# NTSB WPR10LA022: Cessna 208B, N861MA, Molokai, HI, October 15, 2009 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: October 15, 2009, 07:45 local (17:45 UTC) - Place: Molokai, HI - Coordinates: 21.152778, -157.096115 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=21.1528&lon=-157.0961&mi=10 - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Defining event: [Standing-engine(s) shutdown: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) - Highest injury: No injuries - Injuries: 7 uninjured - Status: Completed, report April 19, 2010 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: FAA FSDO - NTSB case key (mKey): 74923 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR10LA022 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/74923/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=74923 - Page: https://openairdocs.org/ntsb/WPR10LA022 ## Probable cause The failure of the ramp agent to use a tail stand. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Parking/securing: tie-down/mooring](https://openairdocs.org/ntsb-findings/01011020): Aircraft › Aircraft handling/service · Incorrect use/operation; cases with it: [Cessna 208B, 1 case](https://openairdocs.org/ntsb-findings/01011020/cases.md?model=2073701), [All aircraft, 33 cases](https://openairdocs.org/ntsb-findings/01011020/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Ground crew (probable cause); cases with it: [Cessna 208B, 3 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=2073701), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Standing-engine(s) shutdown: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) (defining event); cases with it: [Cessna 208B, 5 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=2073701), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) ## 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](https://openairdocs.org/aircraft/N861MA), registered now, S/N 208B0825, built 2000 (OpenAirDocs) - Reported make and model: CESSNA 208B - Registry model: [Cessna 208B](https://openairdocs.org/model/cessna-208b) (registry code 2073701) (OpenAirDocs) - Registry engine: [Pratt & Whitney PT6A series](https://openairdocs.org/engine/pratt-whitney-pt6a-series) (registry code 52032, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 208B0825 - Airframe hours: 5008 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 24; injuries: none; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; flight hours: 1,275 total - Co-pilot; age 25; injuries: none; 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 ## 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 20091015019549A](https://openairdocs.org/incident/20091015019549A), Oct 15, 2009: Cessna 208B, Kaunakakai, HI, Substantial damage. Aircraft N861MA sustained damage to the tail skid and fuselage aft bulkhead due to the aircraft falling on the tail while parked on the Molokai Airport ramp… ## Other investigations on N861MA (1) 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 WPR14FA024](https://openairdocs.org/ntsb/WPR14FA024), Oct 22, 2013: Cessna 208 (N861MA), Wailea, HI, substantial damage. Probable cause: Improper maintenance that resulted in contamination of the engine's compressor turbine disc and blade assembly by glass bead remnants, which resulted in a blade failure. ## Docket (6 files) The files NTSB released with the investigation on January 26, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=74923. 1.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 222 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324431&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Crew Statements (item 2, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324432&FileExtension=.PDF&FileName=Crew%20Statements-Redacted.PDF - FAA Form 337 861MA (item 3, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324433&FileExtension=.PDF&FileName=FAA%20Form%20337%20861MA-Redacted.PDF - Image 1. Bulkhead damage (item 4, .PDF, 72 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324434&FileExtension=.PDF&FileName=Image%201.%20Bulkhead%20damage-Master.PDF - Image 2. Bulkhead damage (item 5, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324435&FileExtension=.PDF&FileName=Image%202.%20Bulkhead%20damage-Master.PDF - Image 3. Bulkhead damage (item 6, .PDF, 70 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324436&FileExtension=.PDF&FileName=Image%203.%20Bulkhead%20damage-Master.PDF 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.