LAX96FA103

NTSB accident investigation · Cessna 402B · Kamuela, HI · January 29, 1996

Accident · FatalField investigationFinal report
Date
January 29, 1996, 04:35 local (14:35 UTC)
Place
Kamuela, HI
Injuries
1 fatal, 2 serious
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N999CRCessna 402B
Weather
Visual (VMC) · Night/dark
Status
Completed · report April 29, 1997
Report
Approved by Office Director
FAA report
19960129001089A
Case key
29255

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

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Probable cause

failure of the copilot (pilot-rated cargo loader, who was flying the aircraft) to establish and maintain a positive rate of climb after taking off at night; and inadequate supervision by the pilot-in-command (PIC), by failing to ensure that proper altitude was obtained and maintained during the departure. Factors relating to the accident were: darkness; the lack of visual cues; and the resultant visual illusion, which the copilot failed to recognize during the night departure. Also, the lack of a restraint system (seat belt and/or shoulder harness) for the passenger was a possible related factor.

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 collision with terrain/waterTakeoff - initial climb
Light condition - dark nightFactor
Visual/aural perceptionFlightcrewFactor
Flight/nav instruments - other
Proper climb rate - not maintainedCopilot/second pilotCause
Visual illusionCopilot/second pilotFactor
Supervision - inadequatePilot in commandCause
Terrain condition - rising
Proper altitude - not obtained/maintainedPilot in commandCause
Seat belt - not availablePassengerFactor

Analysis

The aircraft departed at night from runway 4R on a flight to transport mail. The pilot-in-command (PIC) was in the left seat, a pilot-rated cargo loader was in the right seat, and another cargo loader was aboard the aircraft, but was not in a seat. During takeoff, the aircraft entered a turn and flew into gradually rising terrain. The initial impact point was about 15 feet higher than the runway elevation and about 0.3 miles abeam the departure end of the runway. Investigation revealed that the company allowed pilot-rated cargo loaders to fly the aircraft from the right seat during positioning and ferry flight segments (to build multiengine flight time) as part of their compensation. There was evidence that at the time of the accident, the aircraft was being piloted on this flight from the copilot's position. The right side of the instrument panel was equipped with only EGT gauges (no flight instruments on the copilot's side). There were cloud layers in the vicinity, no moon illumination, and no visible ground lighting in the direction of flight. No preimpact mechanical malfunction or failure was identified during the investigation. Except at the pilot and copilot positions, the airplane had no other seat and/or restraint system. The operator stated that the pilot was not authorized to carry company personnel or passengers without the required seating.

Factual narrative

History of flight

On January 29, 1996, at 0435 hours Hawaiian standard time, a Cessna 402B, N999CR, collided with gradually rising terrain while on takeoff from the Wiamea-Kohala Airport, Kamuela, Hawaii. The aircraft was destroyed. The certificated airline transport pilot sustained fatal injuries, and two onboard cargo loaders received serious injuries. The aircraft was being operated as a contract mail flight by Trans Executive Airlines of Hawaii under 14 CFR Part 135 when the accident occurred. The flight originated in Honolulu, Hawaii, at 0200. The flight departed Kamuela on the return leg of the flight at 0430. Visual meteorological conditions prevailed at the time and no flight plan had been filed.

A worker at the Waimea-Kohala airport reported that about 0530 on the morning of the accident he heard a knock on his door. When he opened the door he saw one of the cargo loaders (hereafter referred to as cargo loader No. 2) who told him that he had just been involved in an aircraft accident. The cargo loader told the worker that he heard a sound he did not recognize and the next thing he remembered was being outside the aircraft. He looked around, saw the airport beacon, and began walking toward it. He estimated that it took him between 45 minutes to 1 hour to reach the airport, which involved climbing over two fences.

One of the police officers who first responded to the scene told the Safety Board that the night was very dark with a clear sky and calm winds. From his vantage point at the accident site, he was unable to see any ground lights toward the south or east.

On the date of the accident police officers interviewed cargo loader No. 2, who had been in the cargo compartment. During the interview, he reportedly told officers that when they left Waimea his friend (cargo loader No. 1) was flying the aircraft, while the pilot acted as the copilot. He later told FAA inspectors who spoke with him on April 24, 1996, that he did not recall who was flying the aircraft. (The Hawaii Police Department report is appended to the report.)

After several attempts by the Safety Board and the Honolulu FSDO to contact cargo loader No. 1, on April 23, 1996, he responded to the FSDO inspector by letter, in which he admitted performing copilot duties, but denied flying the aircraft. According to FAA inspectors, he stated that he remembered something abnormal happened with one of the engines because it was sputtering. He said he looked at the engine gauges and they were not right.

Personnel information

The operator reported the pilot-in-command for the Part 135 flight was current and qualified in the aircraft with about 1,250 hours in the Cessna 402. He had previously flown this regularly scheduled mail flight to and from the airport. The operator stated that the pilot was not authorized to carry company personnel or passengers without required seating. He was, however, permitted to allow rated employees to fly the aircraft on Part 91 positioning and ferry segments. He explained that he did not pay the cargo loaders, but rather allowed them to build multiengine flight time on these flights as compensation.

Cargo loader No. 1 held a commercial pilot certificate, with multiengine and instrument ratings. A pilot's logbook found in the aircraft wreckage bore his name. A review of that logbook revealed that he had logged pilot-in-command time on 47 company flights from December 23, 1995, through January 22, 1996. The logbook also showed that 23 of those flights were flown over the same route as was being flown at the time of the accident.

Aircraft information

A review of the aircraft, engine, and propeller logbooks was conducted by the Safety Board, FAA airworthiness inspectors, and manufacturers' representatives. No discrepancies related to airworthiness were identified. (Extracts of aircraft maintenance records are appended to this report.)

The aircraft had been manufactured and delivered with auxiliary and winglocker fuel tanks in addition to the main fuel tip tanks. However, both the auxiliary and winglocker fuel tanks had been removed from the aircraft, resulting in a total fuel capacity of 102 gallons.

The aircraft was configured for an all cargo flight with seating limited to the pilot and copilot.

Wreckage and impact information

The aircraft crashed on open rolling terrain about .3 miles south of runway 04 at 19 degrees 59.55 minutes north latitude and 155 degrees 39.55 minutes west longitude. The first evidence of ground contact was east, abeam the departure end of runway 04. At this location, ground scars and debris identified as components from the right wing, were near a protruding 5-foot rock formation. The rock formation exhibited an impact mark about 1 foot from its top, which, at that point, was about 2,686 feet msl. The debris included portions of the right tip tank, including the fuel boost pump and the right outboard aileron hinge bracket. The initial ground scar and debris path were along a 148-degree bearing.

There was no evidence of subsequent ground contact for about 128 feet until a second ground scar was located. Sixteen perpendicular slash marks were noted along this scar, and measured on average about 24.25 inches apart. The second ground scar was along a 160-degree bearing.

The final ground scars were about .5 miles south of the airport and .7 miles from the initial impact point along a 264-degree bearing. The terrain at this point had risen to an elevation of about 2,711 feet msl. These ground scars were located on the ascending side of a grassy knoll. The initial portion of the scar revealed five additional perpendicular slashes, averaging about 26 inches between slashes. During the impact sequence the left engine and propeller separated from the left wing. The aircraft continued up and over its crest for an additional 207 feet. The aircraft came to rest on a 072-degree bearing. The relative bearing between the second and final ground scars was 218 degrees.

A ground speed was computed for the first three propeller slashes in the first series of 17 marks using 2,450 rpm. A similar computation was made for the first three propeller slashes in the last series of five marks also using 2,450 rpm. (The theoretical formula and the actual computations are appended to this report.)

An on-site examination was conducted by the Safety Board investigator in coordination with an FAA airworthiness inspector. The aircraft was later re-examined by representatives from the aircraft and engine manufacturers under the supervision of an FAA airworthiness inspector.

All flight control surfaces and load bearing structures were located between the initial point of impact and the final position of the aircraft. Control continuity was not established due to the extent of damage to the airframe, flight control surfaces, and the numerous breaks in the control cables, rods, cranks, and pulleys. No evidence was found of preimpact control binding or chaffing associated with any of the control linkages.

There was an approximate 90 percent empennage separation near FS 213. The nose section of the aircraft was crushed aft to about FS 167. Both wings exhibited leading edge damage as well as buckling, bending, and structural separation. There was impact damage on the top of the vertical stabilizer along with an aft and downward collapse of the forward cabin area. The horizontal stabilizer and elevators exhibited impact damage and were found separated from the empennage.

The landing gear was found in the up and locked position while the wing flaps were in the full up position. The flap motor showed five links extending from the top of the chain drive sprocket to a point where the chain transitions to a cable. The flap control handle and indicator also indicated less than the flaps full up position. The aircraft representative was able to quantify the preimpact

Aircraft

Registration
N999CR
Reported as
Cessna 402B
Category
Airplane
Serial number
402B0616
Airframe hours
19,764
Engine
Continental TISO-520-E, 300 horsepower, reciprocating
Damage
Destroyed
Flight
Part 135
Registered owner
Trans Executive Air Of Hawaii
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · January 22, 1996 · 49 hours before
Departed
MUE · HI
Destination
HNL · Honolulu, HI
Airport
MUE · Waimea-Kohala, runway 4R, 5,190 × 100 ft, asphalt

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
29
Certificates
Flight instructor, Airline transport
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
3,434 total · 1,250 in this make and model · 3,350 as pilot in command · 250 in the last 90 days · 72 in the last 30 days

Weather

Conditions
Visual (VMC) · Night/dark
Wind
310° at 4 knots
Visibility
10 statute miles
Lowest ceiling
9,000 ft broken
Temperature
68 °F, dew point 64 °F
Altimeter
29.00 inHg
Observed at
ITO, 44 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.