WPR19MA177

NTSB accident investigation · Beech 65-A90 · Mokuleia, HI · June 22, 2019

Accident · FatalClass 2 · MajorFinal report
Date
June 21, 2019, 18:22 local (Jun 22, 2019, 04:22 UTC)
Place
Mokuleia, HI
Injuries
11 fatal
Damage
Destroyed
Phase of flight
Takeoff
Aircraft
N256TABeech 65-A90
Defining event
Takeoff: Abrupt maneuver
Weather
Visual (VMC) · Day
Status
Completed · report March 23, 2021
Report
Board-adopted at Board Meeting · Board meeting March 23, 2021
Investigation class
Class 2
NTSB office
Western Pacific Region
Parties
Hartzell Propeller, Textron Aviation, Transportation Safety Board of Canada, Federal Aviation Administration AVP-100
Safety recommendations
Yes
FAA report
20190622020029A
Case key
99686

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

On this page

Probable cause

The pilot’s aggressive takeoff maneuver, which resulted in an accelerated stall and subsequent loss of control at an altitude that was too low for recovery. Contributing to the accident were (1) the operation of the airplane near its aft center of gravity limit and the pilot’s lack of training and experience with the handling qualities of the airplane in this flight regime; (2) the failure of Oahu Parachute Center and its contract mechanic to maintain the airplane in an airworthy condition and to detect and repair the airplane’s twisted left wing, which reduced the airplane’s stall margin; and (3) the Federal Aviation Administration’s (FAA) insufficient regulatory framework for overseeing parachute jump operations. Contributing to the pilot’s training deficiencies was the FAA’s lack of awareness that the pilot’s flight instructor was providing substandard training.

Findings · 19

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.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotBeech 65-A90: 2 casesAll aircraft: 9,295 casesProbable cause
Training: type/qual of instruct/trainingPersonnel issues › Experience/knowledge · PilotBeech 65-A90: 1 caseAll aircraft: 8 casesProbable cause
Personality/attitude: self confidencePersonnel issues › Psychological · PilotBeech 65-A90: 1 caseAll aircraft: 16 casesProbable cause
Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Capability exceededBeech 65-A90: 2 casesAll aircraft: 990 casesProbable cause
Aircraft capability: cG/weight distributionAircraft › Aircraft oper/perf/capability · Capability exceededBeech 65-A90: 2 casesAll aircraft: 66 casesProbable cause
Wing structure: main frame (on wing)Aircraft › Aircraft structures · Damaged/degradedBeech 65-A90: 1 caseAll aircraft: 8 casesProbable cause
Maintenance/inspectionsAircraft › Aircraft handling/service · Inadequate inspectionBeech 65-A90: 1 caseAll aircraft: 103 casesProbable cause
Maintenance/inspectionsAircraft › Aircraft handling/service · Incorrect service/maintenanceBeech 65-A90: 1 caseAll aircraft: 103 casesProbable cause
Oversight: oversight of operationOrganizational issues › Support/oversight/monitoring · FAA/RegulatorBeech 65-A90: 1 caseAll aircraft: 61 casesProbable cause
Oversight: oversight of maintenanceOrganizational issues › Support/oversight/monitoring · FAA/RegulatorBeech 65-A90: 1 caseAll aircraft: 28 casesProbable cause
Training: initial trainingOrganizational issues › Support/oversight/monitoring · FAA/RegulatorBeech 65-A90: 1 caseAll aircraft: 15 casesProbable cause
Inspection: scheduled/routine inspectionPersonnel issues › Task performance · Maintenance personnelBeech 65-A90: 1 caseAll aircraft: 167 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelBeech 65-A90: 1 caseAll aircraft: 320 casesProbable cause
Culture: safetyOrganizational issues › Management · OperatorBeech 65-A90: 1 caseAll aircraft: 11 cases
Maintenance/inspectionsAircraft › Aircraft handling/service · Related recordsBeech 65-A90: 1 caseAll aircraft: 103 cases
Personality/attitudePersonnel issues › Psychological · Instructor/check pilotBeech 65-A90: 1 caseAll aircraft: 3 cases

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

Analysis pending

Factual narrative

Factual Pending

Aircraft

Registration
N256TA
Reported as
Beech 65-A90
Category
Airplane
Serial number
LJ-256
Built
1967
Engines
Pratt & Whitney Canada PT6 Series, turbo propPratt & Whitney Canada PT6 Series, turbo prop
Damage
Destroyed
Fire
On-Ground
Flight
Skydiving · Part 91
Operator
Oahu Parachute Center
Airworthiness certificate
Standard, Normal
Departed
HDH · Mokuleia, HI
Airport
HDH · Dillingham Airfield, runway 08, 9,007 × 75 ft, asphalt
Equipment
None

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
42
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
December 13, 2017
Seat
Left
Restraint
Lap only
Toxicology
Performed
Flight hours
1,086 total · 214 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
180° at 6 knots
Visibility
10 statute miles
Lowest ceiling
6,000 ft broken
Temperature
75 °F, dew point 70 °F
Altimeter
29.93 inHg
Observed at
PHHI, 10 nm away

Docket · 43

The files NTSB released with the investigation on October 28, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 202 MB in all.

Medical factual reportItem 1 · PDF · 5 pages · 229 KBMedical factual report addendum 1Item 2 · PDF · 2 pages · 208 KBOperations group chairman's factual reportItem 3 · PDF · 61 pages · 9 photos · 3.9 MBOperations attachment 1 - interview summariesItem 4 · PDF · 19 pages · 444 KBOperations attachment 2 - records of conversationItem 5 · PDF · 27 pages · 1.2 MBOperations attachment 3 - pilot informationItem 6 · PDF · 23 pages · 854 KBOperations attachment 4 - pilot's opc training recordItem 7 · PDF · 2 pages · 920 KBOperations attachment 5 - NTSB letter and subpoena to pilota��s instructorItem 8 · PDF · 6 pages · 219 KBOperations attachment 6 - pilot logbookItem 9 · PDF · 39 pages · 76 photos · 103 MBOperations attachment 7 - advisory circular 105-2EItem 10 · PDF · 32 pages · 870 KBOperations attachment 8 - N256TA FAA recordsItem 11 · PDF · 29 pages · 26.5 MBOperations attachment 9 - N256TA lease and insuranceItem 12 · PDF · 13 pages · 949 KBOperations attachment 10 - Beech A90 door-removed proceduresItem 13 · PDF · 3 pages · 238 KBOperations attachment 11 - weight and balanceItem 14 · PDF · 5 pages · 4 photos · 2.6 MBOperations attachment 12 - dillingham airfield FAA informationItem 15 · PDF · 2 pages · 318 KBOperations attachment 13 - previous flight witness statementsItem 16 · PDF · 11 pages · 1 photo · 310 KBOperations attachment 14 - Hawaii dot documentsItem 17 · PDF · 22 pages · 3.0 MBOperations attachment 15 - fsaw bulletin 93-09Item 18 · PDF · 3 pages · 104 KBOperations attachment 16 - Beech A90 normal proceduresItem 19 · PDF · 8 pages · 716 KBOperations attachment 17 - Beech A90 emergency proceduresItem 20 · PDF · 9 pages · 779 KBOperations attachment 18 - Beech A90 engine limitationsItem 21 · PDF · 2 pages · 176 KBOperations attachment 19 - Beech A90 stall speedsItem 22 · PDF · 2 pages · 316 KBOperations attachment 20 - FAA surveillance of sport parachute activitiesItem 23 · PDF · 8 pages · 221 KBOperations attachment 21 - evidence control formsItem 24 · PDF · 2 pages · 161 KBOperations attachment 22 - opc Hawaii recordsItem 25 · PDF · 5 pages · 271 KBOperations attachment 23 - flying for skydive operations - p- 8740-62Item 26 · PDF · 7 pages · 140 KBOperations attachment 24 - FAA legal interpretationsItem 27 · PDF · 4 pages · 472 KBOperations addendum 1 - instructor recordsItem 28 · PDF · 18 pages · 4.2 MBOperations addendum 2 - FAA CFI pass_fail statisticsItem 29 · PDF · 3 pages · 100 KBElectronic devices - specialist's factual reportItem 30 · PDF · 5 pages · 8 photos · 1.3 MBElectronic devices - attachment 1 (suny SD card analysis)Item 31 · PDF · 34 pages · 34 photos · 4.5 MBMaintenance records factual reportItem 32 · PDF · 82 pages · 492 KBPowerplants group chairman's factual reportItem 33 · PDF · 88 pages · 124 photos · 6.5 MBSystems and structures group chairman's factual reportItem 34 · PDF · 82 pages · 99 photos · 18.1 MBSystems and structures group chairman's factual report - errata 1Item 35 · PDF · 2 pages · 103 KBSystems and structures group chairman's factual report - addendum 1Item 36 · PDF · 2 pages · 1 photo · 471 KBNTSB - adopted board report - safety recommendation report ASR-20-06Item 37 · PDF · 5 pages · 253 KBAirplane performance studyItem 38 · PDF · 17 pages · 2.1 MBRestraint system factual reportItem 39 · PDF · 9 pages · 2.8 MBRestraint system factual report - attachement 1Item 40 · PDF · 7 pages · 10.2 MBRestraint system factual report - attachement 2Item 41 · PDF · 4 pages · 214 KBToxicological report - pilotItem 42 · PDF · 1 page · 506 KBVideo studyItem 43 · PDF · 7 pages · 1.3 MB

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 N256TA · 1

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