NTSB Factual Report

1.1 HISTORY OF FLIGHT

On April 18, 2004, about 1645 Hawaiian standard time, a Piper, PA 28-161, N8198A, impacted rising terrain near Holoaloa, Hawaii. Above It All, Inc., d.b.a. Island Hoppers, was operating the airplane under the provisions of 14 CFR Part 135. The commercial pilot and two passengers sustained serious injuries; the airplane was destroyed. The on demand cross-country tour flight departed Kona International Airport (KOA), Kailua/Kona, Hawaii, at 1620 to conduct a 2-hour tour of the volcanos and return to KOA. Visual meteorological conditions prevailed, and a visual flight rules (VFR) flight plan had been filed. The primary wreckage was at 19 degrees 12.318 minutes north latitude and 155 degrees 48.777 minutes west longitude.

At 1646, the pilot made a cellular 911 telephone call and reported that she had crashed about 10 miles south of Milolii, Hawaii. The County of Hawaii Fire Department dispatched a helicopter and fire crews to the area and attempted to locate the accident site. Due to the inaccurate location, the reduced visibility because of low clouds and rain showers in the area, the failure of the Emergency Locating Transmitter (ELT) to activate, and the loss of daylight, they were unable to immediately locate the accident site. The U.S. Coast Guard responded. With the use of a helicopter and night vision equipment, the accident site was located at about 2200. The passengers and pilot were removed from the accident site by use of the helicopter's hoist system. The actual accident site was located 6 miles northeast of Milolii.

The pilot and passengers all received serious burns from the post impact fire.

During the transportation to the hospital, the pilot stated she encountered a downdraft. She did not report any mechanical failures or malfunctions with the airplane prior to the accident.

The operator submitted a written report.

1.1.1 Passengers' Statements

The National Transportation Safety Board investigator-in-charge (IIC) interviewed the two passengers on May 21, 2004, and May 22, 2004. They related the following:

The two passengers arrived at Island Hoppers for a tour of the Big Island. It was sunny at KOA. They met the pilot and saw her "check out the airplane." When they made a comment about the pilot's young age, a representative from Island Hoppers indicated that she had been flying for "a number of years." After the passengers boarded the airplane, the pilot briefed them on the location of the fire extinguisher and use of the door exit handle, and helped them buckle their seat belts.

The flight departed at 1430. The pilot provided tour information along the way. Within 10 minutes of takeoff, they began to encounter weather, specifically the weather would "get bad, clear up, and get bad again." According to the female passenger who was seated in the right rear, it was rainy and foggy, but the flight was not bumpy or turbulent. She could not see the hillsides or the ground but could see the ocean at times. The pilot advised them that the sun would probably be shining on the other side of the mountain. After a discussion about the weather, the pilot became quiet, no longer providing tour information. The male passenger who was seated in the right front opined that he did not believe the pilot was familiar with the aircraft or the area by the way she handled the tour.

According to the male passenger, they were in the clouds and then could see the mountain in front of them. According to the female passenger, the pilot was maneuvering the airplane. She thought the pilot was trying to get out of the weather. The pilot was trying to climb, but "there was too much hill there." The pilot stated something to the effect of "I'm too low. It won't climb. I can't get it to go up. Oh my God, we're going to hit. I'm so sorry." They were not in the weather for long when they flew over some trees and then hit the ground. The male passenger hit his head on the instrument panel during the impact sequence. According to the female passenger, the airplane seemed to hit very slow.

The airplane began to burn as soon as it impacted the terrain. The pilot helped the male passenger unbuckle his seat belt. The male passenger helped the pilot and the female passenger exit the airplane. They ran about 40 feet and took refuge in a lava gap. The aircraft made a loud "boom" noise.

It was raining on and off from the time they hit the ground until they were rescued. It was still early in the day when they crashed, but it was dark from the clouds.

The pilot used the passenger's cellular telephone to call 911 emergency response personnel. The 911 personnel kept asking the pilot where they were, and she kept saying, "I don't know; you have to find us." Once the airplane stopped burning, they crawled back into the airplane shell to get out of the wind and rain. The pilot left to get help. The male passenger continued talking to 911 personnel.

The passengers heard the rescue helicopter fly by on two occasions. The third time, the male passenger crawled out on the wing of the airplane and waived something in the air to get the helicopter's attention. The Coast Guard helicopter located the wreckage and picked up the passengers and the pilot. Approximately 6 hours had elapsed from the time of impact until they were rescued.

1.1.2 Pilot's Statement

A Safety Board investigator interviewed the pilot on June 10, 2004. The pilot reported the following:

The pilot awoke at 0600 on the date of the accident. She did not have a flight scheduled until late in the afternoon but went to Island Hoppers at 0900 in an attempt to fly with someone else. Another pilot agreed she could fly with him. They conducted a preflight inspection shortly before 1100. The 1100 flight was a tour in a Cessna 207, which would circle the island. The flight ended around 1300.

Upon return, the pilot checked the weight and balance information for her upcoming flight, checked the weather, and filed a flight plan. According to the weather briefing, "heavy rain was reported in Hilo, and the wind was blowing between 12 and 15 knots." There was no other significant weather reported at the time.

The passengers arrived and spoke with the pilot while they waited for the flight airplane to arrive back. When the plane arrived, the pilot's boss fueled the airplane, while the pilot conducted the preflight inspection. She provided the passengers with a preflight safety briefing and briefed the passengers on their route of flight.

A few minutes after 1600, the flight departed. The pilot called the flight service station to open her flight plan. She received a weather update, but it only pertained to the Hilo side of the island. According to the pilot, the flight was "perfect." She had a sectional map in her kneeboard and another map with the reporting points and points of interest depicted. She had gone around the island 11 times previously.

As the flight neared Milolii, the pilot initiated a climb to 3,500 feet and followed the highway (with the airplane to the left of the highway to allow viewing by the rear passenger). At this point, everything was fine. There was rain on the coast, which she could see through, and clouds near the mountain. The flight remained in visual flight rules (VFR) conditions over the highway.

The pilot said that shortly after passing Milolii, she "could feel a strong downdraft" and noticed the vertical speed indicator (VSI) needle depicting a more than 1,000 feet/minute descent rate. The airplane was then "blown toward the mountain" very fast, and the pilot said she was "fighting to stay straight and level." She stated that she could not turn left due to a tailwind. She turned right, facing into the wind, and added full power. The airplane then slowed and she reported the "headwind was very powerful." While turning the airplane, the pilot heard the stall warning horn on a couple of occasions and she was afraid of getting into a stall/spin situation. She kept turning the airplane to the right, but she could not remember how far to the right she turned. Up until the point of the downdraft, the pilot was confident in her location. She had been heading in a southeasterly direction. She could not recall what direction she was pushed by the downdraft. She did not know how high she was at the time, but they normally flew 1,500 feet above the ground.

They were getting closer to the ground, and the pilot told the passengers that they may have to land. The terrain was a "very rough lava field with woods scattered about." She "became scared" when she saw the terrain. She noted a spot with bushes and turned right to see it better. She wanted to go further to the right to the shoreline, but the downdraft prevented her from doing so because of the sink rate. She continued to fly toward the bushes and told the passengers that they were going to land. She did not turn off the engine because she needed the power to offset the downdraft. As they flew over the intended landing spot, she reduced engine power. The airplane "flew backwards" due to the force of the wind. She then added full power and landed "like a helicopter."

After the airplane impacted the mountain, the pilot noted no one was injured on the landing. The emergency locator transmitter (ELT) did not go off. She was not aware of this at the time of the accident. After the airplane came to rest and the front seat passenger began to open the door, a fire erupted (approximately 10 to 15 seconds after impact). The fire started at the front of the airplane and worked its way toward them. As the front seat passenger exited the airplane, the "flames were following him out of the airplane." The pilot helped the rear seat passenger out of the airplane then followed her out.

They moved away from the airplane. It began to rain heavily, and it was very cold. The pilot attempted to call 911 many times. The 911 operator asked her "weird" questions, such as how much they weighed. The pilot knew they were close to Milolii, but because of the turns she made during the downdraft, she did not know if she was north or south of town.

When the fire was out, they returned to the airplane for shelter. After they heard a helicopter fly over, the pilot walked away from the wreckage in an attempt to find help. She subsequently fell into a hole. She waited there until she heard rescuers. She called for help, and Coast Guard personnel assisted her back to the accident scene.

Prior to the date of the accident, the pilot underwent 32 hours of ground training. She also flew the route once with the president of the company and three or four times with the chief pilot. She also observed a number of tour flights conducted by other pilots. The accident flight was the first tour flight conducted by herself. There were no anomalies with the airplane and/or engine.

1.1.3 Other Pilot Interviews

On April 23, 2004, Safety Board investigators interviewed two pilots; one pilot was employed by Island Hoppers and had flown a tour with the accident airplane just prior to the accident flight. The other tour pilot was employed by Mokulele Flight Service, and had departed on a tour flight from KOA about 15 minutes before the accident flight.

The Island Hopper pilot related that he departed KOA about 1300 in the accident airplane. He related that the weather did not allow him to fly the normal route; he had to stay along the shoreline due to low clouds. He completed the tour of the volcanos. Upon his return, he told the accident pilot about the low visibility and the low clouds.

The Mokulele Flight Service pilot related that when he departed on his last tour of the day, about 1600, the weather in the area of the accident was bad with low visibility, had light rain, and the mountains obscured. He made the decision to fly along the shore because of the low clouds.

1.2 PERSONNEL INFORMATION

A review of Federal Aviation Administration (FAA) airman records revealed that the pilot held a commercial pilot certificate with ratings for airplane single engine land, multiengine land, and instrument airplane. The pilot held a certified flight instructor (CFI) certificate with a rating for airplane single engine land and instrument airplane.

The pilot held a second-class medical certificate that was issued on April 15, 2004. It had no limitations or waivers.

An examination of the pilot's flight records indicated an estimated total flight time of 1,254 hours. She logged 910 hours in the last 12 months and 53 in the last 30 days. She had en estimated 50 hours in this make and model. She completed a 14 CFR Part 135 check ride on April 15, 2004.

The operator reported that the pilot had been employed with the company since April 7, 2004. The accident flight was the pilot's first 14 CFR Part 135 revenue flight.

1.3 AIRCRAFT INFORMATION

The airplane was a Piper PA-28-161, serial number 28-8216144. A review of the airplane's logbooks revealed a total airframe time of 9,371 hours at the last 100-hour inspection. The logbooks had an entry for an annual inspection dated March 4, 2004. The total time on the airplane at the time of the accident was 9,379 hours.

The engine was a Textron Lycoming O-320-D3G, serial number L-14070-39A. Total time since major overhaul (SMOH) of the engine at the time of the accident was 392 hours.

Fueling records at Island Hoppers established that the airplane was last fueled on April 18, 2004, with a total of 35 gallons of 100-octane aviation fuel. Examination of the maintenance and flight department records revealed no unresolved maintenance discrepancies against the airplane prior to departure.

1.4 METEOROLOGICAL CONDITIONS

A staff meteorologist for the Safety Board prepared a factual report, which included the following weather for the departure area, route of flight, and destination.

The closest weather surface observing site to the accident location was the Kailua/Kona automated surface observing system (ASOS). This station was located about 35 nautical miles from the accident site at 337 degrees. Near the time of the accident, the ASOS station was reporting winds out of the southeast at 6 knots, a 10-mile visibility, and scattered sky conditions at 5,500 feet above ground level. Data from the South Shore Hawaii weather radar (HWA) indicated echoes along the south shore of the island at the time of the accident, with reflectivity values as high as 50 dBZ. Velocity Azimuth Display (VAD) data from this radar also suggested easterly winds at upper levels of the atmosphere. Because of the mountain ridge separating the accident location from the radar site, a measure of echo intensity near the accident location could not be derived from HWA. However, the 0.50 scan from the Kamuela radar (HKM) at 0245Z noted reflectively values between 5 and 10 dBZ in the vicinity of the accident site. This radar did not sense echo returns along the southern portion of the western shore. Geostationary Operational Environmental Satellite (GOES) visible imagery valid at 0230Z showed clouds in the accident region, and RAOB (RAwinsonde Observation), a program used to display and analyze upper air data, showed the potential for mountain wave activity in the area, with maximum vertical velocities on the order of 100 feet per minute. Further, an AIRMET valid at the time of the accident suggested temporary moderate turbulence below 6,000 feet immediately south and west of mountainous terrain.

1.5 COMMUNICATIONS

The airplane was not in contact with, nor required to be in contact with, with any FAA facility. The area of the accident site has no radio communications for the use of flight following. The tour operators utilize a common aircraft frequency to report between aircraft their position and altitude and direction of travel.

1.6 WRECKAGE AND IMPACT INFORMATION

Investigators from the Safety Board, the FAA, Piper, and Textron Lycoming, who were parties to the investigation, examined the wreckage at the accident scene on April 21, 2004.

The first identified point of contact (FIPC) was a ground scar. The terrain was a rugged 20-degree ups

NTSB Probable Cause

The pilot's continued flight into adverse weather conditions that resulted in an in-flight collision with mountainous terrain. Factors in the accident were rising terrain, low clouds and rain, and the pilot's lack of familiarity with the geographic area.