LAX04FA190

NTSB accident investigation · Piper PA 28-161 · Holoaloa, HI · April 19, 2004

Accident · Serious injuriesField investigationFinal report
Date
April 18, 2004, 16:45 local (Apr 19, 2004, 02:45 UTC)
Place
Holoaloa, HI
Injuries
3 serious
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N8198APiper PA 28-161
Weather
Instrument (IMC) · Day
Status
Completed · report February 28, 2006
Report
Approved by Office Director
Parties
New Piper Aircraft Company, Lycoming, FAA Headquarters, AAI-100
FAA report
20040418017689A
Case key
59092

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot's continued flight into adverse weather conditions that resulted in an in-flight collision with mountainous terrain. Factors in the accident were rising terrain, low clouds and rain, and the pilot's lack of familiarity with the geographic area.

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 encounter with weatherCruise
Lack of familiarity with geographic areaPilot in commandFactor
Weather condition - clouds
Flight into adverse weather - continuedPilot in commandCause
In flight collision with terrain/waterManeuvering
Terrain condition - mountainous/hillyFactor
Terrain condition - risingFactor

Analysis

During a for hire sightseeing tour flight, the airplane impacted rising mountainous volcanic terrain following the pilot's encounter with deteriorating weather. The pilot had been employed by the operator for 11 days prior to the accident and this flight was the pilot's first 14 CFR Part 135 revenue tour flight. Two pilots were interviewed who had flown the route shortly before the accident flight. They both reported encountering low visibility and light rain in the area of the accident. They conducted their flights along the shoreline to avoid the weather conditions. After departure, the pilot was flying south along a highway between the mountains and the coast. The passengers said that within 10 minutes of takeoff, they began to encounter weather conditions that would "get bad, clear up, and get bad again." Both passengers believed the pilot was trying to get out of the clouds. The passengers stated that they were in the clouds and then suddenly they could see the mountain in front of them and the airplane hit the ground. The pilot stated that the airplane remained clear of the clouds, but encountered a severe downdraft and turbulence that she was maneuvering to get out of when the airplane hit the mountain. A review of the weather reports, forecasts, and satellite data for the area of the accident was conducted. Clouds covered the accident site. Upper air data analysis showed the potential for mountain wave activity with maximum vertical velocities of 100 feet per minute. An AIRMET was valid for the time and location of the accident and called for potential moderate turbulence below 6,000 feet. No evidence of preimpact mechanical malfunction or failure was found during an examination of the wreckage.

Factual narrative

1.1 History of flight

On April 18, 2004, about 1645 Hawaiian standard time, a Piper, PA 28-161, N8198A, impacted rising terrain near Holoaloa, Hawaii. Above It All, Inc., d.b.a. Island Hoppers, was operating the airplane under the provisions of 14 CFR Part 135. The commercial pilot and two passengers sustained serious injuries; the airplane was destroyed. The on demand cross-country tour flight departed Kona International Airport (KOA), Kailua/Kona, Hawaii, at 1620 to conduct a 2-hour tour of the volcanos and return to KOA. Visual meteorological conditions prevailed, and a visual flight rules (VFR) flight plan had been filed. The primary wreckage was at 19 degrees 12.318 minutes north latitude and 155 degrees 48.777 minutes west longitude.

At 1646, the pilot made a cellular 911 telephone call and reported that she had crashed about 10 miles south of Milolii, Hawaii. The County of Hawaii Fire Department dispatched a helicopter and fire crews to the area and attempted to locate the accident site. Due to the inaccurate location, the reduced visibility because of low clouds and rain showers in the area, the failure of the Emergency Locating Transmitter (ELT) to activate, and the loss of daylight, they were unable to immediately locate the accident site. The U.S. Coast Guard responded. With the use of a helicopter and night vision equipment, the accident site was located at about 2200. The passengers and pilot were removed from the accident site by use of the helicopter's hoist system. The actual accident site was located 6 miles northeast of Milolii.

The pilot and passengers all received serious burns from the post impact fire.

During the transportation to the hospital, the pilot stated she encountered a downdraft. She did not report any mechanical failures or malfunctions with the airplane prior to the accident.

The operator submitted a written report.

1.1.1 Passengers' Statements

The National Transportation Safety Board investigator-in-charge (IIC) interviewed the two passengers on May 21, 2004, and May 22, 2004. They related the following:

The two passengers arrived at Island Hoppers for a tour of the Big Island. It was sunny at KOA. They met the pilot and saw her "check out the airplane." When they made a comment about the pilot's young age, a representative from Island Hoppers indicated that she had been flying for "a number of years." After the passengers boarded the airplane, the pilot briefed them on the location of the fire extinguisher and use of the door exit handle, and helped them buckle their seat belts.

The flight departed at 1430. The pilot provided tour information along the way. Within 10 minutes of takeoff, they began to encounter weather, specifically the weather would "get bad, clear up, and get bad again." According to the female passenger who was seated in the right rear, it was rainy and foggy, but the flight was not bumpy or turbulent. She could not see the hillsides or the ground but could see the ocean at times. The pilot advised them that the sun would probably be shining on the other side of the mountain. After a discussion about the weather, the pilot became quiet, no longer providing tour information. The male passenger who was seated in the right front opined that he did not believe the pilot was familiar with the aircraft or the area by the way she handled the tour.

According to the male passenger, they were in the clouds and then could see the mountain in front of them. According to the female passenger, the pilot was maneuvering the airplane. She thought the pilot was trying to get out of the weather. The pilot was trying to climb, but "there was too much hill there." The pilot stated something to the effect of "I'm too low. It won't climb. I can't get it to go up. Oh my God, we're going to hit. I'm so sorry." They were not in the weather for long when they flew over some trees and then hit the ground. The male passenger hit his head on the instrument panel during the impact sequence. According to the female passenger, the airplane seemed to hit very slow.

The airplane began to burn as soon as it impacted the terrain. The pilot helped the male passenger unbuckle his seat belt. The male passenger helped the pilot and the female passenger exit the airplane. They ran about 40 feet and took refuge in a lava gap. The aircraft made a loud "boom" noise.

It was raining on and off from the time they hit the ground until they were rescued. It was still early in the day when they crashed, but it was dark from the clouds.

The pilot used the passenger's cellular telephone to call 911 emergency response personnel. The 911 personnel kept asking the pilot where they were, and she kept saying, "I don't know; you have to find us." Once the airplane stopped burning, they crawled back into the airplane shell to get out of the wind and rain. The pilot left to get help. The male passenger continued talking to 911 personnel.

The passengers heard the rescue helicopter fly by on two occasions. The third time, the male passenger crawled out on the wing of the airplane and waived something in the air to get the helicopter's attention. The Coast Guard helicopter located the wreckage and picked up the passengers and the pilot. Approximately 6 hours had elapsed from the time of impact until they were rescued.

1.1.2 Pilot's Statement

A Safety Board investigator interviewed the pilot on June 10, 2004. The pilot reported the following:

The pilot awoke at 0600 on the date of the accident. She did not have a flight scheduled until late in the afternoon but went to Island Hoppers at 0900 in an attempt to fly with someone else. Another pilot agreed she could fly with him. They conducted a preflight inspection shortly before 1100. The 1100 flight was a tour in a Cessna 207, which would circle the island. The flight ended around 1300.

Upon return, the pilot checked the weight and balance information for her upcoming flight, checked the weather, and filed a flight plan. According to the weather briefing, "heavy rain was reported in Hilo, and the wind was blowing between 12 and 15 knots." There was no other significant weather reported at the time.

The passengers arrived and spoke with the pilot while they waited for the flight airplane to arrive back. When the plane arrived, the pilot's boss fueled the airplane, while the pilot conducted the preflight inspection. She provided the passengers with a preflight safety briefing and briefed the passengers on their route of flight.

A few minutes after 1600, the flight departed. The pilot called the flight service station to open her flight plan. She received a weather update, but it only pertained to the Hilo side of the island. According to the pilot, the flight was "perfect." She had a sectional map in her kneeboard and another map with the reporting points and points of interest depicted. She had gone around the island 11 times previously.

As the flight neared Milolii, the pilot initiated a climb to 3,500 feet and followed the highway (with the airplane to the left of the highway to allow viewing by the rear passenger). At this point, everything was fine. There was rain on the coast, which she could see through, and clouds near the mountain. The flight remained in visual flight rules (VFR) conditions over the highway.

The pilot said that shortly after passing Milolii, she "could feel a strong downdraft" and noticed the vertical speed indicator (VSI) needle depicting a more than 1,000 feet/minute descent rate. The airplane was then "blown toward the mountain" very fast, and the pilot said she was "fighting to stay straight and level." She stated that she could not turn left due to a tailwind. She turned right, facing into the wind, and added full power. The airplane then slowed and she reported the "headwind was very powerful." While turning the airplane, the pil

Aircraft

Registration
N8198A
Reported as
Piper PA 28-161
Category
Airplane
Serial number
28-8216144
Airframe hours
9,379.7
Engine
Lycoming O-320-D3G, 160 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Part 135
Registered owner
Above It All Inc.
Airworthiness certificate
Standard, Normal; Standard, Utility
Last inspection
100 hour · March 1, 2004 · 42 hours before
Departed
KOA · Kailua/Kona, HI
Destination
KOA · Kailua/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
35
Injuries
Serious
Certificates
Commercial, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
April 1, 2004
Seat
Left
Flight hours
1,254 total · 50 in this make and model · 1,000 as pilot in command · 53 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
110° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
82 °F, dew point 64 °F
Altimeter
30.03 inHg
Observed at
KOA, 35 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.