NTSB office: Alaska Regional Office
- Parties: FAA
- NTSB case key (mKey): 106742
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC23LA023
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106742/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=106742
- Page: https://openairdocs.org/ntsb/ANC23LA023

## 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

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

- [Power plant](https://openairdocs.org/ntsb-findings/01057100): Aircraft › Aircraft power plant · Unknown/Not determined (probable cause); cases with it: [Cessna P337H, 1 case](https://openairdocs.org/ntsb-findings/01057100/cases.md?model=2075731), [All aircraft, 198 cases](https://openairdocs.org/ntsb-findings/01057100/cases.md)
- [Use of equip/info: use of available resources](https://openairdocs.org/ntsb-findings/02063035): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna P337H, 1 case](https://openairdocs.org/ntsb-findings/02063035/cases.md?model=2075731), [All aircraft, 41 cases](https://openairdocs.org/ntsb-findings/02063035/cases.md)
- [Performance/control parameters: powerplant parameters](https://openairdocs.org/ntsb-findings/01062050): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Cessna P337H, 1 case](https://openairdocs.org/ntsb-findings/01062050/cases.md?model=2075731), [All aircraft, 81 cases](https://openairdocs.org/ntsb-findings/01062050/cases.md)
- [Info processing/decision: identification/recognition](https://openairdocs.org/ntsb-findings/02041510): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna P337H, 1 case](https://openairdocs.org/ntsb-findings/02041510/cases.md?model=2075731), [All aircraft, 559 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md)
- [Use of equip/info: use of policy/procedure](https://openairdocs.org/ntsb-findings/02063032): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna P337H, 1 case](https://openairdocs.org/ntsb-findings/02063032/cases.md?model=2075731), [All aircraft, 191 cases](https://openairdocs.org/ntsb-findings/02063032/cases.md)
- [Action: incorrect action sequence](https://openairdocs.org/ntsb-findings/02041020): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna P337H, 1 case](https://openairdocs.org/ntsb-findings/02041020/cases.md?model=2075731), [All aircraft, 77 cases](https://openairdocs.org/ntsb-findings/02041020/cases.md)

## Sequence of events

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

- [Takeoff: Unknown or undetermined](https://openairdocs.org/ntsb-events/000) (defining event); cases with it: [Cessna P337H, 1 case](https://openairdocs.org/ntsb-events/000/sequence.md?model=2075731), [All aircraft, 1,703 cases](https://openairdocs.org/ntsb-events/000/sequence.md)

## 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](https://openairdocs.org/aircraft/N5KR), registered now, S/N P3370335, built 1979 (OpenAirDocs)
- Reported make and model: CESSNA P337H
- Registry model: [Cessna P337H](https://openairdocs.org/model/cessna-p337h) (registry code 2075731) (OpenAirDocs)
- Registry engine: [Continental TSIO-360 series](https://openairdocs.org/engine/continental-tsio-360-series) (registry code 17019, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: P3370335
- Year built: 1979
- Airframe hours: 2118
- Engines: Continental TSIO-360-CB3B 225 horsepower reciprocating; Continental 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 62; injuries: minor; 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

## 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 20230214002279A](https://openairdocs.org/incident/20230214002279A), Feb 14, 2023: Cessna P337H, Kona, HI, Substantial damage. During takeoff aircraft crashed off the departure end of runway 35 past the runway safety area. Pilot was cleared for take-off and departed runway 35 @ golf.…

## Docket (10 files)

The files NTSB released with the investigation on August 1, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=106742.

- Engine data monitor - specialist's factual report (item 1, PDF, 7 pages, 968 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15467738&FileExtension=pdf&FileName=ANC23LA023%20Engine%20Data%20Monitor%20-%20Specialist%27s%20Factual%20Report-Rel.pdf
- Attachment 1 to engine data monitor - specialist's factual report (item 2, CSV, 26 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15464611&FileExtension=csv&FileName=ANC23LA023%20Attachment%201%20to%20Engine%20Data%20Monitor%20-%20Specialist%27s%20Factual%20Report-Rel.csv
- Pilot/operator aircraft accident report, NTSB form 6120.1 (item 3, PDF, 10 pages): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15308158&FileExtension=pdf&FileName=ANC23LA023%206120_Redacted-Rel.pdf
- Pilot's statement (item 4, PDF, 1 page, 215 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15306336&FileExtension=pdf&FileName=Pilot%20Incident%20Statement%20-%20Signed_Redacted-Rel.pdf
- Engine exam notes (item 5, PDF, 8 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17451752&FileExtension=pdf&FileName=ANC23LA023%20Engine%20Examination%20combined_Redacted-Rel.pdf
- Excerpts from the owner's manual (item 6, PDF, 3 pages, 422 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17022907&FileExtension=pdf&FileName=Excerpts%20from%20Owners%20Manual-Rel.pdf
- Maintenance logbook (item 7, PDF, 21 pages, 12.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17221305&FileExtension=pdf&FileName=ANC23LA023%20Maintance%20logbooks_Redacted-Rel.pdf
- Airplane weight and balance (item 8, PDF, 1 page, 337 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15308168&FileExtension=pdf&FileName=ANC23LA023%20Weight%20%26%20Balance%202-14-2023_Redacted-Rel.pdf
- Release of aircraft wreckage, NTSB form 6120.15 (item 9, PDF, 2 pages, 616 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15348455&FileExtension=pdf&FileName=ANC23LA23%20Wreckage%20release-Rel.pdf
- Investigative photographs (item 10, PDF, 5 pages, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17222357&FileExtension=pdf&FileName=ANC23LA023%20Photographs%201-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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