Crash of a Boeing 737-297 in Kahului: 1 killed

Date & Time: Apr 28, 1988 at 1346 LT
Type of aircraft:
Operator:
Registration:
N73711
Flight Phase:
Survivors:
Yes
Schedule:
Hilo - Honolulu
MSN:
20209
YOM:
1969
Flight number:
AQ243
Location:
Crew on board:
5
Crew fatalities:
Pax on board:
90
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
8500
Captain / Total hours on type:
6700.00
Copilot / Total flying hours:
8000
Copilot / Total hours on type:
3500
Aircraft flight hours:
35496
Aircraft flight cycles:
89680
Circumstances:
On April 28, 1988, an Aloha Airline Boeing 737, N73711, was scheduled for a series of interisland flights in Hawaii. The crew flew three uneventful roundtrip flights, one each from Honolulu to Hilo (ITO), Kahului Airport, HI (OGG) on the island of Maui, and Kauai Island Airport (LIH). At 11:00, a scheduled first officer change took place for the remainder of the day. The crew flew from Honolulu to Maui and then from Maui to Hilo. At 13:25, flight 243 departed Hilo Airport en route to Honolulu. The first officer conducted the takeoff and en route climb to FL240 in VMC. As the airplane leveled at 24,000 feet, both pilots heard a loud "clap" or "whooshing" sound followed by a wind noise behind them. The first officer's head was jerked backward, and she stated that debris, including pieces of gray insulation, was floating in the cockpit. The captain observed that the cockpit entry door was missing and that "there was blue sky where the first-class ceiling had been." The captain immediately took over the controls of the airplane. He described the airplane attitude as rolling slightly left and right and that the flight controls felt "loose." Because of the decompression, both pilots and the air traffic controller in the observer seat donned their oxygen masks. The captain began an emergency descent. He stated that he extended the speed brakes and descended at an indicated airspeed (IAS) of 280 to 290 knots. Because of ambient noise, the pilots initially used hand signals to communicate. The first officer stated that she observed a rate of descent of 4,100 feet per minute at some point during the emergency descent. The captain also stated that he actuated the passenger oxygen switch. The passenger oxygen manual tee handle was not actuated. When the decompression occurred, all the passengers were seated and the seat belt sign was illuminated. The No. 1 flight attendant reportedly was standing at seat row 5. According to passenger observations, the flight attendant was immediately swept out of the cabin through a hole in the left side of the fuselage. The No. 2 flight attendant, standing by row 15/16, was thrown to the floor and sustained minor bruises. She was subsequently able to crawl up and down the aisle to render assistance and calm the passengers. The No. 3 flight attendant, standing at row 2, was struck in the head by debris and thrown to the floor. She suffered serious injuries. The first officer tuned the transponder to emergency code 7700 and attempted to notify Honolulu Air Route Traffic Control Center (ARTCC) that the flight was diverting to Maui. Because of the cockpit noise level, she could not hear any radio transmissions, and she was not sure if the Honolulu ARTCC heard the communication. Although Honolulu ARTCC did not receive the first officer's initial communication, the controller working flight 243 observed an emergency code 7700 transponder return about 23 nautical miles south-southeast of the Kahalui Airport, Maui. Starting at 13:48:15, the controller attempted to communicate with the flight several times without success. When the airplane descended through 14,000 feet, the first officer switched the radio to the Maui Tower frequency. At 13:48:35, she informed the tower of the rapid decompression, declared an emergency, and stated the need for emergency equipment. The local controller instructed flight 243 to change to the Maui Sector transponder code to identify the flight and indicate to surrounding air traffic control (ATC) facilities that the flight was being handled by the Maui ATC facility. The first officer changed the transponder as requested. At 13:50:58, the local controller requested the flight to switch frequencies to approach control because the flight was outside radar coverage for the local controller. Although the request was acknowledged, Flight 243 continued to transmit on the local controller frequency. At 13:53:44, the first officer informed the local controller, "We're going to need assistance. We cannot communicate with the flight attendants. We'll need assistance for the passengers when we land." An ambulance request was not initiated as a result of this radio call. The captain stated that he began slowing the airplane as the flight approached 10,000 feet msl. He retracted the speed brakes, removed his oxygen mask, and began a gradual turn toward Maui's runway 02. At 210 knots IAS, the flightcrew could communicate verbally. Initially flaps 1 were selected, then flaps 5. When attempting to extend beyond flaps 5, the airplane became less controllable, and the captain decided to return to flaps 5 for the landing. Because the captain found the airplane becoming less controllable below 170 knots IAS, he elected to use 170 knots IAS for the approach and landing. Using the public address (PA) system and on-board interphone, the first officer attempted to communicate with the flight attendants; however, there was no response. At the command of the captain, the first officer lowered the landing gear at the normal point in the approach pattern. The main gear indicated down and locked; however, the nose gear position indicator light did not illuminate. Manual nose gear extension was selected and still the green indicator light did not illuminate; however, the red landing gear unsafe indicator light was not illuminated. After another manual attempt, the handle was placed down to complete the manual gear extension procedure. The captain said no attempt was made to use the nose gear downlock viewer because the center jumpseat was occupied and the captain believed it was urgent to land the airplane immediately. At 13:55:05, the first officer advised the tower, "We won't have a nose gear," and at 13:56:14, the crew advised the tower, "We'll need all the equipment you've got." While advancing the power levers to maneuver for the approach, the captain sensed a yawing motion and determined that the No.1 (left) engine had failed. At 170 to 200 knots IAS, he placed the No. 1 engine start switch to the "flight" position in an attempt to start the engine; there was no response. A normal descent profile was established 4 miles out on the final approach. The captain said that the airplane was "shaking a little, rocking slightly and felt springy." Flight 243 landed on runway 02 at Maui's Kahului Airport at 13:58:45. The captain said that he was able to make a normal touchdown and landing rollout. He used the No. 2 engine thrust reverser and brakes to stop the airplane. During the latter part of the rollout, the flaps were extended to 40° as required for an evacuation. An emergency evacuation was then accomplished on the runway.
Probable cause:
The failure of the Aloha Airlines maintenance program to detect the presence of significant disbonding and fatigue damage, which ultimately led to failure of the lap joint at S-10L and the separation of the fuselage upper lobe. Contributing to the accident were the failure of Aloha Airlines management to supervise properly its maintenance force as well as the failure of the FAA to evaluate properly the Aloha Airlines maintenance program and to assess the airline's inspection and quality control deficiencies. Also contributing to the accident were the failure of the FAA to require Airworthiness Directive 87-21-08 inspection of all the lap joints proposed by Boeing Alert Service Bulletin SB 737-53A1039 and the lack of a complete terminating action (neither generated by Boeing nor required by the FAA) after the discovery of early production difficulties in the 737 cold bond lap joint, which resulted in low bond durability, corrosion and premature fatigue cracking.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain off Molokai: 8 killed

Date & Time: Dec 23, 1987 at 1853 LT
Operator:
Registration:
N712AN
Flight Phase:
Survivors:
No
Site:
Schedule:
Honolulu – Molokai
MSN:
31-7652151
YOM:
1976
Flight number:
PV082
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
2987
Captain / Total hours on type:
617.00
Aircraft flight hours:
6516
Circumstances:
The flight was to be flown across a 22 mile channel between islands on an overcast night with no moon and no ground reference lights. The aircraft disappeared from radar and, after extensive searches, could not be found. A three dimensional flight track was reconstructed using recorded radar data. The data indicated that in the last 60 seconds the aircraft slowed from 170 to 95 knots, gained 500 feet in altitude, and turned left 190° before abruptly disappearing from radar. Flight tests indicated that the movements of the aircraft in the last 60 seconds of the flight were consistent with a loss of the left engine, without compensation by the pilot. The operator's training program did not provide for night or instrument flight conditions. The last documented instrument time for the pilot was 15 months prior during a checkride. The pilot flew sporadic night flights. The pilot had previously flown during the day and was on his thirteenth hour of duty. The wreckage and all eight occupants were never found. However it is believed it crashed about 13 miles northwest of Maunaloa, on Molokai Island.
Probable cause:
Occurrence #1: loss of engine power
Phase of operation: cruise - normal
Findings
1. (f) 1 engine - undetermined
----------
Occurrence #2: loss of control - in flight
Phase of operation: cruise - normal
Findings
2. (f) light condition - dark night
3. (c) aircraft control - not maintained - pilot in command
4. (f) spatial disorientation - pilot in command
5. (c) airspeed (vmc) - not maintained - pilot in command
6. (f) fatigue (flight and ground schedule) - pilot in command
7. (f) lack of recent instrument time - pilot in command
8. (f) inadequate training - company/operator management
9. (c) stall/spin - inadvertent - pilot in command
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Honolulu

Date & Time: Nov 20, 1987 at 1124 LT
Operator:
Registration:
N27512
Survivors:
Yes
Schedule:
Kona - Honolulu
MSN:
31-7852035
YOM:
1978
Flight number:
PV084
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4190
Captain / Total hours on type:
1685.00
Aircraft flight hours:
6315
Circumstances:
The pilot estimated that the aircraft's reduced fuel quantity was adequate for the flight during his preflight inspection. As the aircraft descended for the traffic pattern near the destination airport both engines failed. After the loss of power the pilot executed a forced landing into a park with the landing gear not fully extended. The aircraft impacted the terrain and slid into a fence before coming to a stop.
Probable cause:
Occurrence #1: loss of engine power (total) - nonmechanical
Phase of operation: descent - normal
Findings
1. (c) fluid, fuel - exhaustion
2. (c) fuel consumption calculations - inaccurate - pilot in command
3. (f) preflight planning/preparation - inadequate - pilot in command
----------
Occurrence #2: forced landing
Phase of operation: descent - emergency
----------
Occurrence #3: on ground/water collision with object
Phase of operation: landing
Findings
4. (f) object - fence
5. Gear extension - not attained - pilot in command
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 Beechcraft H18 off Honolulu

Date & Time: Jul 17, 1984 at 0600 LT
Type of aircraft:
Registration:
N21S
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Honolulu - Lihue
MSN:
BA-690
YOM:
1964
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4772
Captain / Total hours on type:
99.00
Circumstances:
During takeoff at about 50 feet agl and 4,000 feet down runway 04R, the right engine lost power. According to the pilot, his airspeed was 105 mph and the right engine 'popped' before it lost power. He also stated that power on the left engine deteriorated after the the right prop was feathered. The aircraft went into a right bank and the pilot maintained control of the aircraft until impact with the water. Examination of the right engine revealed that the right magneto, american bosch sb9ru-3, ser #b88470, was not timed correctly. Disassembly of the magneto revealed that all except 11 distributor gear teeth were stripped off. At the time of the power loss of the right engine, about 5,000 feet of rwy was remaining.
Probable cause:
Occurrence #1: loss of engine power (total) - mech failure/malf
Phase of operation: takeoff - initial climb
Findings
1. (c) ignition system, magneto - failure,total
----------
Occurrence #2: forced landing
Phase of operation: landing - flare/touchdown
----------
Occurrence #3: ditching
Phase of operation: landing - flare/touchdown
Findings
2. (c) in-flight planning/decision - improper - pilot in command
3. (c) emergency procedure - improper - pilot in command
4. (c) aborted takeoff - not performed - pilot in command
Final Report:

Crash of a Beechcraft H18 off Kona

Date & Time: Sep 8, 1983 at 0934 LT
Type of aircraft:
Operator:
Registration:
N2990F
Flight Phase:
Survivors:
Yes
Schedule:
Kona - Honolulu
MSN:
BA-753
YOM:
1968
Flight number:
PV060
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8026
Captain / Total hours on type:
2960.00
Aircraft flight hours:
16873
Circumstances:
About one minute after takeoff, between 400-500 feet msl and during the first power reduction, the right engine backfired. Following some more violent backfires the rpm went to zero. The right engine was restarted but the same result occurred. The pilot attempted to feather the right prop but to no avail. The aircraft was then deliberately ditched to avoid an outcropping of lava. The aircraft came to rest in about 25-30 feet of water. Engine inspection revealed that the #2 cylinder exhaust rocker arm shaft, p/n45937, was missing. Drive train continuity was established with the exception of the #2 exhaust valve. Centrifugal stops prevent feathering of the prop below an engine speed of 500 rpm. All 10 occupants were rescued.
Probable cause:
Occurrence #1: loss of engine power (total) - mech failure/malf
Phase of operation: takeoff - initial climb
Findings
1. (c) exhaust system, actuator - separation
----------
Occurrence #2: ditching
Phase of operation: landing - flare/touchdown
Findings
2. (f) propeller feathering - not possible - pilot in command
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in the Pacific Ocean: 2 killed

Date & Time: Dec 9, 1982 at 0228 LT
Registration:
N74957
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Oakland - Honolulu
MSN:
31-7305106
YOM:
1973
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
6000
Captain / Total hours on type:
100.00
Aircraft flight hours:
5093
Circumstances:
The aircraft departed Oakland, CA at 1733 PST on a night flight to Honolulu, HI. The flight proceeded without incident until approximately 0050 PST when the pilot advised that the left engine was slowly losing oil pressure. At that time, the aircraft was at an altitude of 6,000 feet. At 0205, the pilot reported he shut down the engine and was unable to maintain 6000 feet. A descent was started. In his last transmission at 0228 PST, the pilot reported that he was at 500 feet, barely maintaining altitude. Radio contact was lost when the aircraft was approximately 500 miles east of Honolulu. At 1559, the crew of a search aircraft sighted floating debris and one body floating in that area. A marker buoy was deployed, but no recovery was accomplish. The aircraft was presumed to have been destroyed and both occupants were presumed to have been fatally injured. The aircraft crashed in moderate sea conditions with waves heights estimated at three to five feet.
Probable cause:
Occurrence #1: loss of engine power
Phase of operation: cruise
Findings
1. (c) reason for occurrence undetermined
2. (f) fluid,oil - pressure too low
3. Propeller feathering - intentional - pilot in command
----------
Occurrence #2: ditching
Phase of operation: landing
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: landing - flare/touchdown
Findings
4. (f) light condition - night
5. (f) terrain condition - water,rough
Final Report:

Crash of a Beechcraft C-45G Expeditor off Waimanalo: 3 killed

Date & Time: Oct 3, 1982 at 1510 LT
Type of aircraft:
Operator:
Registration:
N215H
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Honolulu - Honolulu
MSN:
AF-405
YOM:
1953
Flight number:
PV055
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
6904
Captain / Total hours on type:
2529.00
Aircraft flight hours:
15860
Circumstances:
The purpose of the flight was to be a reindoctrination/training flight for the second-in-command. Witnesses observed the aircraft off shore flying parallel to the cliffs approximately 500 feet over the water. The aircraft banked left then right to a 90° right wing low attitude wing-over type maneuver and descend into the ocean off Waimanalo. The aircraft was not recovered. All three occupants were killed.
Probable cause:
Occurrence #1: in flight collision with terrain/water
Phase of operation: maneuvering
Findings
1. (c) flight controls - improper use of - pilot in command
Final Report:

Crash of a Beechcraft E18S in Hakalau: 2 killed

Date & Time: Apr 29, 1982 at 2134 LT
Type of aircraft:
Operator:
Registration:
N6911
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Hilo - Honolulu
MSN:
BA-445
YOM:
1959
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4200
Captain / Total hours on type:
775.00
Aircraft flight hours:
14216
Circumstances:
The aircraft departed Hilo on the last leg of a three flight. A few minutes after takeoff, the pilot called the tower to ask for return and indicated he had a difficulty. No further transmission was made. Witnesses heard intermittent engine sputtering and then the whine of a high speed dive. The aircraft impacted in a sugar cane field at a steep angle. Both pilots were killed.
Probable cause:
Occurrence #1: loss of engine power
Phase of operation: climb - to cruise
Findings
1. (c) reason for occurrence undetermined
----------
Occurrence #2: loss of control - in flight
Phase of operation: maneuvering - turn to reverse direction
Findings
2. (f) light condition - dark night
3. (c) aircraft handling - not maintained - pilot in command
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Convair CV-440 Metropolitan in Pearl Harbor

Date & Time: Jan 17, 1982 at 2245 LT
Operator:
Registration:
N21DR
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Honolulu - Kahului
MSN:
325
YOM:
1956
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3550
Captain / Total hours on type:
88.00
Aircraft flight hours:
40846
Circumstances:
After liftoff, the pilot called for the landing gear to be raised. As the plane was climbing through about 100 feet agl, the pilot noted a loss of power in the right engine and saw a fire light. Ground witnesses heard a muffled explosion and saw smoke and fire trailing from the right engine. The right engine was feathered and the pilot attempted to return to the airport, but was unable to maintain altitude. The plane was ditched near the entrance of Pearl Harbor. A tear down of the right engine revealed that the top ring lands of the n° 10 and n°14 pistons were broken and the top ring was missing from each of the pistons. Also, the rear counterbalance drive intermediate gear was worn and 11 gear teeth were missing. Additionally, the rear counterbalance drive gear was worn.
Probable cause:
Loss of engine power and mechanical failure during initial climb due to partial piston failure. The following findings were reported:
- Engine assembly, ring, partial failure,
- Fire, explosion,
- Dark night.
Final Report: