# NTSB LAX89FA307: Aero Commander 680FLP, N22LR, Kailua-Kona, HI, September 11, 1989 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: September 10, 1989, 15:18 local (Sep 11, 1989, 01:18 UTC) - Place: Kailua-Kona, HI - Location: 19.6452° N, 155.9979° W: Placed by OpenAirDocs: center of Kailua, HI, within about 6 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=19.6452&lon=-155.9979&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed, report September 5, 1991 - Report: Approved by Office Director - NTSB case key (mKey): 26249 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX89FA307 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/26249/pdf - Page: https://openairdocs.org/ntsb/LAX89FA307 ## Probable cause INADEQUATE MAINTENANCE, AND OPERATION BY THE PILOT WITH KNOWN DEFICIENCIES IN THE AIRCRAFT. FACTORS RELATED TO THE ACCIDENT WERE: EXCESSIVE WEAR IN BOTH ENGINES, IMPROPER USE OF POWERPLANT CONTROLS BY THE PILOT, SUBSEQUENT OVERTEMPERATURE/DETONATION IN BOTH ENGINES, IMPROPER EMERGENCY PROCEDURES BY THE PILOT (INCLUDING PREMATURE GEAR EXTENSION AND/OR FAILURE TO PROPERLY REDUCE DRAG ON THE AIRCRAFT AFTER LOSS OF ENGINE POWER), AND THE PILOT'S LACK OF EXPERIENCE IN MULTI-ENGINE AND THIS MAKE AND MODEL OF AIRCRAFT. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, takeoff - initial climb - 1 engine - engine assembly - worn (contributing factor) - fluid,oil - contamination - maintenance - inadequate, other maintenance personnel (cause) - operation with known deficiencies in equipment - performed, pilot in command (cause) - engine assembly - overtemperature (contributing factor) - engine assembly,piston - failure,total (contributing factor) - Loss of engine power(total) - mech failure/malf, maneuvering - turn to landing area (emergency) - all engines - precautionary landing - initiated, pilot in command - gear extension - premature, pilot in command (contributing factor) - powerplant controls - improper use of, pilot in command (contributing factor) - engine assembly,piston - overtemperature (contributing factor) - engine assembly,piston - failure,total (contributing factor) - Forced landing, maneuvering - turn to landing area (emergency) - emergency procedure - improper, pilot in command (contributing factor) - lack of total experience in type of aircraft, pilot in command (contributing factor) - In flight collision with terrain/water, landing - terrain condition - rough/uneven (contributing factor) ## Analysis AS THE ACFT WAS DEPG FM RWY 17, SMOKE WAS OBSERVED COMING FM THE RGT ENG. THE PLT CONFIRMED A LOSS OF PWR & MADE A RGT TURN BACK TOWARD THE RWY, THEN RPRTD HE HAD 'LOST BOTH ENGINES.' THE ACFT WAS EXTENSIVELY DMGD DURING A LNDG ON ROUGH, ROCKY TRRN ABT 1/4 MI SW OF THE RWY THRESHOLD. INVESTIGATION REVEALED THE ACFT HAD JUST CHANGED OWNERSHIP. DURING PRE- PURCHASE INSPN IN FLORIDA, METAL PARTICLES WERE FND IN THE OIL SCREENS OF BOTH ENGS. OIL WAS CHGD & FLUSHED, BUT METAL PARTICLES WERE FND AFTER ANOTHER ENG RUN. IN MAY 1989, THE RGT ENG WAS REPLACED WITH AN ENG FM ANOTHER ACFT. THE ACFT WAS FLOWN TO OAKLAND, CA, WHERE IT WAS PAINTED & NEW INTERIOR WAS INSTALLED. A LCL MECH NOTED METAL PARTICLES IN BOTH ENG OIL SCREENS & RCMNDD OIL ANALYSIS, BUT FERRYING PLT REFUSED. AFTER FLT TO HAWAII, NO OIL STAIN NOTED ON FUSELAGE BFRFLT ON 9/9/89. EXAM OF WRECKAGE REVEALED BOTH ENGS FAILED FM DETONATION. HVY OIL STREAKS FND BHND RGT ENG, SOME STREAKS OF OIL FND BHND LEFT ENG. RGT ENG CRANKSHAFT/ROD BRG SURFACE WAS 0.010' UNDER STANDARD, BUT ROD BRGS WERE STANDARD SIZE. ## Aircraft - Registration: [N22LR](https://openairdocs.org/deregistered/N22LR-2013-09-24), registration cancelled 2013-09-24, S/N 1503-18, built 1965 (OpenAirDocs) - Reported make and model: AERO COMMANDER 680FLP - Registry model: [Aero Commander 680FL P](https://openairdocs.org/model/aero-commander-680fl-p) (registry code 0141610) (OpenAirDocs) - Registry engine: [Lycoming IGSO-540-B1A](https://openairdocs.org/engine/lycoming-igso-540-b1a) (registry code 41535, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 1503-18 - Airframe hours: 4790 - Engines: LYCOMING IGSO-540-B1A 380 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Peter M. Maveal - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 2, 1988, 72 hours before - Departed: KOA - Destination: HNL, HONOLULU, HI - Flight plan: VFR - Airport: KOA, Keahole, runway 17, 6,500 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 30; private; airplane ratings: multi-engine land, single-engine land; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 203 total, 23 in this make and model, 148 as pilot in command, 34 in the last 90 days, 10 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 160° at 6 knots - Visibility: 15 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point -0 °F - Altimeter: 29.00 inHg - Observed at: KOA ## 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 19890910034089A](https://openairdocs.org/incident/19890910034089A), Sep 10, 1989: Gulstm 680FLP, Kailua-Kona, HI, Destroyed, 1 fatal. Smoke from right engine on climbout,lost both returning. Engines had 4790 hours since overhaul. Detonation damage. 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.