# NTSB LAX03FA077: Cessna 172N, N911FC, Kalaupapa, HI, January 25, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: January 25, 2003, 12:22 local (22:22 UTC) - Place: Kalaupapa, HI - Coordinates: 21.166666, -156.949996 - Nearby events: https://openairdocs.org/map.md?lat=21.1667&lon=-156.9500&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report March 30, 2004 - Report: Approved by Office Director - Parties: Cessna Aircraft Company, Federal Aviation Administration - NTSB case key (mKey): 56419 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX03FA077 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56419/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=56419 - Page: https://openairdocs.org/ntsb/LAX03FA077 ## Probable cause the student pilot's inadvertent VFR flight into IMC, which resulted in his in-flight collision with mountainous terrain while maneuvering. A contributing factor was the low ceiling weather condition. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, cruise - meteorological service - obtained, pilot in command - meteorological service - obtained, flight instructor(on ground) - vfr flight into imc - inadvertent, pilot in command (cause) - weather condition - low ceiling (contributing factor) - In flight collision with terrain/water, maneuvering - terrain condition - mountainous/hilly ## Analysis The student pilot obtained an in-person weather briefing from the local flight service station (FSS) prior to departure for a solo cross-country flight between two islands. The printed weather information used to provide the briefing depicted visual flight rule (VFR) conditions throughout the planned route of flight. During the time the student was obtaining weather information and planning his flight, the flight instructor obtained a weather briefing from the FSS via telephone. Review of the recorded conversation between the weather briefer and the flight instructor revealed current and forecast weather conditions provided were above VFR weather minimums, and a recommendation discouraging VFR flight was not provided. The accident flight was the student's first solo cross-country. He had flown the same route of flight with his flight instructor 1 week prior to the accident. According to the flight instructor, the student planned to make the flight at 3,500 feet msl. The majority of the flight was to be over open ocean water along the north shore of an island with rugged mountainous terrain of elevations up to 4,961 feet msl. Review of radar data revealed the student pilot descended the airplane from 2,200 feet msl to as low as 1,000 feet msl as it traveled along the planned route. According to two military pilots, who were flying helicopters in the opposite direction along the same route and one of whom observed the accident airplane, the student was eventually going to encounter instrument meteorological conditions at the elevation he was flying. They reported the weather conditions as scattered clouds at 700 feet agl and broken clouds at 1,000 feet agl with precipitation and visibilities between 3 to 5 miles. Radar data depicted the airplane gaining altitude to about 1,500 feet msl before turning south toward higher terrain on the coast of the island. The wreckage was located at the 1,500-foot level of a steeply rising mountain. No preaccident anomalies were noted with the aircraft. According to the flight instructor, if her student could not see the next visual checkpoint during the cross-country flight, he was to turn around and return to the departure airport. Steep mountains separated the accident site from the closest weather reporting facility (11 miles away). The weather conditions at the reporting facility when the accident flight passed that location were a few clouds at 800 feet agl, scattered clouds at 2,400 feet agl, and broken clouds at 5,500 feet agl, with a visibility 10 miles. ## Factual narrative HISTORY OF FLIGHT On January 25, 2003, at 1222 Hawaiian standard time, a single engine Cessna 172N airplane, N911FC, was destroyed when it impacted mountainous terrain while maneuvering approximately 5 miles east of the town of Kalaupapa on the island of Molokai, Hawaii. The student pilot, who was the sole occupant, was fatally injured. The airplane was registered to a private individual and was operated by George's Aviation Service, Inc., of Honolulu, Hawaii. The solo instructional flight was being conducted under the provisions of 14 CFR Part 91. The cross-country flight originated from the Honolulu International Airport (HNL), Honolulu, approximately 1140, and was destined for the Kahului Airport (OGG) on Maui Island, Hawaii. Instrument meteorological conditions (IMC) prevailed at the accident site at the time of the accident, and the student pilot had filed a visual flight rules (VFR) flight plan for the flight. According to the student's flight instructor, the student was to fly from Oahu to Maui by flying over the north shore of Molokai at 3,500 feet msl. The student was utilizing an island reporting method to report his current and forecast positions to air traffic controllers and flight service stations (FSS). Reports from the Federal Aviation Administration (FAA) indicate that the student spoke with the Molokai air traffic control tower. The student was instructed to contact Honolulu radio after leaving the Molokai control area; however, the Honolulu (HNL) FSS never received the pilot's next position report (which was supposed to be over Cape Halawa on the east side of the island). When the FSS did not receive the next radio call from the student, they issued an "alert notice (ALNOT)" for a missing aircraft. The U.S. Coast Guard started search and rescue mission flights approximately 1400. Interviews with the Coast Guard pilots, who executed the initial search efforts, revealed they encountered visual meteorological conditions (VMC) from Honolulu to the west side of Molokai. They observed hazier visibility conditions when they neared the northwest side of the island. The pilots reported encountering instrument meteorological conditions (IMC) once they passed halfway over the island, with cloud ceilings around 500 feet and visibility between 1-2 miles. Weather hampered search efforts until January 27, 2003, when a Maui Fire Department helicopter spotted the wreckage on the west slope of the Manuahi Ridge. The burned remains of the wreckage were located approximately 1,500 feet above sea level, approximately 75 feet below the crest of the ridge. PERSONNEL INFORMATION The pilot obtained his third-class medical certificate and student pilot certificate on November 20, 2002. His medical certificate had no limitations placed upon it. The pilot's logbook, endorsements, and medical certificate were not located during the investigation, and were presumed burned in the wreckage. The flight school's records and flight instructor's logbook were utilized to determine the student's flight history. The student had accumulated approximately 33 total flight hours. Of those 33 hours, the student had flown 1.2 hours of simulated instrument flight time, and 1.7 hours of pilot-in-command solo time. According to his flight instructor, this was his first solo cross-country flight. He had flown two cross-country flights with his flight instructor prior to the solo, one of which was along the same route of flight as the one the student was flying the day of the accident. The similar dual cross-country flight was conducted on January 18, 2003. Review of the student's pre solo written examination revealed he was asked to, "Explain student pilot limitations concerning visibility and flight above the clouds." The student answered, "you can't be pilot-in-command if visibility is less than 3 statute miles during daylight or 5 statute miles at night [or] when the flight can't be made with visual references to surface." During an interview with the flight instructor conducted by the National Transportation Safety Board investigator-in-charge (IIC), she indicated she was confident in the student's cross-country flying ability, and reported he was comfortable using navigation aides during his flights. When asked about the student's diversion training, the flight instructor reported she instructed her student to turn around and return to the departure airport if at anytime he could not visually locate the next checkpoint. AIRCRAFT INFORMATION The four-seat, high-wing airplane was powered by a 160-horsepower Lycoming O-320-H2AD engine. The airplane and engine underwent their last 100-hour inspection on January 19, 2003, at an aircraft total time of 8,763.5 hours, and a total time since engine overhaul of 323.7 hours. The aircraft underwent its last annual inspection on October 29, 2002, at an aircraft total time of 8,476.7 hours and a time since engine overhaul of 36.9 hours. The engine was last overhauled on October 6, 2002. AIR TRAFFIC CONTROL AND RADAR DATA The student filed a flight plan with the HNL FSS. According to the flight instructor, the student's planned route of flight was from Honolulu International Airport (Oahu) to Kahului Airport (Maui) via the north shore of Molokai, then return from Kahului, land at Molokai Airport, and finish back at Honolulu. The instructor added the student was to fly at an elevation of 3,500 feet on the way to Maui and 3,000 feet on the way back. Review of unclassified radar data provided by the U.S. Army, revealed the accident airplane was at an altitude of 2,200 feet as it initially crossed the channel eastbound between Oahu and Molokai. Approximately midway over the channel, the radar data depicted the airplane at 1,700 feet. As the accident aircraft neared the east end of the channel, radar data depicted its altitude as 2,600 feet; however, as the airplane approached Ilio Point (on the northwest corner of Molokai), radar data depicted the airplane descending to 1,000 feet. The airplane proceeded eastbound along the north shore of Molokai and remained between 1,000 and 1,200 feet. As the airplane crossed over the Kalaupapa Peninsula, the radar data depicted the airplane at 1,300 feet. The last four radar returns provided by the Army radar service depicted the airplane level at 1,500 feet as it turned south towards the north coast of Molokai. The last radar return was in the vicinity of the accident site at 1221:07. METEOROLOGICAL INFORMATION According to the flight instructor, the student visited the HNL FSS between 0824 and 0900, for a personal weather briefing. The flight instructor then called the HNL FSS and obtained a weather briefing for the student's planned route of flight. The flight instructor met with the student at the airport approximately 1030, to review the weather printout and flight plan information. The printed material, utilized for both the student's and the instructor's briefings, was provided to the Safety Board IIC. It should be noted that the island of Hawaii is referred to as the Big Island in the provided weather information. Printed Weather Used for Student Briefing: Review of the weather briefing material for the student revealed an area summary indicating a frontal shower band had just cleared the island of Molokai and was arriving over the Big Island. The summary continued by indicating the islands of Maui and Lanai would be clearing later in the morning. An AIRMET for mountain obscurement over the islands of Lanai, Maui, and the Big Island was issued for temporary mountain obscurement above 2,000 feet in clouds and showers. The mountain obscurement conditions were forecast to end over the islands of Lanai and Maui after 1100. An AIRMET for turbulence over the islands of Oahu, Molokai, Lanai, Maui, and Big Island was issued indicating temporary moderate turbulence was expected below 7,000 fee ## Aircraft - Registration: [N911FC](https://openairdocs.org/deregistered/N911FC-2004-04-02), registration cancelled 2004-04-02, S/N 17271940, built 1978 (OpenAirDocs) - Reported make and model: Cessna 172N - Registry model: [Cessna 172N](https://openairdocs.org/model/cessna-172n) (registry code 2072434) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17271940 - Airframe hours: 8763.5 - Engines: Lycoming O-320-H2AD 160 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Instructional, Part 91 - Registered owner: George's Aviation Services, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, January 19, 2003 - Departed: HNL, Honolulu, HI - Destination: OGG, Kahului, HI - Flight plan: VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 17; injuries: fatal; medical: class 3, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 33 total, 33 in this make and model ## Weather - Conditions: Instrument (IMC), Day - Wind: 40° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: 5,500 ft broken - Temperature: 73 °F, dew point 70 °F - Altimeter: 30.00 inHg - Observed at: MKK, 11 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 20030125001589A](https://openairdocs.org/incident/20030125001589A), Jan 25, 2003: Cessna 172N, Kaunakakai, HI, Destroyed, 1 fatal. (.19) On January 25, 2003, at 1222 hawaiian standard time, a single engine Cessna 172N airplane, N911FC, was destroyed when it impacted mountainous terrain… ## Docket (14 files) The files NTSB released with the investigation on February 5, 2004, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=56419. 7.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 319 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205020&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Witness Statement (item 2, .PDF, 26 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205021&FileExtension=.PDF&FileName=Witness%20Statement-Master.PDF - Weather Reports and Records (item 3, .PDF, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205022&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Weather Briefing, Flight Instructor (item 4, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205023&FileExtension=.PDF&FileName=Weather%20Briefing,%20Flight%20Instructor-Master.PDF - Weather Briefing, Student (item 5, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205024&FileExtension=.PDF&FileName=Weather%20Briefing,%20Student-Master.PDF - Radar Data (item 6, .PDF, 605 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205025&FileExtension=.PDF&FileName=Radar%20Data-Master.PDF - Audio Tapes (2) (item 7, .PDF, 8 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205026&FileExtension=.PDF&FileName=Audio%20Tapes%20(2)-Master.PDF - Toxicological Report (item 8, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205029&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 9, .PDF, 349 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205027&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 10, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40380823&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Engine and Airframe Maintenance Records (item 11, .PDF, 599 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205032&FileExtension=.PDF&FileName=Engine%20and%20Airframe%20Maintenance%20Records-Master.PDF - Instructor's Records (item 12, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205034&FileExtension=.PDF&FileName=Instructor%27s%20Records-Master.PDF - Rental Records (item 13, .PDF, 165 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205035&FileExtension=.PDF&FileName=Rental%20Records-Master.PDF - Pre-Solo Written Exam Excerpts (item 14, .PDF, 499 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205036&FileExtension=.PDF&FileName=Pre-Solo%20Written%20Exam%20Excerpts-Master.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.