KAUNAKAKAI, HI, USA
N241H
Rockwell NA-265-65
The airplane collided with mountainous terrain after the flight crew terminated the instrument approach and proceeded visually at night. The flight crew failed to brief or review the instrument approach procedure prior to takeoff and exhibited various cognitive task deficiencies during the approach. These cognitive task deficiencies included selection of the wrong frequency for pilot controlled lighting, concluding that the airport was obscured by clouds despite weather information to the contrary, stating inaccurate information regarding instrument approach headings and descent altitudes, and descending below appropriate altitudes during the approach. This resulted in the crew's lack of awareness regarding terrain in the approach path. Pilots approaching a runway over a dark featureless terrain may experience an illusion that the airplane is at a higher altitude that it actually is. In response to this illusion, referred to as the featureless terrain illusion or black hole phenomenon, a pilot may fly a lower than normal approach potentially compromising terrain clearance requirements. The dark visual scene on the approach path and the absence of a visual glideslope indicator were conducive to producing a false perception that the airplane was at a higher altitude. A ground proximity warning device may have alerted the crew prior to impact. However, the amount of advanced warning that may have been provided by such a device was not determined. Although the flight crew's performance was consistent with fatigue-related impairment, based on available information, the Safety Board staff was unable to determine to what extent the cognitive task deficiencies exhibited by the flight crew were attributable to fatigue and decreased alertness.
1.1 HISTORY OF FLIGHT On May 10, 2000, at 2031 Hawaiian standard time (HST), a Rockwell NA 265-65 Sabreliner corporate jet, N241H, collided with mountainous terrain 3.3 nautical miles (nm) southwest of the Kaunakakai Airport (PHMK), on the island of Molokai, Hawaii. The airplane was on a night visual approach for landing; it was destroyed in the collision sequence and post crash fire. Price Aircraft Company, LLC, of Broomfield, Colorado, owned the airplane, and they were operating it as a personal transportation flight under the provisions of 14 CFR Part 91. The airline transport pilot captain, commercial copilot, and four passengers sustained fatal injuries. Night visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed. The flight originated from Tahiti (NTAA) in the mid Pacific Ocean at an estimated departure time of 1300 HST and made an en route refueling stop at Christmas Island (PLCH). It departed Christmas Island about 1600 HST for Maui (PHOG), Hawaii. It cleared customs in Maui about 1930 and departed for Molokai at 2008 HST. The accident site location was 21 degrees 07.634 minutes north latitude and 157 degrees 08.994 minutes west longitude. The operator detailed the airplane's scheduled itinerary. The trip originated from Jeffco Airport (BJC) in Boulder, Colorado, on April 23, 2000, about 1800 central daylight time (CDT). This allowed the flight to arrive at its destination in Argentina in daylight conditions. Cumulative flight time for this trip was approximately 13 hours, and the flight made four intermediate stops for fuel and customs. The copilot for the trip to Argentina returned to the United States, and the copilot for the accident trip arrived in Argentina on May 7. The operator said their last conversation with the captain was on May 8, about 2200 Argentine time. On May 9, the airplane departed Esquel (SAVE), Argentina, and made a stop in San Carlos de Bariloche (SAZS), Argentina, to pickup a passenger. It made stops in Chile (SCIE), Easter Island (SCIP), and Tortegegie (NTGJ) for fuel and customs en route to Tahiti. The operator estimated the flight arrived in Tahiti in the early evening hours. Tahiti is in the same time zone as Hawaii. The copilot telephoned his dispatch office about 0800 HST on May 10, the day of the accident. He said they originally planned to stay in Tahiti until Friday, May 12. However, the airplane's owner left his luggage in Argentina and wanted to continue to his home on Molokai. The crew planned to stop at Christmas Island for fuel, but Christmas Island required 24-hour advance notification for intended fuel purchases. The captain was attempting to get this requirement waived; if he succeeded, they would leave later that day. Otherwise, the copilot said they would leave early on the 11th. He said he would inform dispatch either way, but they did not hear from him. The crew filed a Jeppesen dataplan indicting an estimated time of departure of 1200 HST from Tahiti. It estimated 3 hours 14 minutes en route to Christmas Island. Another dataplan indicated an estimated time of departure of 1600 HST from Christmas Island. Estimated time en route to Maui was 2 hours 55 minutes. The Safety Board investigator-in-charge (IIC) reviewed transcripts of recorded radio transmissions between the crew and various Federal Aviation Administration (FAA) air traffic control (ATC) facilities. The transcripts indicated the airplane landed on Maui about 1920 HST. US Customs agents began clearing the flight about 1930. The agents reported the crew was in good spirits; however, one pilot mentioned it had been a long day. The IIC reviewed a transcript of the cockpit voice recorder (CVR) made by the CVR group. The CVR transcript times did not exactly match the ATC transcript times. The IIC used the ATC times as the reference time and blended pertinent CVR information in at the appropriate relative time. All times listed are in HST. Evidence from the CVR group indicated that the captain was flying the airplane and the copilot broadcast all radio transmissions. Safety Board staff converted recorded radar data to latitude and longitude coordinates. The IIC reviewed and plotted the computed data. The airplane transmitted a secondary beacon code of 6005 throughout the flight. Mode C reported altitudes were corrected msl (mean sea level) altitudes. The local controller in the Maui Airport Traffic Control Tower (ATCT) told the crew to file their flight plan to Molokai with the Honolulu Automated Flight Service Station (AFSS) on frequency 123.6. The copilot contacted the AFSS at 1926:05 while on the ground at Maui. He filed an IFR flight plan from Maui to Molokai. The CVR transcript does not indicate that the crew briefed or reviewed the route of flight or approach. The copilot requested "eight thousand feet, three thousand feet, we'll say three thousand feet." This request did not include route of flight. Clearance delivery responded that preferred routing to Molokai would be "Victor six Blush, Victor eight, and minimum en route altitude is six thousand feet." The copilot responded that they could accept that altitude and routing. Victor six was the 320-degree radial from the Maui (OGG) VORTAC (very high frequency omni-directional radio range/Tactical Air Navigation). Blush intersection was the point where Victor eight (the 056-degree radial from the Molokai (MKK) VORTAC) intersected Victor six. At 2002:26, the Maui ATCT said "cleared to Molokai as filed, maintain six thousand and fly heading three four zero, departure one two zero point two, squawk six zero zero five." The copilot requested and received verification of the routing. The CVR transcript indicated that the crew began setting their instruments. The captain told the copilot he thought they would receive radar vectors and would not even get on the airway. At 2008:11, on frequency 118.7, Maui ATCT cleared the airplane for takeoff on runway 02. About 2 minutes later they instructed the crew to contact Departure Control. Departure Control established radar contact about 2010, and instructed the crew to join Victor six. The captain asked the copilot to set "that number for me." The copilot responded "three twenty." The captain remarked "join it, we're past it." The copilot agreed. The captain queried, "right then?" At 2010:37, the copilot asked Departure Control to verify that it was a left turn to intercept their assigned radial. Departure advised them to turn to 310 degrees to join the "three twenty." About 1 minute later, Departure instructed them to contact Honolulu Center on frequency 124.1. At 2013:17, Honolulu Center briefed the crew on the Molokai weather. It was: wind 060 degrees at 8 knots; visibility 10 miles; sky clear; temperature 23 degrees (Celsius); and dew point 18 degrees. This brief also informed the crew to expect a visual approach to Molokai Airport. The mode C reported altitude was 6,000 feet. During the next 6 minutes of the CVR recording, the crew discussed bookkeeping issues and an instrument problem. The captain remarked "it really didn't grab it right?" Later the sound of tapping was heard followed by the comment "it's doin' it again." The captain then said it was "holding it or it's giving good directions, the autopilot just isn't uh, capturing it." About 2020, the copilot noted they were about 10 miles out from Molokai. The captain replied they would be taken around to runway 05 and they would probably pass over the airport before being let down. He also commented that he was not watching where they were going. At 2020:53, the copilot asked for and received clearance to descend to 5,000 feet. The copilot remarked they would probably be let down once they were on the other side of the airport. The captain asked if they were past the airport. During several verbal exchanges trying to clarify their position, the copilot instructed the captain to stay on his heading. At 2021:45, the airplane was at a mode C reported altitude of 5,000 feet when Honolulu Center pointed the airport out at 11 to 12 o'clock and 3 miles. The copilot responded they were looking, and he told the captain they were still going to the VOR. The captain agreed then asked "7 miles out, to what?" The copilot replied from the VOR and the airport was about 3 miles this side of it. The captain asked what they passed over. The copilot responded he was on "FMS and it switches *** course guidance." About 2022:37, the copilot told the captain that they should be right over the airport. The copilot said they could ask for the approach, since there were still clouds below them. The crew decided to ask for an instrument approach. At 2023:23, the copilot reported the field was not in sight and requested the VOR Alpha approach. The crew initiated the instrument approach. The copilot directed the captain to proceed outbound on the 254-degree radial. During the next minute, the copilot advised the captain that the desired course was a radial, not a heading. The captain asked the copilot if the tower was closed and pilot controlled lighting was available. He asked for the frequency and the copilot responded "eighteen seven." The copilot added that he still saw clouds below them and told the pilot to watch his radial. At 2024:19, the CVR group heard sounds similar to 7 microphone clicks. Then the captain remarked, "now there it is." As the flight continued on the instrument approach, the copilot briefed parts of the approach. About 2024:59, the captain informed the copilot to just direct him around because the briefing was confusing him. The airplane was at a mode C reported altitude of 4,600 feet. The copilot instructed the pilot to fly 300 degrees for 1 minute for the procedure turn. The captain asked if they could go down to 2,500 feet, and the copilot responded affirmatively. The captain directed the copilot to set the flaps to 10 degrees and the copilot complied. The captain asked for the inbound course, and the copilot responded it would be the opposite of 254 degrees. When the captain asked if 300 degrees was the right heading, the copilot said no, they were doing the procedure turn. The captain remarked he had to make a left turn and they were coming around. The copilot responded that they were turning back around to, "one nineteen, one twenty." Then the captain said, "oop, not too far. Coming the other way. There you go." The captain said they were out of 2,500 feet and asked the copilot for the field elevation and was informed 400 feet. The copilot said the radial was alive and they could descend to 2,200 feet inbound to the VOR. The captain requested some clicks to see where the runway was. The CVR group heard two series of sounds similar to 7 microphone clicks beginning at 2027:28. The airplane was at a mode C reported altitude of 2,500 feet. At 2027:33, Honolulu Center terminated radar service and approved a change to advisory frequency. The airplane was at a mode C reported altitude of 2,400 feet. About 30 seconds later, the CVR group heard another series of 7 clicks. Then the copilot remarked "radial on your side there. Watch your radial." The captain stated they were 6 miles from the runway. The copilot responded they were 6 miles from the VOR and then they could go down to 1,000 feet. The pilot said, "that's another thousand feet." The copilot said they were 10 miles from the airport, and reported that he selected flaps 20. He said the missed approach was a climbing left turn to a 360-degree heading. The captain said, "this wasn't supposed to be difficult," then chuckled. He still didn't see the runway and asked the copilot to verify the frequency for the pilot controlled lighting. The copilot advised him they did not have the proper frequency; he said they should be on 125.7. About 2029:47, the CVR group heard 7 sounds similar to microphone clicks. The airplane was at a mode C reported altitude of 2,200 feet. A few seconds later the copilot said he had the runway in sight and, "you have * you're right here." About 2030:12, the airplane was at a mode C reported altitude of 2,100 feet. Safety Board software determined this position was 1.3 nm on a magnetic bearing of 251 degrees from the VORTAC, and 5.3 nm and 232 degrees from the airport. Then the CVR group heard a sound similar to a decrease in engine rpm. The captain said the landing gear was going down. Then he said the flaps were going to full down. He later added that the landing lights were out. At 2030:51, the copilot reported to Honolulu Center that they had the airport in sight and cancelled their IFR clearance. The airplane was at a mode C reported altitude of 1,800 feet. Safety Board software determined this position was 0.6 nm on a magnetic bearing of 175 degrees from the VORTAC, and 4.3 nm and 239 degrees from the airport. About 10 seconds later, the copilot broadcast to Molokai traffic that they were inbound to runway 05. The captain said he was going down a little bit. At 2031:24, the airplane was at a mode C reported altitude of 1,300 feet. Safety Board software determined this position was 1.2 nm on a magnetic bearing of 111 degrees from the VORTAC, and 3.3 nm and 232 degrees from the airport. At this time the captain said, "oop." The copilot said, "that's the clouds." The captain queried, "let's have that again. That's the clouds, huh? Oh." Three seconds later, the captain said, "ooh, wadoyou..." and the CVR recording ended 1 second later. The airplane obliquely impacted the side of a mountain ridge about 100 feet from the crest of a 1,400-foot ridge. 1.1.1 Statements of Witnesses A security guard at the airport heard the crew report their intention to land, and then the runway lights illuminated. She saw two blinking lights on the hills west of the airport. She saw the white blinking light of an airplane left of the right light. She normally observes airplanes on the right side of this light and not far away. This airplane was still far away and appeared low over the mountains. She said it was a very clear night and she could see the outline of the mountains. The airplane turned toward her left. She thought this was to align with the runway, but this was farther away from the airport than normal. She stopped watching and went to open a gate. She was out of her vehicle when another person drove up and told her they saw the lights disappear, and then they saw a fireball. She said there were no clouds. Security guards patrolled the ranch grounds on which the accident occurred. Several of them noted the airplane passed lower than normal over the ridgelines they were on. They also stated it was a clear night. 1.2 INJURIES TO PERSONS Both flight crewmembers and all four passengers sustained fatal injuries in the collision sequence and post crash fire. 1.3 DAMAGE TO AIRPLANE The impact and post crash fire destroyed the airplane. 1.4 PERSONNEL INFORMATION 1.4.1 The Captain The IIC reviewed FAA airman records. The captain held an airline transport pilot certificate with an airplane multiengine land rating. He held a commercial pilot certificate with a rating for airplane single engine land. He held airline transport pilot type ratings in the following airplanes: CE-500, G-S2, HE-25, L-12329, LR-Jet, and N-265. He also held a flight instructor certificate with ratings for single and multiengine land. He held a first-class medical certificate, issued on March 22, 2000, with the restriction that he must wear corrective lenses and possess glasses for near and interim vision. The operator listed the captain's total flight time as 12,775 hours, and he had logged 70 hours in the last 90 days. He had 1,370 hours in this make and model. The IIC interviewed the chief pilot for the copilot's employer, for whom the captain had also previously worked. The chief pilot flew from Boulder to Argentina with the captain. He reported that they experienced no difficulties with the airplane on the trip to Argentina. He said the captain did not like to use a challenge-response approach to checklists. When they arrived in Argentina at dusk, they encount
Inadequate crew coordination led to the captain's decision to discontinue the instrument approach procedure and initiate a maneuvering descent solely by visual references at night in an area of mountainous terrain. The crew failed to review the instrument approach procedure and the copilot failed to provide accurate information regarding terrain clearance and let down procedures during the instrument approach.
Source: NTSB Aviation Accident Database
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