LAX04FA113

The airplane collided with trees and mountainous terrain at the 3,600-foot-level of Mauna Kea Volcano during an en route cruise descent toward the destination airport that was 21 miles east of the accident site. The flight departed Honolulu VFR at 0032 to pickup a patient in Hilo, on the Island of Hawaii. The inter island cruising altitude was 9,500 feet and the flight was obtaining VFR flight advisories. At 0113, just before the flight crossed the northwestern coast of Hawaii, the controller provided the pilot with the current Hilo weather, which was reporting a visibility of 1 3/4 miles in heavy rain and mist with ceiling 1,700 feet broken, 2,300 overcast. Recorded radar data showed that the flight crossed the coast of Hawaii at 0122, descending through 7,400 feet tracking southeast bound toward the northern slopes of Mauna Kea and Hilo beyond. The last recorded position of the aircraft was about 26 miles northwest of the accident site at a mode C reported altitude of 6,400 feet. At 0130, the controller informed the pilot that radar contact was lost and also said that at the airplane's altitude, radar coverage would not be available inbound to Hilo. The controller terminated radar services. A witness who lived in the immediate area of the accident site reported that around 0130 he heard a low-flying airplane coming from the north. He walked outside his residence and observed an airplane fly over about 500 feet above ground level (agl) traveling in the direction of the accident site about 3 miles east. The witness said that light rain was falling and he could see a half moon, which he thought provided fair illumination. The area forecast in effect at the time of the flight's departure called for broken to overcast layers from 1,000 to 2,000 feet, with merging layers to 30,000 feet and isolated cumulonimbus clouds with tops to 40,000 feet. It also indicated that the visibility could temporarily go below 3 statute miles. The debris path extended about 500 feet along a magnetic bearing of 100 degrees with debris scattered both on the ground and in tree branches. Investigators found no anomalies with the airplane or engines that would have precluded normal operation. Pilots for the operator typically departed under VFR, even in night conditions or with expectations of encountering adverse weather, to preclude ground holding delays. The pilots would then pickup their instrument flight rules (IFR) clearance en route. The forecast and actual weather conditions at Hilo were below the minimums specified in the company Operations Manual for VFR operations.

History of flight

On January 31, 2004, about 0140 Hawaiian standard time, a Cessna 414A, N5637C, collided with trees and mountainous terrain during an en route cruise descent near Laupahoehoe, Hawaii. Hawaii Air Ambulance was operating the airplane as a cross-country positioning flight under the provisions of 14 CFR Part 91. The airline transport pilot and two passengers sustained fatal injuries; the airplane was destroyed. The flight departed Honolulu, Hawaii, at 0032, en route to Hilo, Hawaii, to pickup a patient. A combination of visual and instrument meteorological conditions prevailed along the route of flight, and a visual flight rules (VFR) flight plan had been filed. The primary wreckage was at 19 degrees 57.366 minutes north latitude and 155 degrees 19.841 minutes west longitude at an estimated elevation of 3,600 feet.

The National Transportation Safety Board investigator-in-charge (IIC) reviewed a transcript of radio communications between the pilot and air traffic control (ATC).

At 0019, the pilot filed a canned flight plan (number forty-eight tango) indicating a proposed departure time of 0030, with three people on board for the outbound leg, and five on board for the return. ATC provided a clearance during taxi of the shoreline departure to 15,500 feet. ATC cleared him for takeoff at 0031:55. At 0040:47, the pilot checked in with Honolulu Center passing 6,400 feet and stated an intended altitude of 9,500 feet en route to Hilo.

At 0113, the controller provided the pilot with the current Hilo weather. The controller asked him if he was going to Kamuela or Hilo. The pilot responded that he was going to try to go to Hilo. The pilot asked if anyone coming out of Hilo had reported lightening; the controller responded no, but he had just come on duty. At 0130, the controller informed the pilot that he lost radar contact 3 miles east of Kamuela VOR (very high frequency omni-directional radio range). The controller also pointed out that at the airplane's altitude, he would probably not be able to pickup the airplane inbound to Hilo. The controller terminated radar services, and instructed the pilot to change to advisory frequency. The pilot acknowledged the transmission.

The IIC reviewed recorded radar data, and noted that the airplane crossed the island of Hawaii coastline north of Mahukona (near Upolu Point) at a mode C reported altitude of 7,400 feet and flying in an east-southeast direction. The mode C altitude reports showed the aircraft descending, and at the time radar contact was lost, the mode C report showed the airplane at an altitude of 6,400 feet.

The Civil Air Patrol located the wreckage on Monday, February 2. They detected a weak emergency locator transmitter signal and guided ground personnel to the wreckage.

Safety Board software computed that Hilo was 21 miles at 117 degrees magnetic from the accident site.

Personnel information

A review of Federal Aviation Administration (FAA) airman records revealed that the pilot held an airline transport pilot certificate with a rating for airplane multiengine land, and a commercial pilot certificate with a rating for airplane single engine land. The pilot held a certified flight instructor (CFI) certificate with ratings for airplane single engine land, multiengine land, and instrument airplane.

The pilot held a first-class medical certificate issued on April 26, 2003. It had no limitations or waivers.

The operator reported that the pilot had a total flight time of 8,230 hours. He logged 110 hours in the last 90 days, and 30 in the last 30 days. He had 1,037 hours in this make and model. He completed a biennial flight review on December 30, 2003. His last flight check occurred on December 30, 2003, in a Cessna 414A. It included instrument procedures, holding, an instrument localizer system (ILS) approach, a nonprecision approach, a VOR approach, and a missed approach. He scored satisfactory on all phases of the flight, as he had on previous check flights.

The pilot was on the 4th day of a 4-day shift. His shift began at 2200 and was scheduled to end at 0600. He would have then had 2 days off, and rotate to the morning shift for 4 days. Following the 4-day morning rotation, he was going to go on vacation.

The director of operations (DOO) described the pilot's abilities as average for a pilot with that amount of flight time. There was no obvious change in the pilot's attitude the day prior to the accident.

Emergency Medical Technicians (EMTs) who had flown with the pilot reported that they were very confident in the pilot's flying abilities. EMTs who had flown with him the night prior to the accident reported that they did not notice any problems with the pilot and he did not report any.

Aircraft information

The airplane was a Cessna 414A, serial number 414A0118. The operator reported a total airframe time of 11,899 hours at the last scheduled maintenance on an approved inspection program. This inspection occurred on January 16, 2004. The airplane had flown 39 hours since that inspection. The previous flight ended at a Hobbs hour meter reading 845.1.

The left engine was a Teledyne Continental Motors (TCM) TSIO-520-NB, serial number 521067. Total time on the engine was 412 hours.

The right engine was a TCM TSIO-520JC-NB, serial number 514071. Total time on the engine at the last inspection was 1,539 hours.

Air Service Corporation (HNL) refueled the airplane with 700 to 800 pounds of fuel prior to departure.

Meteorological information

The director of operations said that pilots obtained their weather information prior to flight through DUATS (direct user access terminal system) at the company office.

A staff meteorologist provided weather data. There was a band of echoes over the southeastern section of the island that impacted Hilo with echoes in the VIP (Video and Integrator Processor) level 2. FAA Advisory Circular AC 00-24B titled "Thunderstorms" dated January 2, 1983, defines the echo intensity levels and potential weather phenomena associated with those levels. If the maximum VIP levels are 1 "weak" and 2 "moderate," then light to moderate turbulence is possible with lightning.

The Aeronautical Information Manual (AIM) also references these levels in the Pilot/Controller Glossary under radar weather echo intensity levels.

In-Flight Weather Advisories

The National Weather Service issues in-flight weather advisories designated as Severe Weather Forecast Alerts (AWW's), Convective SIGMET's (WST's), SIGMET's (WS's), Center Weather Advisories (CWA's), and AIRMET's (WA's). In-flight advisories serve to notify en route pilots of the possibility of encountering hazardous flying conditions, which may not have been forecast at the time of the preflight briefing. Whether or not the condition described is potentially hazardous to a particular flight is for the pilot to evaluate on the basis of experience and the operational limits of the aircraft.

AIRMET Tango was in effect for over and immediately south through west of the mountains on all islands. It indicated temporary changing conditions of moderate turbulence below 10,000 feet, and that the conditions would continue beyond 0600.

The area forecast for the eastern half of the big island and adjacent waters issued at 2340 and valid until 1200 called for broken to overcast layers from 1,000 to 2,000 feet. It indicated merging layers to 30,000 feet with isolated cumulonimbus clouds with tops to 40,000 feet. It also indicated that the visibility could temporarily go below 3 statute miles.

The Terminal Aerodrome Forecast issued at 1930 was valid beginning at 2000. It predicted variable winds at 5 knots; visibility greater than 6 miles; and clouds scattered at 1,500 feet to overcast at 3,000 feet.

The closest official weather observation station was Hilo (PHTO). The elevation of the weather observation station was 38 feet