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Crash of a Cessna 208B Grand Caravan off Kalaupapa: 1 killed

Date & Time: Dec 11, 2013 at 1522 LT
Type of aircraft:
Operator:
Registration:
N687MA
Flight Phase:
Survivors:
Yes
Schedule:
Kalaupapa - Honolulu
MSN:
208B-1002
YOM:
2002
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
16000
Captain / Total hours on type:
250.00
Aircraft flight hours:
4881
Circumstances:
The airline transport pilot was conducting an air taxi commuter flight between two Hawaiian islands with eight passengers on board. Several passengers stated that the pilot did not provide a safety briefing before the flight. One passenger stated that the pilot asked how many of the passengers had flown over that morning and then said, “you know the procedures.” The pilot reported that, shortly after takeoff and passing through about 500 ft over the water, he heard a loud “bang,” followed by a total loss of engine power. The pilot attempted to return to the airport; however, he realized that the airplane would not be able to reach land, and he subsequently ditched the airplane in the ocean. All of the passengers and the pilot exited the airplane uneventfully. One passenger swam to shore, and rescue personnel recovered the pilot and the other seven passengers from the water about 80 minutes after the ditching. However, one of these passengers died before the rescue personnel arrived. Postaccident examination of the recovered engine revealed that multiple compressor turbine (CT) blades were fractured and exhibited thermal damage. In addition, the CT shroud exhibited evidence of high-energy impact marks consistent with the liberation of one or more of the CT blades. The thermal damage to the CT blades likely occurred secondary to the initial blade fractures and resulted from a rapid increase in fuel flow by the engine fuel control in response to the sudden loss of compressor speed due to the blade fractures. The extent of the secondary thermal damage to the CT blades precluded a determination of the cause of the initial fractures. Review of airframe and engine logbooks revealed that, about 1 1/2 years before the accident, the engine had reached its manufacturer-recommended time between overhaul (TBO) of 3,600 hours; however, the operator obtained a factory-authorized, 200-hour TBO increase. Subsequently, at an engine total time since new of 3,752.3 hours, the engine was placed under the Maintenance on Reliable Engines (MORE) Supplemental Type Certificate (STC) inspection program, which allowed an immediate increase in the manufacturer recommended TBO from 3,600 to 8,000 hours. The MORE STC inspection program documents stated that the MORE STC was meant to supplement, not replace, the engine manufacturer’s Instructions for Continued Airworthiness and its maintenance program. Although the MORE STC inspection program required more frequent borescope inspections of the hot section, periodic inspections of the compressor and exhaust duct areas, and periodic power plant adjustment/tests, it did not require a compressor blade metallurgical evaluation of two compressor turbine blades; however, this evaluation was contained in the engine maintenance manual and an engine manufacturer service bulletin (SB). The review of the airframe and engine maintenance logbooks revealed no evidence that a compressor turbine metallurgical evaluation of two blades had been conducted. The operator reported that the combined guidance documentation was confusing, and, as a result, the operator did not think that the compressor turbine blade evaluation was necessary. It is likely that, if the SB had been complied with or specifically required as part of the MORE STC inspection program, possible metal creep or abnormalities in the turbine compressor blades might have been discovered and the accident prevented. The passenger who died before the first responders arrived was found wearing a partially inflated infant life vest. The autopsy of the passenger did not reveal any significant traumatic injuries, and the autopsy report noted that her cause of death was “acute cardiac arrhythmia due to hyperventilation.” Another passenger reported that he also inadvertently used an infant life vest, which he said seemed “small or tight” but “worked fine.” If the pilot had provided a safety briefing, as required by Federal Aviation Administration regulations, to the passengers that included the ditching procedures and location and usage of floatation equipment, the passengers might have been able to find and use the correct size floatation device.
Probable cause:
The loss of engine power due to the fracture of multiple blades on the compressor turbine wheel, which resulted in a ditching. The reason for the blade failures could not be determined due to secondary thermal damage to the blades.
Final Report:

Crash of a Beechcraft E18S in Kalaupapa

Date & Time: Feb 13, 1986 at 0900 LT
Type of aircraft:
Registration:
N30Y
Flight Type:
Survivors:
Yes
Schedule:
Honolulu - Kalaupapa
MSN:
BA-93
YOM:
1955
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1328
Captain / Total hours on type:
775.00
Aircraft flight hours:
5589
Circumstances:
The aircraft crashed off the end of runway 23 during an attempted go-around after touchdown. The pilot stated that after the aircraft touched down approximately 300 feet down the 2,760 foot runway he raised the flaps along with the nose of the aircraft to slow down. Brakes were applied and the left main gear skidded 2/3 the way down the runway at which time full power was applied to go-around. The aircraft mushed off the end of the runway where it contacted a rock pile and was destroyed by impact and post crash fire. The pilot reported winds from 270° at 10 knots when the accident occurred.
Probable cause:
Occurrence #1: overrun
Phase of operation: landing
Findings
1. Weather condition - crosswind
2. (f) all available runway - not used - pilot in command
3. (f) planned approach - misjudged - pilot in command
4. (c) go-around - delayed - pilot in command
----------
Occurrence #2: loss of control - in flight
Phase of operation: go-around (vfr)
Findings
5. (c) airspeed (vmc) - not attained - pilot in command
6. (c) stall/mush - inadvertent - pilot in command
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: go-around (vfr)
Final Report:

Crash of a De Havilland DH.104 Riley Dove in Kalaupapa

Date & Time: Nov 3, 1969 at 1527 LT
Type of aircraft:
Registration:
N669R
Survivors:
Yes
Schedule:
Honolulu – Kalaupapa – Kaanapali
MSN:
04388
YOM:
1953
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6559
Captain / Total hours on type:
567.00
Circumstances:
On final approach to Kalaupapa in good weather conditions, the crew failed to realize his altitude was insufficient when the airplane struck the ground 38 feet short of runway threshold. On impact, the undercarriage were torn off and the airplane came to rest on its belly. All 13 occupants were injured, four of them seriously. The aircraft was written off.
Probable cause:
The pilot-in-command misjudged the distance and altitude during the last segment of the flight and failed to initiate a go-around. The following factors were reported:
- Downdrafts, updrafts,
- Overload failure,
- Wind gusting up to 20 knots.
Final Report:

Crash of a De Havilland DH.104 Riley Dove in Kekaha: 1 killed

Date & Time: Jul 25, 1969 at 1745 LT
Type of aircraft:
Operator:
Registration:
N88G
Flight Phase:
Survivors:
Yes
Schedule:
Kalaupapa - Lihue
MSN:
04360
YOM:
1952
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
13900
Captain / Total hours on type:
2100.00
Circumstances:
The aircraft was engaged in a sightseeing flight from Kalaupapa – Lihue, carrying 11 passengers and two pilots. En route, the left engine lost power. Unable to maintain flying speed, the crew attempted an emergency landing when the airplane struck trees and crashed in a wooded area. A passenger was killed while 12 other occupants were injured, some of them seriously.
Probable cause:
Partial loss of power on the left engine in flight caused by the number three exhaust valve failure. The following factors were considered as contributing:
- Engine structure, valve assemblies,
- The pilot exercised poor judgment,
- Unwarranted low flying,
- Presence of downdrafts.
Final Report: