Accident at Maui, Hawaii, 22 Apr 1992

Accident narrative

On April 22, 1992, at approximately 1553 Hawaiian Standard Time, Scenic Air Tours flight 22, a Beech Model E18S, collided with mountainous terrain on Mount Haleakala on the Island of Maui, Hawaii. The on-demand air taxi flight was operating under visual flight rules (VFR) from Hilo to Honolulu. The pilot and all eight passengers sustained fatal injuries, and the airplane was destroyed by impact forces and a postcrash fire.

### The flight

Flight 22 was the return leg of a "Volcano Special" day tour. The 26-year-old captain had reported for duty at 0545 in Honolulu and flew the passengers to Hilo, landing about 0920. During a six-hour ground stop, the captain topped off the airplane's main fuel tanks with 60.2 gallons of fuel and had lunch with a fellow Scenic Air Tours pilot.

At 1512, flight 22 departed Hilo for the nonstop return to Honolulu. At 1520, the captain radio-filed a VFR flight plan with the Honolulu flight service station (FSS), estimating one hour and 25 minutes en route. The FSS specialist provided a full VFR weather briefing, advising that VFR flight was not recommended over the interior sections of all islands and forecasting isolated areas of three miles visibility in haze and moderate rain showers.

### Sequence of events

The company's normal return route from Hilo was flown at 2,500 feet. It proceeded westbound along the north coast of Hawaii to Upolu Point, then continued westbound on a 294-degree magnetic heading to overfly Makena on the southern shore of Maui, pass over Lanai, and return to Honolulu.

At 1542, the captain contacted the Honolulu FSS to ask about restricted area R-3104, located over the island of Kahoolawe, a few miles south of the normal route. Advised that the area was closed from the surface to 5,000 feet, the captain stated he would fly over the top at 6,500 feet. The FSS advised that transition above 5,000 feet was authorized for the next 30 minutes.

At 1550, the pilot of another Scenic Air Tours flight, trailing about 30 minutes behind flight 22, requested a position report on the company radio frequency. The captain of flight 22 replied, "37 DME off Upolu, standby Lanai."

At 1553, a remote radio receiver on Mount Haleakala detected an emergency locator transmitter signal. A witness standing near the summit of Mount Haleakala between 1545 and 1615 reported hearing smooth engine sounds from a multiengine airplane for 10 to 15 seconds before the noise stopped abruptly. The witness noted that the volcano crater was obscured by heavy, rolling clouds.

### What the investigation found

Search crews located the wreckage the following morning at an elevation of 9,600 feet on Mount Haleakala. The airplane had struck the terrain on a magnetic heading of approximately 200 degrees with little forward motion and high vertical impact forces, consistent with ground contact in a stalled condition. There was no evidence of preimpact failure of the flight control systems, structure, or powerplants.

Navy radar data showed that after passing Upolu Point, flight 22 tracked northwest toward Maui, climbing continuously to 8,500 feet. The airplane crossed the Maui shoreline at 8,100 feet. The radar track terminated approximately 2.1 nautical miles from the accident site.

Weather data and pilot reports indicated that instrument meteorological conditions prevailed at the accident site, with an almost continuous cloud cover moving over the summit and cloud bases at about 1,000 feet. The Board believed that the captain did not make visual contact with the rising terrain until the final seconds of the flight because it was obscured by clouds, and that he attempted evasive maneuvers close to the ground, resulting in the stalled condition.

The Board sought to determine why the flight deviated from its intended route over Kahoolawe. The radar track of 300 to 321 degrees magnetic led directly toward the high terrain of Mount Haleakala. The Board considered whether the deviation was intentional, perhaps to show passengers the crater, but discounted this because weather at the summit was not suitable for sightseeing.

Instead, the Board believed the deviation was unintentional. The accident site was located on the 310-degree radial of the Upolu Point (UPP) VOR at 39 DME. The radial to the captain's intended overflight point was approximately 287 degrees. The Board noted that the 310-degree radial is customarily used by company pilots departing Hilo for a northern route to Honolulu. It is possible that the captain tuned the UPP VOR frequency but failed to turn the omni bearing selector to the 287-degree radial. The Board found no evidence that the captain referred to an aeronautical chart to verify his heading, noting that three folded VFR sectional charts were found in his flight bag.

The investigation also reviewed the captain's qualifications. Scenic Air Tours required its pilots to have 2,500 total flight hours and 1,000 hours in multiengine airplanes. The captain had submitted a resume claiming 3,200 total hours and 1,500 multiengine hours. However, a reconstruction of his flight time using FAA and previous employer records revealed he had no more than 2,100 total hours and 800 multiengine hours at the time of the accident. The investigation found that the captain had been dismissed by five previous employers for reasons including misrepresentation of qualifications and poor performance. Scenic Air Tours did not have a policy to verify applicant backgrounds and had not conducted a substantive preemployment check.

### Probable cause

The National Transportation Safety Board determined that the probable cause of this accident was "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."

The Board found that 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."