Honolulu, HI, USA
N8934N
PIPER PA-32-300
The non-instrument-rated pilot was on the return leg of his regular 63-nautical-mile commute between two islands. He was cleared for a visual flight rules arrival, which entailed passing over a very high frequency omni-directional radio aid (VORTAC), continuing over a golf course, and then following a freeway before entering the traffic pattern. The approach controller told the pilot to proceed to the VORTAC, but the pilot replied that he wanted a vector. The controller provided a vector and the pilot said that he did not have the island in sight. The controller told the pilot to resume his own navigation. The airplane flight path crossed over the VORTAC and proceeded north into mountainous terrain instead of the cleared arrival path. While the pilot said that he was in the rain at the golf course, radar data indicate that he was actually about 2.5 miles to the east of that location. About 1 minute 20 seconds later, the pilot said that he was inbound for landing, and the controller told him that he was heading toward the mountains. The pilot immediately requested a vector "to intercept landing," which was the last transmission he made. The controller told the pilot to make either a left or right turn southbound to a 180-degree heading. The airplane was substantially off course for almost 1 minute 30 seconds before impact. A group of hikers who were near the accident site heard the airplane operating in the clouds prior to impact. Weather at the time of the accident included light to moderate rain showers and reduced visibility that would have been encountered by the airplane. A postaccident examination revealed no evidence of a mechanical malfunction or failure with the airframe or engine prior to impact. Despite the pilot’s two radio calls suggesting disorientation during the flight’s final 90 seconds, the controller did not issue a safety alert to the pilot. Although the responsibility for flight navigation rests with the pilot, Federal Aviation Administration Order 7110.65, paragraph 2-1-6, directs controllers, in part, to “Issue a safety alert to an aircraft if you are aware the aircraft is in a position/altitude which, in your judgment, places it in unsafe proximity to terrain, obstructions, or other aircraft.” The investigation concluded that the controller had sufficient information to determine that a low altitude alert was necessary, as evidenced by her attempt to turn the airplane. A timely low altitude alert may have enabled the pilot to climb and avoid the accident. When the controller recognized that there was a problem with the airplane, she concentrated on correcting his lateral track rather than helping him immediately climb to a safe altitude.
HISTORY OF FLIGHT On January 10, 2010, about 1345 Hawaiian standard time, a Piper PA-32-300, N8934N, impacted the southeast side of a ridge while approaching the Honolulu International Airport, Honolulu, Hawaii. The pilot, who was additionally the owner, was operating the airplane under the provisions of 14 Code of Federal Regulations Part 91. The non-instrument rated private pilot and one passenger were killed. The airplane was substantially damaged during the impact and subsequent on-ground fire. The personal cross-country flight originated from Lanai Airport on the island of Lanai, Hawaii, about 1315, with a planned destination of Honolulu on the island of Oahu. Instrument meteorological conditions prevailed in the area surrounding the accident site, and the pilot was receiving visual flight rules (VFR) flight following; he had not filed a flight plan. A group of hikers were near the accident site and observed the airplane just prior to impact. One hiker reported that in "very cloudy, poor visibility," conditions he heard an airplane crash into a ridge about 50 yards from his location. He recalled that he could "hear the engine all the way," and that the airplane did not make a sound consistent with turning or pulling up. He further stated that visibility was so bad that he was not able to see the airplane. Another hiker reported that the ridge was obscured by clouds and he heard the engine "running the whole time," prior to the airplane crashing. Another hiker stated that she heard an airplane flying low and briefly observed it pass by before it disappeared in the cloud layer. A different hiker recalled that he was almost at the peak of the ridge when he noticed an airplane flying low in the mountains; he observed it crash into an adjacent ridge. Shortly thereafter, he observed the clouds move in and he could no longer see the wreckage. He stated that when the airplane impacted, there were "heavy clouds and the mountain was hard to see." Another hiker stated that she heard the airplane as it came closer and the noise became louder. It was flying toward the ocean and then suddenly turned into the mountain. An additional hiker observed the airplane flying at eye-level to him. It veered to the right and he heard it crash into the ridge. The direct route of flight from Lanai to Honolulu is about 63 nautical miles (nm) on a course of 300 degrees true. The pilot was on the Kona Arrival to Honolulu Airport at the time of the accident, which is an arrival procedure for VFR aircraft. As published, the arrival procedure is to proceed to KoKo Head very high frequency omni-directional radio range tactical air navigation aid (VORTAC) and then continue to the Waialae Golf Course. Thereafter, the pilot is to follow the H-1 Freeway to enter the left base of the traffic pattern for runway 22L. During the investigation, the recorded voice channels from the Honolulu Air Traffic Control Facility, and recorded radar data, were obtained and reviewed by a National Transportation Safety Board investigator. While the airplane was en route to Honolulu, the pilot was in communication with Honolulu air traffic controllers and receiving flight following services. At 1332:51, the approach controller directed the pilot to proceed to KoKo Head, to which the pilot replied that he would like to receive a vector. The controller provided a vector of 290 degrees, and at 1335:20, the pilot reported, "no joy on Oahu." The controller directed the pilot to resume his own navigation to runway 22L via the Kona Arrival. At 1339:10, the pilot reported that he was abeam KoKo Head and the controller replied that after passing Koko Head the pilot could descend at his discretion. Several minutes later, at 1342:40, the pilot reported that he was "in the rain at golf course [and] proceeding to Punchbowl." At 1344:00, the pilot reported that he was at Punchbowl at an altitude of 1,900 feet mean sea level (msl), and proceeding inbound for landing on runway 22L. The controller responded by stating that the airplane was in actuality "heading toward the mountains, toward the other side of the island," and that he was going into Ana Hina. The pilot immediately requested for the controller to vector him "to intercept landing," which was the last transition he made. The controller instructed the pilot to make either a left or right turn southbound to a suggested heading of 180 degrees. Recorded radar data covering the area of the accident was examined for the time frame, and a discreet secondary beacon code target was observed that matched the anticipated flight track of the airplane en route from Lanai to Honolulu. A review of the data disclosed that at 1339:10, when the pilot reported that he was abeam KoKo Head, the target at the corresponding time was located about 5 miles from the VORTAC to the east-southeast. Several minutes later, when the pilot reported he was at the golf course, the target was about 0.5 miles off the shoreline and about 2.5 miles east of the golf course. As the radar track reached land, the altitude remained at 1,700 feet until reaching the rising terrain, where the last recorded altitudes were 1,800 feet. The majority of these radar returns were spaced uniformly, and followed a track of about 330 degrees true. The last radar return was recorded at 1344:23, and located about 0.5 miles southeast of the accident site. PERSONNEL INFORMATION According to the Federal Aviation Administration (FAA) Airman and Medical records, the 81-year-old pilot held a private pilot certificate with single and multi engine land airplane ratings. A third-class airman medical certificate was issued on June 20, 2009, with the limitation that he must wear corrective lenses while exercising the privileges of his airman certificate. No personal flight records were recovered for the pilot. On the application for his last medical certificate, the pilot stated that his total flight experience was 5,900 hours. He was a member of the local United Flying Octogenarians chapter. Family members reported that the purpose of the accident flight was for the pilot, a veterinarian, to return from working on Lanai. As on almost every Sunday, the pilot commuted from Honolulu to Lanai to see veterinary patients, with his work hours ending around 1200. The pilot had a history flying on the island and had performed "thousands" of flights between Lanai and Honolulu. Although the passenger did not hold a pilot certificate, he would often fly with the pilot, his father. AIRCRAFT INFORMATION A review was conducted of the material maintained by the FAA in the Aircraft and Registry files for this airplane. The Piper PA-32-300 single-engine airplane, serial number 32-40734, was manufactured in 1969, and purchased by the pilot in February 2000. According to the airworthiness documents, the airplane was originally equipped with a Lycoming IO-540-K1A5 engine. No airplane or engine maintenance records were located in the wreckage, or submitted to the Safety Board. METEOROLOGICAL INFORMATION A routine aviation weather report (METAR) for Honolulu recorded at 1353 stated: sky condition 1,800 feet scattered, 2,400 feet broken; visibility 7 statute miles (sm) with light rain; temperature 23 degrees Celsius; dew point 21 degrees Celsius; altimeter 29.91 inches of mercury; visibility to the west 1.5 sm. Approximately 25 minutes after the accident, Honolulu reported lowered ceilings to 2,200 feet, with few clouds at 1,200 feet, in heavy rain. Analysis of Doppler weather radar at the time of the accident identified light to moderate rain showers around the southeastern edge of Oahu. Weather radar imagery also indicated Honolulu likely did not observe similar rain conditions at the time of the accident. Tops of the highest clouds reached 8,000 feet msl. An advancing, but weakening cold front pushing through the area was the cause of the inclement weather and forecast. WRECKAGE AND IMPACT The wreckage was located at an estimated 21 degrees 19 minutes 33 seconds north latitude and 157 degrees 45 minutes 58.8 seconds west longitude, and at an elevation of about 1,950 feet msl. The accident site was approximately 10 nautical miles east of the airport. The main wreckage, consisting of the fuselage, tail section, and wings, had come to rest about 30 feet below the peak of an east-west oriented ridge. The wreckage was in rugged terrain, on a slope of about 80 degrees that was comprised of rock outcroppings and thick vegetation. A complete pictorial of the wreckage location and surrounding terrain is contained in the public docket for this accident. MEDICAL AND PATHOLOGICAL INFORMATION The Department of the Medical Examiner for the City and County of Honolulu completed an autopsy on the pilot. The FAA Forensic Toxicology Research Team at the Civil Aviation Medical Institute (CAMI) performed toxicological testing of specimens collected during the autopsy. The results of the specimens were negative for carbon monoxide, cyanide, and listed drugs. TESTS AND RESEARCH Following recovery, a Safety Board investigator examined the airplane in a private hangar at the Honolulu International Airport, on January 16, 2010. Present to the examination was an Airworthiness Inspector from FAA Honolulu Flight Standards District Office. The airplane was disassembled during the recovery process. The separated sections consisted of the following: left wing, empennage, belly skin sections. The engine, main fuselage, and right wing were all still connected. Airframe The cockpit area was consumed by fire, with only remnants of the instrument panel remaining. The altimeter was imbedded in the firewall area and, although thermally damaged, displayed an altitude reading of just over 2,000 feet with the setting in the Kollsman window indicating 29.90. The left wing was separated from the airframe at the wing root as part of the recovery effort; it had sustained thermal damage with numerous burned holes in the skin. Sections of the leading edge had ballooned open, consistent with high speed impact and fuel in the wing tank. The leading edge crush damage encompassed the skin deformed upward creating crush lines of about 70-80 degrees; there were numerous divots breaking up the uniformity of the crush lines. The right wing was partially burned, sustained crush damage, and remained loosely attached to the airframe. The main spar was intact and ran continually through the cabin area to the right wing. The pilot seat tracks were secured to the floorboards; no anomalies were noted. The right wing's leading edge was bent inward toward the spar with an accordioned appearance. The crush deformation and angles that were aft of the ballooned leading edge were consistent with about a 60-70 degree edge. The aileron and flap remained attached. The empennage section consisted of the vertical stabilator and rudder, with a portion of tail skin. Thermal damage was present to the bottom section. The rudder remained affixed to the stabilizer, and control continuity was established from the control surface to the rudder horn, where the cables were affixed. The stabilator had become detached from the balance arm and weight, had sustained thermal damage, and was slightly bowed downward. The fuel system was compromised, and investigators were unable to establish continuity. The fuel selector was found, and removed from the deformed cabin area. Compressed air was forced through the input, and air was observed to egress from the "left tip tank" selection. Engine The engine was examined following recovery of the wreckage; the data plate was not located. An external examination of the engine revealed that the cylinder fins and outer case was packed with soft dirt, mostly on the left side of the engine. The mounts and support structure had bent inward, and were imbedded into the accessory section. Only several pieces of cowling surrounded the engine. The engine case appeared to be intact with no holes or perforations observed. The exhaust system was observed to have sustained ductile bending and crushing. Disassembly of the fuel manifold revealed that the cavity contained a trace amount of liquid that was consistent in odor to that of 100LL Avgas. The diaphragm was pliable and no debris was found in the cavity. The ignition harnesses were attached from both magnetos to their respective spark plugs. The magnetos remained securely attached to their respective mounts. Investigators removed both magnetos and attempted to test their internal continuity via hand rotation. The right magneto was fractured, and internal integrity could not be confirmed. Removal of the casing revealed that the points and cam lobe were intact and appeared to have little wear; the gear teeth were intact. The left magneto was rotated, and the impulse couplings audibly appeared to operate; investigators observed spark at two of the six posts. The top spark plugs were removed; no mechanical damage was noted and the electrodes and posts exhibited a light ash gray coloration on the No. 1, No.3, and No.5 plugs, which corresponds to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart.; the lower No.2, No.4, and No.6 plugs had a light film of oil, which is consistent with the engine leaning on the right side after the accident. Investigators rotated the engine via the propeller. Internal mechanical continuity was established during rotation of the crankshaft and upon attainment of thumb compression in all cylinders but the No.5 cylinder. Upon further examination, it was determined the No.5 cylinder pushrods had been bent, consistent with impact. Visual inspection of the combustion chambers was accomplished through the spark plug bores; there was no evidence of foreign object damage or detonation, and no indication of excessive oil consumption. The valve train was observed to operate in proper order (with the exception of the No.5 cylinder) and equal lift action occurred at each rocker assembly. Greenish-brown tinted oil was present in the 6 rocker box areas. The vacuum pump remained secure to its mounting pad. The pump was removed, and it was noted that the drive gear was intact. There was no visible evidence of damage. The rotor/vane assembly was also intact and undamaged. Light rotational scoring was observed on both the rotor and housing. The two propeller blades were observed attached to their hub assemblies, which were attached to the propeller shaft flange. The propeller blades were torsionally twisted and exhibited an "S" bend. The propeller spinner was crushed upward. There was no evidence of mechanical malfunction or failure with the airframe or engine. A detailed examination report with accompanying pictures is contained in the public docket for this accident. ADDITIONAL INFORMATION Air Traffic Control HCF Air Traffic Control Tower (ATCT) was an ATC-9 level facility responsible for aircraft operations on the airport surface and in the Class B airspace in the immediate vicinity of the airport. A Safety Board investigator interviewed the controller who was handling the airplane at the time of the accident. The controller stated that the pilot was well known to controllers, and that they all recognized the airplane registration number and the pilot’s voice. She recalled one previous incident where she had to correct the pilot’s course when he did not follow a clearance. His reputation was that he would navigate as he saw fit, rather than complying with the procedures. At the time of the accident, the airplane was the only one under her control. The pilot had already been cleared into class B airspace via the Kona arrival. She instructed the pilot to maintain 2,000 feet until passing abeam KoKo Head in order to ensure continued radar coverage. As the pilot approached the area of the golf course, he stated that he was over the golf course and proceeding direct Punchbowl, although the airplane headed north. She believed he was possibly trying to avoid clouds and because he was operating under VFR, she was not concerned about the heading. The controller further stated that she became concerned about the airplane's course when the pilot reported he was over Punchbowl, wh
The pilot's continued visual flight into instrument meteorological conditions at an altitude insufficient to ensure adequate terrain clearance. Contributing to the accident was the air traffic controller's failure to issue a safety alert after observing the pilot's navigational deviation toward high terrain.
Source: NTSB Aviation Accident Database
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