# NTSB ANC25LA011: Raytheon C90A, N438CA, Honolulu, HI, December 21, 2024 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: December 20, 2024, 23:15 local (Dec 21, 2024, 09:15 UTC) - Place: Honolulu, HI - Coordinates: 21.32, -157.91 - Nearby events: https://openairdocs.org/map.md?lat=21.3200&lon=-157.9100&mi=10 - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Defining event: [Standing-engine(s) start-up: Ground collision](https://openairdocs.org/ntsb-events/200) - Highest injury: No injuries - Injuries: 4 uninjured - Status: Completed, report October 16, 2026 - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Alaska Regional Office - Parties: Guardian Flight, LLC., FAA FSDO - NTSB case key (mKey): 199457 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC25LA011 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/199457/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=199457 - Page: https://openairdocs.org/ntsb/ANC25LA011 ## Probable cause A temporary reduction in the airplane’s braking effectiveness during engine start following an exterior wash, which resulted in its uncommanded forward movement and collision with a parked airplane. Contributing to the accident was the flight crew’s delayed recognition of the airplane’s movement under low-light conditions. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Light condition: low light](https://openairdocs.org/ntsb-findings/03036015): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Raytheon C90A, 1 case](https://openairdocs.org/ntsb-findings/03036015/cases.md?model=7150004), [All aircraft, 36 cases](https://openairdocs.org/ntsb-findings/03036015/cases.md) - [Info processing/decision: identification/recognition](https://openairdocs.org/ntsb-findings/02041510): Personnel issues › Action/decision · Flight crew (probable cause); cases with it: [Raytheon C90A, 1 case](https://openairdocs.org/ntsb-findings/02041510/cases.md?model=7150004), [All aircraft, 559 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md) - [Landing gear system: brake](https://openairdocs.org/ntsb-findings/01023242): Aircraft › Aircraft systems · Unknown/Not determined (probable cause); cases with it: [Raytheon C90A, 1 case](https://openairdocs.org/ntsb-findings/01023242/cases.md?model=7150004), [All aircraft, 297 cases](https://openairdocs.org/ntsb-findings/01023242/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Standing-engine(s) start-up: Ground collision](https://openairdocs.org/ntsb-events/200) (defining event); cases with it: [Raytheon C90A, 1 case](https://openairdocs.org/ntsb-events/200/sequence.md?model=7150004), [All aircraft, 618 cases](https://openairdocs.org/ntsb-events/200/sequence.md) ## Analysis The pilot-in-command (PIC), seated in the left seat, and the second-in-command (SIC), seated in the right seat, reported that, just after starting the airplane’s engines, it began to roll forward uncommanded and unnoticed. The airplane subsequently struck an unoccupied, parked airplane across the ramp, substantially damaging the accident airplane’s right engine firewall and engine mounts. Both pilots reported that the area of the ramp where the airplane was parked was very dark. The PIC stated that, during the engine starts, he had the parking brake set and the toe brakes applied. The SIC reported that the parking brake was set during his preflight checks and just before removing the wheel chocks. Both pilots reported that the airplane remained stationary after the right engine was started. During the start of the left engine, the PIC reported that he did not notice that the airplane was moving until just before the collision. The SIC reported that, after confirming that the airplane was stationary following the right-engine start, he looked down to adjust his shoulder harness and did not notice the airplane was moving before the collision. Postaccident examination and operational testing of the brake system revealed no anomalies that would have precluded normal braking. Maintenance records showed that the accident airplane had undergone an exterior wash and an external and compressor rinse of both engines before the accident flight. After the accident, another pilot flying the same model airplane from the same base reported reduced braking effectiveness during the initial taxi after an exterior and compressor wash. Given the PIC’s report that the parking brake was set and that he was applying the toe brakes when the airplane began moving, the absence of a brake-system fault during postaccident testing, and the subsequent report of reduced braking effectiveness in another company airplane of the same model following a similar wash, the accident airplane likely exhibited temporarily reduced braking effectiveness during the engine start following the exterior wash. ## Factual narrative On December 20, 2024, about 2315 Hawaii-Aleutian standard time, a Raytheon Aircraft Company (formerly Beech) C90A airplane, N438CA, was substantially damaged when it was involved in an accident near Honolulu, Hawaii. The pilot-in-command, seated in the left seat, the second-in-command, seated in the right seat, and two medical personnel were uninjured. The airplane was operated as a Title 14 Code of Federal Regulations Part 135 air medical flight. According to the operator, the medical transport flight was en route to a neighboring island to pick up a patient and had two medical personnel from the Kapiolani Medical Center on board. The pilots reported that, just after starting the engines, the airplane began to roll forward uncommanded and subsequently struck an unoccupied, parked company airplane, about 50 to 75 ft across the ramp. As a result, the accident airplane sustained substantial damage to the right engine firewall and engine mounts. Both pilots reported that the ramp area where the airplane was parked was very dark. The PIC reported that he had set the parking brake and was applying the toe brakes during the engine starts. The SIC reported that the parking brake was set during his preflight checks and before the wheel chocks were removed. Both pilots reported that the airplane remained stationary after the right engine was started. The PIC reported that he did not notice that the airplane was moving until just before the collision. The SIC reported that, after confirming that the airplane was stationary following the right-engine start, he looked down to adjust his shoulder harness and did not notice the airplane’s movement before the collision. An examination of the airplane’s brake system by FAA inspectors found an adequate amount of hydraulic fluid in the brake reservoir. During an operational check from both pilot stations, the brakes held under load and released normally, and the parking brake could be set and released normally, with no faults noted. The inspectors observed the operator bleed the brake system using the gravity method; no air was noted in the brake system. The inspectors observed a minor amount of hydraulic fluid on the fuselage beneath the parking brake valve. They found the hydraulic lines tight, and examination of the parking brake valve and lines revealed no faults. According to maintenance records, the accident airplane had undergone an exterior wash and an external and compressor rinse of both engines before the accident flight. After the accident, a different pilot flying another company airplane of the same make and model from the same base reported through the operator’s internal safety reporting program that he experienced moderately reduced braking effectiveness during the initial taxi after an exterior and compressor wash. He reported that he had to apply the brakes aggressively for about one-half mile before normal braking effectiveness returned. During the investigation, the operator revised itsaircraft wet wash procedures to require that wheel and brake assemblies be rinsed with fresh water, dried, and visually inspected for contamination before return to service. ## Aircraft - Registration: [N438CA](https://openairdocs.org/deregistered/N438CA-2026-02-06), registration cancelled 2026-02-06, S/N LJ-1541, built 1998 (OpenAirDocs) - Reported make and model: RAYTHEON AIRCRAFT COMPANY C90A - Registry model: [Raytheon C90A](https://openairdocs.org/model/raytheon-c90a) (registry code 7150004) (OpenAirDocs) - Registry engine: [Pratt & Whitney PT6A series](https://openairdocs.org/engine/pratt-whitney-pt6a-series) (registry code 52032, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: LJ-1541 - Year built: 1998 - Airframe hours: 11306.8 - Engines: Pratt and Whitney, Canada PT6A-21 550 horsepower turbo prop; Pratt and Whitney, Canada PT6A-21 550 horsepower turbo prop - Damage: Substantial damage - Flight: Other work use, Part 135 - Operator: Guardian Flight LLC, doing business as Hawaii Lifeflight, LLC - Registered owner: Guardian Flight, LLC - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, September 9, 2024, 398 hours before - Destination: HOG, Kahului, HI - Flight plan: IFR - Airport: HNL, Daniel K. Inouye International Airport - Equipment: Satellite tracking device, Stall warning system, Video recording device, ADS-B, Auto-pilot, Electronic flight bag or handheld device, Electronic primary flight display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: none; commercial, flight instructor, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review November 21, 2024; seat: left; restraint: 4-point; flight hours: 6,091 total, 2,647 in this make and model, 5,817 as pilot in command, 70 in the last 90 days, 13 in the last 30 days, 0 in the last 24 hours - Co-pilot; age 42; injuries: none; airline transport, private; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review October 25, 2024; seat: right; restraint: 4-point; flight hours: 2,145 total, 55 in this make and model, 1,506 as pilot in command - Other flight crew; injuries: none; seat: left; restraint: 3-point - Other flight crew; injuries: none; seat: right; restraint: 3-point ## Weather - Conditions: Visual (VMC), Night - Wind: calm - Visibility: 10 statute miles - Temperature: 75 °F, dew point 81 °F - Altimeter: 30.06 inHg - Observed at: HNL - METAR: 210853Z 00000KT 10SM SCT027 24/21 A3006 RMK AO2 SLP178 T02440211 51004 PNO VISNO RWY04R $ ## 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 20241220022352A](https://openairdocs.org/incident/20241220022352A), Dec 20, 2024: Raytheon Aircraft Company C90A, Honolulu, HI, Substantial damage. During the start-up of the right engine of the king air (N438CA) by the pilot in command (PIC), the second in command (SIC) visually confirmed that the… ## Docket (11 files) The files NTSB released with the investigation on October 16, 2026, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=199457. 36.3 MB in all. - Appareo vision (no data) - specialist's brief report (item 1, PDF, 4 pages, 3 photos, 437 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=20970572&FileExtension=pdf&FileName=ANC25LA011%20Appareo%20Vision%20(No%20Data)%20-%20Specialist%27s%20Brief%20Report-Rel.pdf - Cockpit voice recorder - specialist's factual report (item 2, PDF, 6 pages, 149 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=21074140&FileExtension=pdf&FileName=Cockpit%20Voice%20Recorder%20-%20Specialist%27s%20Factual%20Report-Rel.pdf - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 3, PDF, 10 pages, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19034743&FileExtension=pdf&FileName=ANC25LA011%206120_Redacted-Rel.pdf - FAA interviews (item 4, PDF, 6 pages, 92 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19648593&FileExtension=pdf&FileName=ANC25LA011%20FAA%20Interviews-Rel.pdf - FAA inspector's statement (item 5, PDF, 5 pages, 732 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19651284&FileExtension=pdf&FileName=ANC25LA011%20Ryan%20Torres%20FAA%20Inspection%20MOR-Rel.pdf - Maintenance records (item 6, PDF, 31 pages, 29.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19650055&FileExtension=pdf&FileName=%2377%20N438CA%20AFL%20359551-359580%20(12.06.24%20to%2012.20.24)_Redacted-Rel.pdf - Memorandum for record a�� telephone interviews (item 7, PDF, 5 pages, 106 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19693148&FileExtension=pdf&FileName=ANC24LA011%20MORs-Rel.pdf - Memorandum for record - assistant director of maintenance (item 8, PDF, 2 pages, 127 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=20965126&FileExtension=pdf&FileName=ANC26LA011%20Assistant%20Director%20of%20Maintenance%20MOR_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation (item 9, PDF, 15 pages, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19649982&FileExtension=pdf&FileName=ANC25LA011%20Party%20Forms_Redacted-Rel.pdf - Release of aircraft wreckage (item 10, PDF, 2 pages, 163 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19673172&FileExtension=pdf&FileName=ANC25LA011%20Release%20of%20Wreckage_Redacted-Rel.pdf - Photos (item 11, PDF, 3 pages, 467 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19669790&FileExtension=pdf&FileName=ANC25LA011%20Photos-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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.