WPR10LA022

NTSB accident investigation · Cessna 208B · Molokai, HI · October 15, 2009

Accident · No injuriesLimited investigationFinal report
Date
October 15, 2009, 07:45 local (17:45 UTC)
Place
Molokai, HI
Injuries
7 uninjured
Damage
Substantial damage
Phase of flight
Standing
Aircraft
N861MACessna 208B
Defining event
Standing-engine(s) shutdown: Miscellaneous/other
Weather
Visual (VMC) · Day
Status
Completed · report April 19, 2010
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
FAA FSDO
FAA report
20091015019549A
Case key
74923

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

The failure of the ramp agent to use a tail stand.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Parking/securing: tie-down/mooringAircraft › Aircraft handling/service · Incorrect use/operationCessna 208B: 1 caseAll aircraft: 33 cases
Action: lack of actionPersonnel issues › Action/decision · Ground crewCessna 208B: 3 casesAll aircraft: 792 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The director of operations reported that after the passengers were boarded, the flight crew noted a discrepancy in the load manifest and the pilot-in-command (PIC) exited the airplane. The PIC reported that the ramp agent was instructed to put the tail stand in place; however, the agent ignored the instructions and entered the airplane via the aft door with the passengers still on board. The airplane subsequently tilted downward and sustained a tail strike, which resulted in structural damage to a fuselage bulkhead.

Factual narrative

On October 15, 2009, at 0745 Hawaiian standard time, a Cessna 208B airplane, N861MA, sustained substantial damage when the airplane's tail impacted the ground during the passenger boarding process at the Molokai Airport, Kaunakakai, Hawaii. Mokulele Airlines operated the airplane under the provisions of Title 14 Code of Federal Regulations (CFR) Part 135, when the accident occurred. The captain, first officer and five passengers were not injured. Visual meteorological conditions prevailed at the time of the accident. In a written report submitted to the National Transportation Safety Board (NTSB), the director of operations reported that after the passengers were boarded, the second-in-command (SIC) pilot noted a discrepancy in the load manifest. The SIC communicated the error to the ramp agent who then opened the aft door and boarded the airplane with the passengers still on board. The airplane subsequently "tilted downward" and the tail struck the tarmac. In a written statement the pilot-in-command (PIC) reported that after discovering the error in the load manifest, the SIC instructed the ramp agent to put the tail stand in place. He reported that the ramp agent "ignored" the instructions and boarded the airplane through the aft door. The PIC reported that this occurred after he exited the airplane. Review of postaccident photos of the airplane revealed structural damage to an aft bulkhead (FS 427.88) and the tail tie down assembly. On October 21, 2009, a Major Repair and Alteration Form 337 was submitted to the Federal Aviation Administration detailing the repairs to the airplane.

Aircraft

Registration
N861MA
Reported as
Cessna 208B
Category
Airplane
Serial number
208B0825
Airframe hours
5,008
Engine
P&W PT6A SER, 675 horsepower, turbo prop
Damage
Substantial damage
Flight
Part 135
Operator
Mokulele Air Group Inc
Registered owner
Mokulele Air Group Inc
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · October 12, 2009 · 11 hours before
Departed
PHMK · Molokai Airport, HI
Destination
PHMK · Molokai Airport, HI
Flight plan
Unknown
Airport
PHMK · Molokai Airport

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
24
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Flight hours
1,275 total
Role
Co-pilot
Age
25
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Right
Flight hours
545 total

Weather

Conditions
Visual (VMC) · Day
Visibility
25 statute miles
Lowest ceiling
None

Docket · 6

The files NTSB released with the investigation on January 26, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.7 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N861MA · 1

Matched to the same aircraft by N-number and date.