# NTSB LAX92MA184: Beech E18S, N342E, Mount Haleakala, HI, April 23, 1992 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 1 · Major · Final report - Date: April 22, 1992, 15:53 local (Apr 23, 1992, 01:53 UTC) - Place: Mount Haleakala, HI - Coordinates: 20.850532, -156.319412 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=20.8505&lon=-156.3194&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 9 fatal - Status: Completed, report May 26, 1994 - Report: Approved by Office Director - Investigation class: Class 1 - Safety recommendations: Yes - NTSB case key (mKey): 28315 - NTSB case page: https://www.ntsb.gov/investigations/Pages/LAX92MA184.aspx - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28315/pdf - Board report AAR9301 (PDF): https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR9301.pdf - Page: https://openairdocs.org/ntsb/LAX92MA184 ## Probable cause THE CAPTAIN'S DECISION TO CONTINUE VISUAL FLIGHT INTO INSTRUMENT METEOROLOGICAL CONDITIONS THAT OBSCURED RISING MOUNTAINOUS TERRAIN AND HIS FAILURE TO PROPERLY USE AVAILABLE NAVIGATIONAL INFORMATION TO REMAIN CLEAR OF THE ISLAND OF MAUI. CONTRIBUTING TO THE ACCIDENT WAS THE FAILURE OF SCENIC AIR TOURS TO CONDUCT SUBSTANTIVE PILOT PREEMPLOYMENT BACKGROUND SCREENING, AND THE FAILURE OF THE FEDERAL AVIATION ADMINISTRATION TO REQUIRE COMMERCIAL OPERATORS TO CONDUCT SUBSTANTIVE PILOT PREEMPLOYMENT SCREENING. (NTSB REPORT AAR-93/01) ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, cruise - weather condition - obscuration (contributing factor) - weather condition - fog (contributing factor) - vfr flight into imc - continued, pilot in command (cause) - flight/navigation instrument(s) - improper use of, pilot in command (cause) - supervision - inadequate, company/operator management (contributing factor) - insufficient standards/requirements, faa(organization) (contributing factor) - In flight collision with terrain/water, cruise - terrain condition - mountainous/hilly (contributing factor) ## Analysis DURING THE AIR TOUR FLT THE PLT HAD RADIOED HIS INTENTIONS TO FSS TO OVERFLY AN AREA ABOUT 5 MI SW OF THE ISLAND OF MAUI. APRX 10 MIN LATER THE AIRPLANE IMPACTED MOUNTAINOUS TERRAIN ON THE ISLAND. IMC PREVAILED AT THE TIME AND LOCATION OF THE ACCIDENT. THE PLT DID NOT POSSESS THE MINIMUM HOURS STIPULATED IN THE COMPANY OPS MANUAL TO QUALIFY AS A CAPTAIN. HE FALSIFIED THE EMPLOYMENT APPLICATION & RESUME. THE COMPANY DID NOT PURSUE SUBSTANTIVE PREEMPLOYMENT BACKGROUND CHECKS, NOR WERE THEY REQUIRED BY THE FAA TO DO SO. REGULATIONS ARE NEEDED FOR AIR TOUR OPERATORS THAT WILL ENABLE FAA INSPECTORS TO REQUIRE, RATHER THAN MERELY ENCOURAGE, OPERATORS TO ADHERE TO PROCEDURES THAT OFFER THE SAFETY IMPROVEMENTS OF SFAR 50-2 AND FAA HANDBOOK 8400.10 BULLETIN 92-01. ## Factual narrative History of the Flight On April 22, 1992, at about 1553 hours Hawaiian standard daylight time, a Beech E-18S, N342E, operated by Scenic Air Tours, Inc., as Scenic 22, collided with mountainous terrain on the Island of Maui, in the Haleakala National park, near Makawao, Hawaii. The airplane was destroyed by impact and a post impact fire. The certificated airline transport pilot and eight passengers received fatal injuries. The airplane was being operated as a scenic tour flight under the provisions of 14 CFR Part 135 when the accident occurred. The flight originated in Hilo, Hawaii, at 1512 hours for a return flight to Honolulu, Hawaii, as a completion of a tour that departed Honolulu at 0700 hours. Instrument meteorological conditions prevailed at the time and a VFR flight plan was filed. The operator reported the flight overdue at 1657 hours. The airplane wreckage was located at about 0630 hours, by search personnel on April 23, 1992, about one mile east of Magnetic Peak, near the summit of the Haleakala Crater. The accident location is in an area of volcanic boulders, on downsloping terrain on the south rim of the crater at about 9,660 feet, mean sea level. Scenic 22 was marketed as Tour No. 5, the "Volcano Special". After Departing Honolulu, the flight was planned to proceed eastbound along the north shore of the islands of Molokai, Maui, and Hawaii, landing at Hilo at about 0900 hours. On the accident date, the route of flight from Honolulu to Hilo for Scenic 22 differed from the planned route, as a landing in Maui was conducted to drop off a van driver employed by the company. Upon arrival in Hilo, passengers then deplaned to participate in local area ground tours of the island of Hawaii. The return flight was scheduled to depart Hilo, at about 1500 hours for the return flight to Honolulu, arriving at about 1630 hours. The operator reported that the normal return route of flight is a departure from Hilo; flight westbound along the north coast of Hawaii; upon reaching Upolu point, continued flight westbound on about a 294 degree magnetic heading to overfly Molokini Island, located between Maui and Kahoolawe Island; and returning to Honolulu on about a 290 degree magnetic heading. Upon completion of the flight to Honolulu, the pilot was scheduled to fly to Maui, pick up tourists, and return to Honolulu. A second Scenic tour flight number 23, landed at Hilo after the arrival of Scenic 22, with a tour, and the two pilots waited at the airport for the return of their passengers. The pilot of Scenic 23 reported that he departed about 1542 hours, placing it about 70 miles and 30 minutes behind Scenic 22. Scenic 23 reported that once airborne, at about 1550 hours, he contacted Scenic 22 on a company used radio frequency and asked the position of flight 22. In response, the pilot of flight 22 reported that he was..."37 DME off Upolu Point", then words to the affect of..."standby, checking Lanai." No other communications were received from Scenic 22. The pilot of Scenic 23 reported that his return flight to Honolulu was conducted initially at 2,000 feet MSL. He later climbed to 3,000 feet and finally 6,000 feet while crossing the Alenuihaha Channel. He reported that the cloud conditions in the area of Makena, Maui, were scattered, with the cloud tops at about 8,000 feet MSL. He could not see Mt. Haleakala due to haze that limited visibility in his area of flight to about 5 miles. The Federal Aviation Administration, Honolulu Flight Service Station (FSS) reported that the accident airplane departed Hilo at 1512 hours, and the pilot opened his VFR flight plan at about 1520 hours. The FSS specialist provided a full weather briefing, which included an advisory that VFR flight was not recommended over the interior sections of all islands, and a forecast for isolated areas of 3 miles visibility due to haze and moderate rain showers. At about 1542 hours, the pilot requested the status of restricted area R-3104, located over the island of Kahoolawe. The restricted area prohibits flights into the area if flight restrictions are in force. On the accident date, the airspace was restricted below 5,000 feet. The pilot stated to the FSS that he would transit the restricted area at 6,500 feet. The flight routing requested by the pilot was authorized for the next 30 minutes and would have placed the airplane on about a 287 degree magnetic heading. No other communications were received from flight 22. At about 1553 hours, the FSS monitored an emergency locator transmitter (ELT) signal, received through a remote sensor on Mt. Haleakala. The signal ceased at 1600 hours. An employee of the Pacific Tsunami Warning Center, located near the summit of Haleakala Crater, reported that a seismic sensor recorded a "local" seismic event at 1554 hours, with a duration of 20 seconds. No other seismic activity was recorded during the day. The accident occurred during the hours of daylight at latitude 20 degrees, 42.33 minutes north and longitude 156 degrees, 14.48 minutes west. Injuries to Persons Fatal Injuries to crew - 1 Fatal Injuries to passengers - 8 Total Fatal Injuries - 9 Crew Information The pilot, held an airline transport pilot certificate, that was issued on January 14, 1991, with an airplane multiengine land and instrument airplane ratings. He held commercial privileges for airplane single engine land. The most recent first class medical certificate was issued to the pilot on February 11, 1992 and contained no limitations. No personal flight records were located for the pilot and the aeronautical experience was obtained from a review of the airmen FAA records on file in the Airman and Medical Records Center located in Oklahoma City, pilot resumes, employment applications, and previous employer records. A Scenic Air Tours Inc., Pilot Experience Form, completed by the pilot on July 28, 1991, indicated that his total aeronautical experience consisted of 3,400 flight hours, of which 3,200 was pilot-in-command. The form listed multiengine experience that consisted of 1,450 hours; and instrument experience of 400 hours, of which 150 hours accrued in actual instrument conditions. Safety Board investigators conducted an examination of the pilot's employment history, and were able to document only 2,057 hours of total aeronautical experience, which included a total of 765 hours of multiengine experience. An inquiry with past employers revealed that the pilot had been employed by at least 9 employers, including two positions with Scenic, from 1988 to the accident date. Five of the previous employers dismissed the pilot. Causes for dismissal included misrepresentation of qualifications andexperience, failure to report to duty, disciplinary action, training performance, and work performance. In 1991, a scheduled FAR Part 135 operator rejected the pilot's application for a pilot position for failing to disclose information and misrepresentation concerning previous employment. An examination of that file also revealed that a fraudulent letter of recommendation had been submitted on stationary from the pilot's most recent employer. See Appendix A for details of the pilots aeronautical experience. The pilot's experience in the accident airplane make and model was accrued at Scenic, and totaled 464.7 hours. Reconstruction of the pilot's flight and duty time indicates the following: Duty time last 24 hours - 12 Duty time last 72 hours - 33 Duty time last 30 days - 125.5 Duty time last 60 days - 343 Duty time last 90 days - 464 Flight time last 24 hours - 4.5 Flight time last 72 hours - 10.5 Flight time last 30 days - 44.0 Flight time last 60 days - 108.8 Flight time last 90 days - 138.8 The pilot was initially employed with Scenic Air Tours in 1988 as a van driver. In July 1991, he was rehired as a pilot. The Director of Operations for Scenic reported that a pre-employment check of the ## Aircraft - Registration: [N342E](https://openairdocs.org/deregistered/N342E-2012-10-03), registration cancelled 2012-10-03, S/N BA-308, built 1957 (OpenAirDocs) - Reported make and model: BEECH E18S - Registry model: [Beech E18S](https://openairdocs.org/model/beech-e18s) (registry code 1151006) (OpenAirDocs) - Registry engine: [Pratt & Whitney R-985 series](https://openairdocs.org/engine/pratt-whitney-r-985-series) (registry code 52008, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: BA-308 - Airframe hours: 15925 - Engines: P&W R-985 450 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Part 135 - Registered owner: Tomy International, Inc. - Airworthiness certificate: Standard, Utility; Standard, Normal - Last inspection: 100 hour, March 29, 1992, 49 hours before - Departed: ITO, HILO, HI - Destination: HNL, HONOLULU, HI - Flight plan: VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 26; airline transport, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 2,100 total, 465 in this make and model ## Weather - Conditions: Instrument (IMC), Day - Wind: 180° at 15 knots - Visibility: 0.1 statute miles - Temperature: 50 °F ## 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 19920422018939A](https://openairdocs.org/incident/19920422018939A), Apr 22, 1992: Beech E18S, Maui, HI, Destroyed, 9 fatal. Continued VFR into IMC off course and into area of volcanic mountain. Indicates stalled during abrupt avoidence. ## Other investigations on N342E (2) 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. - [NTSB LAX76IL077](https://openairdocs.org/ntsb/LAX76IL077), May 26, 1976: Beech E18S (N342E), San Diego, CA, incident, minor damage - [NTSB LAX76F0015](https://openairdocs.org/ntsb/LAX76F0015), Feb 20, 1976: Beech E18S (N342E), Bahia De L.A., Mexico, substantial 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.