NTSB Factual Report

History of the Flight

On April 22, 1992, at about 1553 hours Hawaiian standard daylight time, a Beech E-18S, N342E, operated by Scenic Air Tours, Inc., as Scenic 22, collided with mountainous terrain on the Island of Maui, in the Haleakala National park, near Makawao, Hawaii. The airplane was destroyed by impact and a post impact fire. The certificated airline transport pilot and eight passengers received fatal injuries. The airplane was being operated as a scenic tour flight under the provisions of 14 CFR Part 135 when the accident occurred. The flight originated in Hilo, Hawaii, at 1512 hours for a return flight to Honolulu, Hawaii, as a completion of a tour that departed Honolulu at 0700 hours. Instrument meteorological conditions prevailed at the time and a VFR flight plan was filed.

The operator reported the flight overdue at 1657 hours. The airplane wreckage was located at about 0630 hours, by search personnel on April 23, 1992, about one mile east of Magnetic Peak, near the summit of the Haleakala Crater. The accident location is in an area of volcanic boulders, on downsloping terrain on the south rim of the crater at about 9,660 feet, mean sea level.

Scenic 22 was marketed as Tour No. 5, the "Volcano Special". After Departing Honolulu, the flight was planned to proceed eastbound along the north shore of the islands of Molokai, Maui, and Hawaii, landing at Hilo at about 0900 hours. On the accident date, the route of flight from Honolulu to Hilo for Scenic 22 differed from the planned route, as a landing in Maui was conducted to drop off a van driver employed by the company. Upon arrival in Hilo, passengers then deplaned to participate in local area ground tours of the island of Hawaii. The return flight was scheduled to depart Hilo, at about 1500 hours for the return flight to Honolulu, arriving at about 1630 hours.

The operator reported that the normal return route of flight is a departure from Hilo; flight westbound along the north coast of Hawaii; upon reaching Upolu point, continued flight westbound on about a 294 degree magnetic heading to overfly Molokini Island, located between Maui and Kahoolawe Island; and returning to Honolulu on about a 290 degree magnetic heading. Upon completion of the flight to Honolulu, the pilot was scheduled to fly to Maui, pick up tourists, and return to Honolulu.

A second Scenic tour flight number 23, landed at Hilo after the arrival of Scenic 22, with a tour, and the two pilots waited at the airport for the return of their passengers.

The pilot of Scenic 23 reported that he departed about 1542 hours, placing it about 70 miles and 30 minutes behind Scenic 22. Scenic 23 reported that once airborne, at about 1550 hours, he contacted Scenic 22 on a company used radio frequency and asked the position of flight 22. In response, the pilot of flight 22 reported that he was..."37 DME off Upolu Point", then words to the affect of..."standby, checking Lanai." No other communications were received from Scenic 22. The pilot of Scenic 23 reported that his return flight to Honolulu was conducted initially at 2,000 feet MSL. He later climbed to 3,000 feet and finally 6,000 feet while crossing the Alenuihaha Channel. He reported that the cloud conditions in the area of Makena, Maui, were scattered, with the cloud tops at about 8,000 feet MSL. He could not see Mt. Haleakala due to haze that limited visibility in his area of flight to about 5 miles.

The Federal Aviation Administration, Honolulu Flight Service Station (FSS) reported that the accident airplane departed Hilo at 1512 hours, and the pilot opened his VFR flight plan at about 1520 hours. The FSS specialist provided a full weather briefing, which included an advisory that VFR flight was not recommended over the interior sections of all islands, and a forecast for isolated areas of 3 miles visibility due to haze and moderate rain showers. At about 1542 hours, the pilot requested the status of restricted area R-3104, located over the island of Kahoolawe. The restricted area prohibits flights into the area if flight restrictions are in force. On the accident date, the airspace was restricted below 5,000 feet. The pilot stated to the FSS that he would transit the restricted area at 6,500 feet. The flight routing requested by the pilot was authorized for the next 30 minutes and would have placed the airplane on about a 287 degree magnetic heading. No other communications were received from flight 22. At about 1553 hours, the FSS monitored an emergency locator transmitter (ELT) signal, received through a remote sensor on Mt. Haleakala. The signal ceased at 1600 hours.

An employee of the Pacific Tsunami Warning Center, located near the summit of Haleakala Crater, reported that a seismic sensor recorded a "local" seismic event at 1554 hours, with a duration of 20 seconds. No other seismic activity was recorded during the day.

The accident occurred during the hours of daylight at latitude 20 degrees, 42.33 minutes north and longitude 156 degrees, 14.48 minutes west.

Injuries to Persons

Fatal Injuries to crew - 1 Fatal Injuries to passengers - 8 Total Fatal Injuries - 9

Crew Information

The pilot, held an airline transport pilot certificate, that was issued on January 14, 1991, with an airplane multiengine land and instrument airplane ratings. He held commercial privileges for airplane single engine land. The most recent first class medical certificate was issued to the pilot on February 11, 1992 and contained no limitations.

No personal flight records were located for the pilot and the aeronautical experience was obtained from a review of the airmen FAA records on file in the Airman and Medical Records Center located in Oklahoma City, pilot resumes, employment applications, and previous employer records.

A Scenic Air Tours Inc., Pilot Experience Form, completed by the pilot on July 28, 1991, indicated that his total aeronautical experience consisted of 3,400 flight hours, of which 3,200 was pilot-in-command. The form listed multiengine experience that consisted of 1,450 hours; and instrument experience of 400 hours, of which 150 hours accrued in actual instrument conditions. Safety Board investigators conducted an examination of the pilot's employment history, and were able to document only 2,057 hours of total aeronautical experience, which included a total of 765 hours of multiengine experience. An inquiry with past employers revealed that the pilot had been employed by at least 9 employers, including two positions with Scenic, from 1988 to the accident date. Five of the previous employers dismissed the pilot. Causes for dismissal included misrepresentation of qualifications andexperience, failure to report to duty, disciplinary action, training performance, and work performance.

In 1991, a scheduled FAR Part 135 operator rejected the pilot's application for a pilot position for failing to disclose information and misrepresentation concerning previous employment. An examination of that file also revealed that a fraudulent letter of recommendation had been submitted on stationary from the pilot's most recent employer. See Appendix A for details of the pilots aeronautical experience.

The pilot's experience in the accident airplane make and model was accrued at Scenic, and totaled 464.7 hours. Reconstruction of the pilot's flight and duty time indicates the following:

Duty time last 24 hours - 12 Duty time last 72 hours - 33 Duty time last 30 days - 125.5 Duty time last 60 days - 343 Duty time last 90 days - 464

Flight time last 24 hours - 4.5 Flight time last 72 hours - 10.5 Flight time last 30 days - 44.0 Flight time last 60 days - 108.8 Flight time last 90 days - 138.8

The pilot was initially employed with Scenic Air Tours in 1988 as a van driver. In July 1991, he was rehired as a pilot. The Director of Operations for Scenic reported that a pre-employment check of the pilot's aeronautical experience consisted of a telephone call to a previous employer. From July 29, 1991, to August 2, 1991, the pilot received initial new hire training, which included 16 hours of ground training, and 3.6 hours of flight training. The operator reported that prior to beginning flight training, the pilot went on 5 or 6 familiarization (FAM) rides as an interested observer to learn the routes. Prior to going on line as a tour pilot-in-command, the pilot received 1 initial operating experience (IOE) route check. On February 20, 1992, the pilot received an 14 CFR Part 135 competency and proficiency check ride, administered by the Director of Operations, who is an authorized FAA check airman for the company.

The company Director of Operations reported that he encouraged each pilot to develop a notebook that served as a memory aid, and included tour routes, recommended headings and altitudes, and distances between islands. The pilot's personnel booklet was not in the airplane at the time of the accident. It was located at the pilot's residence and contained in part, the following:

"Intercepting the 310 degree radial (Victor 22) of the ITO Vortac (frequency 116.9) after departure from ITO will lead you to Akaka Falls, a popular sightseeing attraction located along the Hamakua coast/north shore of the island of Hawaii. Further continuation of the ITO 310 degree radial will place you north of Hana, Hawaii, which is located on the northeastern tip of Maui. Use of the Upolu Point (UPP) Vortac (frequency 112.3) 335 degree radial, will also lead you to Hana. The 294 degree radial of UPP will lead you to Makena, which is a small settlement located on the southeastern tip of Maui."

The booklet did not contain any DME distances between the UPP Vortac and the island of Maui.

FAA personnel recovered a blue flight bag from the scene of the accident that was believed to belong to the pilot. The contents included xerox copies of Hawaiian Islands, Instrument Approach Plates, and 3 VFR aviation navigational charts, one of which was a sectional chart of the Hawaiian Islands.

Aircraft Information

The airplane was manufactured in 1957. The passenger seating configuration was last modified by STC SA19250 for 9 high density passenger seats on December 8, 1975. On June 29, 1981, the airplane's maximum gross takeoff weight was increased to 10,100 pounds by Supplemental Type Certificate (STC) SA572WE. The airplane had accumulated a total time in service of 15,925 flight hours. Examination of the maintenance records revealed that the most recent annual inspection was accomplished on February 2, 1992, 145 flight hours before the accident. In addition, a 100-hour inspection was completed on March 29, 1992, 49 flight hours before the accident.

The left engine had accrued a total time in service of 6,499.4 hours of operation, and 1,485.4 hours since a major overhaul. The right engine had accrued a total time in service of 5,596.9 hours of operation, and 555.9 hours since a major overhaul. Annual and 100-hour inspections were accomplished on the dates specified above for the airframe.

Fueling records at Hilo, established that prior to departure on the accident flight, the aircraft was fueled with the addition of 60.2 gallons of 100LL octane aviation fuel.

The airplane was equipped with basic gyroscopic and navigational equipment required for instrument flight. The operator reported that the equipment is not inspected and maintained to the FAA standards required for instrument flight. An interview with the pilot that flew the accident airplane prior to the accident revealed no unusual maintenance problems with the airplane. The compass and directional gyro (DG) performed satisfactorily, although the DG required resetting to match the magnetic compass heading about every 10 to 20 minutes due to precession. A VOR receiver check was usually not conducted, however past experience revealed that a comparison between radar position reports and the VOR, indicted that the two would agree on location. The VOR receiver did not show erroneous information during flight.

A passenger manifest/weight and balance form for each flight is completed by the pilot. The form lists passenger names and weights that are obtained from tour company agents. Passenger weights are primarily based on visual observations of the tour agents, or provided by the passenger. Passengers are not weighed and the operator does not own a set of scales.

The passenger manifest for the flight was completed and signed by the Captain. An examination of the manifest revealed that the recorded passenger weight prior to the departure from HNL did not subtract the weight of a passenger who had cancelled. The manifest also indicates that the flight took on 340 pounds of fuel in Maui, and no fuel in Hilo.

Despite these two errors, Safety Board investigators calculated the weight and balance of the airplane was within the certified weight and balance limits. Meteorological Information

The closest official weather observation station is Kahului, Maui, which is located about 16 nautical miles northwest of the accident site. At 1554 hours, a surface observation was reporting in part:

Sky condition and ceiling, 1,500 feet scattered, measured ceiling 4,000 feet broken, 6,500 feet overcast; visibility, 15 miles; temperature, 77 degrees F; dew point, 67 degrees F; wind, 360 degrees at 7 knots; altimeter, 29.84 inHg.

The summit of Mt. Haleakala has several research facilities, including observatories operated by the University of Hawaii. A solar observer at the Mees Observatory, located about 3/4 mile west of the accident site, reported that at the time of the accident, fog was present, forcing the closure of the observatory dome from about 1430 to 1730 hours. He indicated that fog was coming up the southern slope of the volcano, the wind was from the south at about 10 - 15 MPH, and the cloud layer was thick at 9,500 to 10,000 feet mean sea level.

A witness who was hiking in park area, reported that between about 1545 and 1615 hours, he was standing at the White Hill observation point near the volcano summit. He indicated hearing what he believed to be a multiengine airplane headed toward him from the general direction of Magnetic Hill. The engine sounds were heard for about 10 to 15 seconds and seemed to be running smoothly. He did not observe the airplane or hear the crash. He also reported that the crater was totally obscured by heavy, rolling clouds.

An Automated Meteorological Observation System (AMOS) weather station is located near the summit of the volcano and is operated by the National Weather Service (NWS). At the time of the accident, wind conditions were reported to be 256 degrees at 10 MPH. Also present near the summit is a time lapse video camera utilizing a wide angle lens that records the cloud and fog activity at the summit. The camera is aimed in a northeasterly direction. This view is toward the accident site and about 200 feet higher that the crash site. An exposure is recorded at 8 second intervals. In the period 1 hour before and 1 hour after the accident, the video documents almost continuous cloud cover moving over the summit of the crater.

A U.S. Marine Air Corp pilot operating a C12 airplane, call sign KBAY 18, reported flying within 2 miles south of the crater center at about 1550 hours, at 21,000 feet MSL. The volcano crater area was surrounded by a heavy cloud layer. An opening in the cloud cover of about 350 yards by 350 yards enabled one of the observatory domes, located in an area known as Science City, to be visible; otherwise the crater was totally obscured.

At 1554 hours, a NWS specialist on duty at the Kahului Airport, performed visual observations of the volcano. He indicated that no rain showers were observed. Clouds were hanging over the slopes leading to the crater. He could not see the summit area due to cloud obscuration.

Aids to Navigation

The Honolulu Flight Inspection Field Office conducted enroute flight checks of the Upolu and Hilo Vortac facilities on May 5 and 6, 1992. Several of the checks were conducted at 6,500 feet MSL. Satisfactory performance was observed.

Communications

There were no reports of communications equipment o

NTSB Probable Cause

THE CAPTAIN'S DECISION TO CONTINUE VISUAL FLIGHT INTO INSTRUMENT METEOROLOGICAL CONDITIONS THAT OBSCURED RISING MOUNTAINOUS TERRAIN AND HIS FAILURE TO PROPERLY USE AVAILABLE NAVIGATIONAL INFORMATION TO REMAIN CLEAR OF THE ISLAND OF MAUI. CONTRIBUTING TO THE ACCIDENT WAS THE FAILURE OF SCENIC AIR TOURS TO CONDUCT SUBSTANTIVE PILOT PREEMPLOYMENT BACKGROUND SCREENING, AND THE FAILURE OF THE FEDERAL AVIATION ADMINISTRATION TO REQUIRE COMMERCIAL OPERATORS TO CONDUCT SUBSTANTIVE PILOT PREEMPLOYMENT SCREENING. (NTSB REPORT AAR-93/01)