3 fatalities

2004-01-31: Cessna 414 Chancellor (N5637C) — Hawaii Air Ambulance — Laupahoehoe, United States of America

Laupahoehoe, United States of AmericaFlight

On January 31, 2004, a Cessna 414 Chancellor (registration N5637C) operated by Hawaii Air Ambulance was involved in an aviation accident near Laupahoehoe, United States of America in flight. 3 people were killed. Investigators recorded the probable cause as: The pilot's disregard for an in-flight weather advisory, his likely encounter with marginal VFR or IMC weather conditions, his decision to continue flight into those conditions, and failure to maintain an adequate terrain clearance altitude resulting in an… This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A); 1 related events involving the same aircraft type or operator are linked below.

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781200543Data APIEditorial standards

An airplane collided with terrain on Mauna Kea after the pilot disregarded a weather advisory and continued into marginal conditions. The debris path extended 500 feet.

Accident Overview

An airplane collided with trees and mountainous terrain at the 3,600-foot level of Mauna Kea Volcano during an en route cruise descent toward the destination airport, located 21 miles east of the accident site. The flight had departed Honolulu under visual flight rules (VFR) at 0032 to pick up a patient in Hilo, on the Island of Hawaii.

Flight Progression

The inter-island cruising altitude was 9,500 feet, and the flight was receiving VFR flight advisories. At 0113, just before the flight crossed the northwestern coast of Hawaii, the controller provided the pilot with the current Hilo weather, which reported visibility of 1 3/4 miles in heavy rain and mist, with a ceiling of 1,700 feet broken and 2,300 feet overcast.

Recorded radar data showed that the flight crossed the coast of Hawaii at 0122, descending through 7,400 feet while tracking southeast bound toward the northern slopes of Mauna Kea and Hilo beyond. The last recorded position of the aircraft was about 26 miles northwest of the accident site at a mode C reported altitude of 6,400 feet. At 0130, the controller informed the pilot that radar contact was lost and also stated that at the airplane's altitude, radar coverage would not be available inbound to Hilo. The controller then terminated radar services.

Witness Account

A witness who lived in the immediate area of the accident site reported that around 0130 he heard a low flying airplane coming from the north. He walked outside his residence and observed an airplane fly over about 500 feet above ground level (agl) traveling in the direction of the accident site about 3 miles east. The witness said that light rain was falling and he could see a half moon, which he thought provided fair illumination.

Weather Conditions

The area forecast in effect at the time of the flight's departure called for broken to overcast layers from 1,000 to 2,000 feet, with merging layers to 30,000 feet and isolated cumulonimbus clouds with tops to 40,000 feet. It also indicated that the visibility could temporarily go below 3 statute miles. The forecast and actual weather conditions at Hilo were below the minimums specified in the company Operations Manual for VFR operations.

Wreckage and Investigation

The debris path extended about 500 feet along a magnetic bearing of 100 degrees, with debris scattered both on the ground and in tree branches. Investigators found no anomalies with the airplane or engines that would have precluded normal operation.

Operational Practices

According to the investigation, pilots for the operator typically departed under VFR, even in night conditions or with expectations of encountering adverse weather, to preclude ground holding delays. The pilots would then pick up their instrument flight rules (IFR) clearance en route.

Probable Cause

The pilot's disregard for an in-flight weather advisory, his likely encounter with marginal VFR or instrument meteorological conditions (IMC), his decision to continue flight into those conditions, and failure to maintain an adequate terrain clearance altitude resulting in an in-flight collision with trees and mountainous terrain. A contributing factor was the pilot's failure to adhere to the VFR weather minimum procedures in the company's Operations Manual.