# NTSB LAX00FA191: Rockwell NA-265-65, N241H, Kaunakakai, HI, May 11, 2000 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: May 10, 2000, 20:31 local (May 11, 2000, 06:31 UTC) - Place: Kaunakakai, HI - Coordinates: 21.127222, -157.149719 - Nearby events: https://openairdocs.org/map.md?lat=21.1272&lon=-157.1497&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 6 fatal - Status: Completed, report July 25, 2002 - Report: Approved by Office Director - Parties: FAA Flight Standards District Office, PRICE AIRCRAFT LLC, Sabreliner Corporation, EXECUTIVE AIRCRAFT SERVICES, Honeywell Engines & Systems - NTSB case key (mKey): 49158 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX00FA191 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/49158/pdf - Page: https://openairdocs.org/ntsb/LAX00FA191 ## Probable cause Inadequate crew coordination led to the captain's decision to discontinue the instrument approach procedure and initiate a maneuvering descent solely by visual references at night in an area of mountainous terrain. The crew failed to review the instrument approach procedure and the copilot failed to provide accurate information regarding terrain clearance and let down procedures during the instrument approach. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, approach - terrain condition - mountainous/hilly (contributing factor) - light condition - night (contributing factor) - preflight planning/preparation - inadequate, flightcrew (cause) - ifr procedure - not followed, flightcrew (cause) - crew/group coordination - inadequate, pilot in command (cause) - became lost/disoriented - inattentive, flightcrew (cause) - descent - initiated, flightcrew (cause) - altitude/clearance - not maintained, flightcrew (cause) ## Analysis The airplane collided with mountainous terrain after the flight crew terminated the instrument approach and proceeded visually at night. The flight crew failed to brief or review the instrument approach procedure prior to takeoff and exhibited various cognitive task deficiencies during the approach. These cognitive task deficiencies included selection of the wrong frequency for pilot controlled lighting, concluding that the airport was obscured by clouds despite weather information to the contrary, stating inaccurate information regarding instrument approach headings and descent altitudes, and descending below appropriate altitudes during the approach. This resulted in the crew's lack of awareness regarding terrain in the approach path. Pilots approaching a runway over a dark featureless terrain may experience an illusion that the airplane is at a higher altitude that it actually is. In response to this illusion, referred to as the featureless terrain illusion or black hole phenomenon, a pilot may fly a lower than normal approach potentially compromising terrain clearance requirements. The dark visual scene on the approach path and the absence of a visual glideslope indicator were conducive to producing a false perception that the airplane was at a higher altitude. A ground proximity warning device may have alerted the crew prior to impact. However, the amount of advanced warning that may have been provided by such a device was not determined. Although the flight crew's performance was consistent with fatigue-related impairment, based on available information, the Safety Board staff was unable to determine to what extent the cognitive task deficiencies exhibited by the flight crew were attributable to fatigue and decreased alertness. ## Factual narrative 1.1 HISTORY OF FLIGHT On May 10, 2000, at 2031 Hawaiian standard time (HST), a Rockwell NA 265-65 Sabreliner corporate jet, N241H, collided with mountainous terrain 3.3 nautical miles (nm) southwest of the Kaunakakai Airport (PHMK), on the island of Molokai, Hawaii. The airplane was on a night visual approach for landing; it was destroyed in the collision sequence and post crash fire. Price Aircraft Company, LLC, of Broomfield, Colorado, owned the airplane, and they were operating it as a personal transportation flight under the provisions of 14 CFR Part 91. The airline transport pilot captain, commercial copilot, and four passengers sustained fatal injuries. Night visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed. The flight originated from Tahiti (NTAA) in the mid Pacific Ocean at an estimated departure time of 1300 HST and made an en route refueling stop at Christmas Island (PLCH). It departed Christmas Island about 1600 HST for Maui (PHOG), Hawaii. It cleared customs in Maui about 1930 and departed for Molokai at 2008 HST. The accident site location was 21 degrees 07.634 minutes north latitude and 157 degrees 08.994 minutes west longitude. The operator detailed the airplane's scheduled itinerary. The trip originated from Jeffco Airport (BJC) in Boulder, Colorado, on April 23, 2000, about 1800 central daylight time (CDT). This allowed the flight to arrive at its destination in Argentina in daylight conditions. Cumulative flight time for this trip was approximately 13 hours, and the flight made four intermediate stops for fuel and customs. The copilot for the trip to Argentina returned to the United States, and the copilot for the accident trip arrived in Argentina on May 7. The operator said their last conversation with the captain was on May 8, about 2200 Argentine time. On May 9, the airplane departed Esquel (SAVE), Argentina, and made a stop in San Carlos de Bariloche (SAZS), Argentina, to pickup a passenger. It made stops in Chile (SCIE), Easter Island (SCIP), and Tortegegie (NTGJ) for fuel and customs en route to Tahiti. The operator estimated the flight arrived in Tahiti in the early evening hours. Tahiti is in the same time zone as Hawaii. The copilot telephoned his dispatch office about 0800 HST on May 10, the day of the accident. He said they originally planned to stay in Tahiti until Friday, May 12. However, the airplane's owner left his luggage in Argentina and wanted to continue to his home on Molokai. The crew planned to stop at Christmas Island for fuel, but Christmas Island required 24-hour advance notification for intended fuel purchases. The captain was attempting to get this requirement waived; if he succeeded, they would leave later that day. Otherwise, the copilot said they would leave early on the 11th. He said he would inform dispatch either way, but they did not hear from him. The crew filed a Jeppesen dataplan indicting an estimated time of departure of 1200 HST from Tahiti. It estimated 3 hours 14 minutes en route to Christmas Island. Another dataplan indicated an estimated time of departure of 1600 HST from Christmas Island. Estimated time en route to Maui was 2 hours 55 minutes. The Safety Board investigator-in-charge (IIC) reviewed transcripts of recorded radio transmissions between the crew and various Federal Aviation Administration (FAA) air traffic control (ATC) facilities. The transcripts indicated the airplane landed on Maui about 1920 HST. US Customs agents began clearing the flight about 1930. The agents reported the crew was in good spirits; however, one pilot mentioned it had been a long day. The IIC reviewed a transcript of the cockpit voice recorder (CVR) made by the CVR group. The CVR transcript times did not exactly match the ATC transcript times. The IIC used the ATC times as the reference time and blended pertinent CVR information in at the appropriate relative time. All times listed are in HST. Evidence from the CVR group indicated that the captain was flying the airplane and the copilot broadcast all radio transmissions. Safety Board staff converted recorded radar data to latitude and longitude coordinates. The IIC reviewed and plotted the computed data. The airplane transmitted a secondary beacon code of 6005 throughout the flight. Mode C reported altitudes were corrected msl (mean sea level) altitudes. The local controller in the Maui Airport Traffic Control Tower (ATCT) told the crew to file their flight plan to Molokai with the Honolulu Automated Flight Service Station (AFSS) on frequency 123.6. The copilot contacted the AFSS at 1926:05 while on the ground at Maui. He filed an IFR flight plan from Maui to Molokai. The CVR transcript does not indicate that the crew briefed or reviewed the route of flight or approach. The copilot requested "eight thousand feet, three thousand feet, we'll say three thousand feet." This request did not include route of flight. Clearance delivery responded that preferred routing to Molokai would be "Victor six Blush, Victor eight, and minimum en route altitude is six thousand feet." The copilot responded that they could accept that altitude and routing. Victor six was the 320-degree radial from the Maui (OGG) VORTAC (very high frequency omni-directional radio range/Tactical Air Navigation). Blush intersection was the point where Victor eight (the 056-degree radial from the Molokai (MKK) VORTAC) intersected Victor six. At 2002:26, the Maui ATCT said "cleared to Molokai as filed, maintain six thousand and fly heading three four zero, departure one two zero point two, squawk six zero zero five." The copilot requested and received verification of the routing. The CVR transcript indicated that the crew began setting their instruments. The captain told the copilot he thought they would receive radar vectors and would not even get on the airway. At 2008:11, on frequency 118.7, Maui ATCT cleared the airplane for takeoff on runway 02. About 2 minutes later they instructed the crew to contact Departure Control. Departure Control established radar contact about 2010, and instructed the crew to join Victor six. The captain asked the copilot to set "that number for me." The copilot responded "three twenty." The captain remarked "join it, we're past it." The copilot agreed. The captain queried, "right then?" At 2010:37, the copilot asked Departure Control to verify that it was a left turn to intercept their assigned radial. Departure advised them to turn to 310 degrees to join the "three twenty." About 1 minute later, Departure instructed them to contact Honolulu Center on frequency 124.1. At 2013:17, Honolulu Center briefed the crew on the Molokai weather. It was: wind 060 degrees at 8 knots; visibility 10 miles; sky clear; temperature 23 degrees (Celsius); and dew point 18 degrees. This brief also informed the crew to expect a visual approach to Molokai Airport. The mode C reported altitude was 6,000 feet. During the next 6 minutes of the CVR recording, the crew discussed bookkeeping issues and an instrument problem. The captain remarked "it really didn't grab it right?" Later the sound of tapping was heard followed by the comment "it's doin' it again." The captain then said it was "holding it or it's giving good directions, the autopilot just isn't uh, capturing it." About 2020, the copilot noted they were about 10 miles out from Molokai. The captain replied they would be taken around to runway 05 and they would probably pass over the airport before being let down. He also commented that he was not watching where they were going. At 2020:53, the copilot asked for and received clearance to descend to 5,000 feet. The copilot remarked they would probably be let down once they were on the other side of the airport. The captain asked if they were past the airport. During several verbal exchanges trying to clarif ## Aircraft - Registration: [N241H](https://openairdocs.org/deregistered/N241H-2000-11-16), registration cancelled 2000-11-16, S/N 465-5 (OpenAirDocs) - Reported make and model: Rockwell NA-265-65 (NA 265-65) - Registry model: [Rockwell International NA-265-65](https://openairdocs.org/model/rockwell-international-na-265-65) (registry code 7630107) (OpenAirDocs) - Category: Airplane - Serial number: 464-5 - Airframe hours: 7934 - Engines: Garrett TFE 731-3R-1D 3700 lbs thrust turbo fan; Garrett TFE 731-3R-1D 3700 lbs thrust turbo fan - Damage: Destroyed - Fire: On-Ground - Flight: Executive/Corporate, Part 91 - Registered owner: Price Aircraft Company, LLC - Airworthiness certificate: Standard, Normal - Last inspection: Continuous airworthiness, April 1, 2001, 6 hours before - Departed: OGG, MAUI, HI - Destination: MKK, KAUNAKAKAI, HI - Flight plan: IFR - Airport: MKK, Kaunakakai, runway 05, 4,494 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 63; injuries: fatal; flight instructor, airline transport, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; last flight review March 8, 2001; seat: left; toxicology performed; flight hours: 12,775 total, 1,370 in this make and model, 9,000 as pilot in command, 70 in the last 90 days, 25 in the last 30 days, 9 in the last 24 hours - Co-pilot; age 28; injuries: fatal; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; last flight review January 18, 2000; seat: right; toxicology performed; flight hours: 1,990 total, 259 in this make and model, 630 as pilot in command, 127 in the last 90 days, 45 in the last 30 days ## Weather - Conditions: Visual (VMC), Night - Wind: 60° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 64 °F - Observed at: PHMK, 3 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 20000510006709A](https://openairdocs.org/incident/20000510006709A), May 10, 2000: Rkwell NA26565, Kaunakakai, HI, Destroyed, 6 fatal. (-23) Saberliner on night approach into the Molokai Airport. IFR departure from kahului, maui. Pilots were behind airplane and required ATC vectors to turn at… 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.