DCA99MA088

NTSB accident investigation · Piper PA-31-350 · Volcano, HI · September 26, 1999

Accident · FatalMajor investigationFinal report
Date
September 25, 1999, 17:26 local (Sep 26, 1999, 03:26 UTC)
Place
Volcano, HI
Injuries
10 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N411WLPiper PA-31-350
Weather
Instrument (IMC) · Day
Status
Completed · report September 26, 2001
Report
Approved by Office Director
NTSB office
Major Investigations Division
FAA report
19990925044529A
Case key
47509

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 pilot's decision to continue visual flight into instrument meteorological conditions (IMC) in an area of cloud-covered mountainous terrain. Contributing to the accident were the pilot's failure to properly navigate and his disregard for standard operating procedures, including flying into IMC while on a visual flight rules flight plan and failure to obtain a current preflight weather briefing.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight collision with terrain/waterClimb
Terrain condition - mountainous/hillyFactor
Planning/decision - improperPilot in commandCause
Vfr flight into imc - continuedPilot in commandCause
Flight/navigation instrument(s) - improper use ofPilot in commandFactor
Preflight briefing service - not usedPilot in commandFactor
Procedures/directives - not followedPilot in commandFactor

Analysis

The full report (NTSB/AAB-01-02) is available on the NTSB Web site. See http://www.ntsb.gov/Publictn/publictn.htm for details.

On September 25, 1999, about 1726 Hawaiian standard time, Big Island Air flight 58, a Piper PA-31-350 (Chieftain), N411WL, crashed on the northeast slope of the Mauna Loa volcano near Volcano, Hawaii. The pilot and all nine passengers on board were killed, and the airplane was destroyed by impact forces and a postimpact fire. The sightseeing tour flight was operating under 14 Code of Federal Regulations Part 135 as an on-demand air taxi operation. A visual flight rules flight plan was filed, and visual meteorological conditions existed at the Keahole-Kona International Airport, Kona, Hawaii, from which the airplane departed about 1622. The investigation determined that instrument meteorological conditions prevailed in the vicinity of the accident site.

Factual narrative

The full report (NTSB/AAB-01-02) is available on the NTSB Web site. See http://www.ntsb.gov/Publictn/publictn.htm for details.

On September 25, 1999, about 1726 Hawaiian standard time, Big Island Air flight 58, a Piper PA-31-350 (Chieftain), N411WL, crashed on the northeast slope of the Mauna Loa volcano near Volcano, Hawaii. The pilot and all nine passengers on board were killed, and the airplane was destroyed by impact forces and a postimpact fire. The sightseeing tour flight was operating under 14 Code of Federal Regulations Part 135 as an on-demand air taxi operation. A visual flight rules flight plan was filed, and visual meteorological conditions existed at the Keahole-Kona International Airport (KOA), Kona, Hawaii, from which the airplane departed about 1622. The investigation determined that instrument meteorological conditions prevailed in the vicinity of the accident site.

A Big Island Air employee who observed the pilot upon his arrival at KOA shortly before 0700 on the day of the accident stated that the pilot appeared to be alert and well rested. The pilot was scheduled to make two air taxi flights that day. The morning sightseeing flight departed about 0700, and the second (accident) flight departed about 1622.

The morning's weather report was included on the "Flight Plans and Weather" form that Big Island Air pilots typically reference before flying with an indicated time of about 0700. Big Island Air's Director of Operations reported to National Transportation Safety Board investigators that he had obtained this weather information from the Federal Aviation Administration's (FAA) Honolulu Automated Flight Service Station (AFSS). No evidence exists to indicate that the pilot sought or obtained an updated weather briefing for the accident flight later that afternoon as required by the FAA.

The pilot departed KOA about 1622 for his second sightseeing tour of the day and followed a half-island tour route. About 1720, the pilot requested permission from the Honolulu AFSS to transition through a restricted area of airspace (R-3103) that encompasses part of the center of the saddle area. The pilot was advised by AFSS that the restricted area was "open," and he was authorized to transition the area for the next 30 minutes. The FAA did not record any further radio transmissions from the accident pilot.

According to FAA-recorded radar data, at 1721:04, the accident airplane was located approximately 16 nautical miles (nm) east-southeast from the eastern side of the restricted area (about 8.5 nms from the crash site). The accident airplane's altitude, as transmitted by its Mode C-equipped transponder, was about 6,600 feet, and the underlying terrain's elevation was about 4,600 feet mean sea level (msl). Both the airplane's altitude and the terrain's elevation were increasing.

Between 1721:04 and the last recorded radar return at 1725:29 (when the airplane was within 1/3-mile of the accident site), the airplane's average ground track was approximately 291 degrees, magnetic. During this time, the accident airplane's altitude increased from about 6,600 to 9,600 feet. Several witnesses observed clouds below the 10,000-foot level around the time of the accident. About 1726, the accident airplane crashed on the northeast slope of the Mauna Loa volcano at 10,100 feet msl.

Aircraft

Registration
N411WL
Reported as
Piper PA-31-350
Category
Airplane
Serial number
8352039
Airframe hours
4,523
Engine
Lycoming TIO-540-J2BD, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Part 135
Registered owner
Big Island Air Inc
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · August 3, 1999 · 44 hours before
Departed
KOA · Kona, HI
Flight plan
VFR

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
51
Certificates
Commercial, Flight instructor, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
11,500 total · 13 in the last 90 days · 13 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Lowest ceiling
6,000 ft overcast

FAA reports on this event · 1

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