1989 — Oct 28, Aloha IslandAir Flight 1712 flies into high terrain, Molokai, HI — 20

— 20  NTSB. AAR. Aloha Island Air…Flight 1712…Halawa Point, Molokai, HI, Oct 28, 1989.

— 20  NTSB. Safety Recommendation A-90-145. 11-21-1990, page 1 of 10.

 

Narrative Information

 

NTSB AAR: “On October 28, 1989, about 1837 Hawaiian Standard Time, Aloha IslandAir, flight 1712, a de Havilland DHC-6-300, Twin Otter, N707PV, collided with mountainous terrain while en route on a scheduled passenger flight from the Kahului Airport, Maui, Hawaii, to Kaunakakai Airport, Molokai, Hawaii. …At 1825, after about 10 minutes on the ground, flight 1712 departed Kahului on a VFR flight plan and was scheduled to arrive at Kaunakakai at 1850. The departure clearance specified a departure heading of 320° and an altitude of 1,000 feet mean sea level (msl)….

 

“Two previous employers of the captain reported that he was intelligent and possessed good to excellent piloting skills. One employer believed that because flying was so easy for the captain, he became too comfortable and had developed a careless attitude toward his duties. The other employer reported that he believed the captain was careless and took unnecessary operating risks. That employer had decided to terminate him about the time he resigned to join Aloha Island Air as a ramp agent. Both of these previous employers reported that they had not been contacted by either Aloha Airlines or-Princeville/Aloha Island Air for a pre-employment reference.  They did report being contacted by other airlines to which the captain had submitted applications for employment. They both stated that they gave unfavorable references to those airlines.  An Aloha Island Air training captain stated that he had flown with the captain when the captain was a first officer and had conducted most of the captain’s upgrade flight training. He described the captain as a very skilled pilot but believed that he was “cocky and irresponsible.” He further….[reported] In one instance, while the captain was flying a scheduled operation, the other pilot observed him to “nod off” and fall asleep. On this occasion, he counseled the captain about his professional responsibilities. The instructor stated that on two occasions during upgrade training, the captain’s performance of maneuvers and instrument procedures was unsatisfactory….

 

“Shortly after leaving the Kahului…flight 1712 descended to 500 feet, an altitude that did not comply with 14 CFR Part 135 or with Aloha IslandAir’s operating procedures for night operations. The flight progressed…to a point about 2 miles east of Molokai, where it turned to a heading of approximately 260°, a heading consistent with paralleling the north shore of Molokai.

“Based on the flight track, the Safety Board concludes that in the reduced visibility conditions of darkness, low clouds, precipitation, and with the lack of lighted visual reference points on the ground, the captain of flight 1712 visually mistook the surf breaking, on Cape Halawa for the portion of land known as Lamaloa Head. Believing that the flight had passed north and east of Lamaloa Head, the captain commenced a turn to a westerly heading to parallel the north shore of Molokai. This error of misidentification caused the flight to enter into’ the north side of the Halawa Valley at an altitude substantially lower than the height of the terrain.

 

“The Safety Board believes that rather than trying to continue the VFR flight at 500 feet above   the water, the prudent action would have been for the captain to have filed IFR enroute. The Safety Board notes that the flight could have flown air route “Victor 6” to Plumb intersection and then air route “Victor 22” to Kaunakakai Airport. This IFR flight path would have added only a few minutes to the total flight time, but it would have ensured that the flight was at a safe altitude and distance from the mountainous terrain on the eastern end of Molokai.

 

“The flight path of flight 1712 did not comply with the requirements of 14 CFR Section 135.203 in that it was operating at less than 1,000 feet above the highest obstacle within a horizontal distance of 5 miles.  Flight 1712 did not comply with this regulation when it let down from 1,000 feet after clearing the Maui ARSA. As the flight approached to within 5 miles of Molokai, it was again not complying with this regulation….

 

“…the Safety Board concludes that Aloha Island Air management provided inadequate supervision of its personnel, training, and flight operations. The numerous deficiencies evident during the investigation relative to the IFR training of the pilots, the reduced ground school training, the lack of CRM training, the captain’s known behavioral traits, and the policy of not using the weather radar systems installed on the airplanes, were the responsibility of the airline’s management to correct. The failure of the management personnel to correct these deficiencies contributed to the events that led to this accident….

 

“The National Transportation Safety Board determines that the probable cause of this accident was the airplane’s controlled flight into terrain as a result of the decision of the captain to continue flight under visual flight rules at night into instrument meteorological conditions, which

obscured rising mountainous terrain. Contributing to the accident was the inadequate supervision of personnel, training, and operations by Aloha IslandAir management and insufficient oversight of Aloha IslandAir by the Federal Aviation Administration particularly during a period of rapid operational expansion….”  (NTSB. AAR. Aloha Island Air…Flight 1712… HI, Oct 28, 1989.)

 

NTSB Safety Recommendation: “….The Safety Board concludes that at the time of the accident it was too dark to avoid the clouds by visual reference and therefore it was unsafe to continue VFR [visual flight rules] flight near Halawa Point. The Safety Board further concludes that the flight entered clouds and continued into high terrain that was obscured by the clouds. The captain might have been able to see the phosphorescence of the surf breaking on the shore of Molokai. However, the forward visibility would have been severely limited by precipitation, clouds, and darkness.

 

“The 500-foot ceiling over the eastern (windward) end of Molokai was considerably lower than the 2,000-foot ceiling predicted by the Area Forecast [issued by National Weather Service], and IMC [instrument meteorological conditions] conditions existed in this region below 4,500 feet. Consequently, the Safety Board concludes that the weather forecast valid at the time of the accident was incomplete, because it did not include the possibility of low cloud conditions along

the intended route of the accident flight….Therefore, the Safety Board concludes that National Weather Service reports should include the possibility of orographic clouds whenever conditions exist that would create such clouds…. [p. 3]

 

“As a result of the Safety Board’s investigation of an accident involving a Beechcraft B-99A, Safety Recommendation A-89-91 was issued to the FAA on August 11, 1989:

 

Restrict 14 CFR Part 135 air carrier (fixed wing) passenger flights from operating in uncontrolled airspace under visual flight rules (VRF) in less than the basic VFR weather minimums of a 1,000-foot ceiling and 3 miles visibility.

 

“In its response dated October 23, 1989, the FAA stated that it believes that the current requirements of 14 DFR Section 135.205 are adequate. The FAA further stated that it did not plan to take any further action regarding this recommendation. The Safety Board believes that scheduled 14 CFR operations should be required to be conducted under instrument flight rules when low ceilings (less than 1,000 feet) or low visibilities (less than 3 miles) are forecast, reported, or encountered enroute. Therefore, the Safety Board classifies Safety Recommendation A-89-91 as ‘Closed-Unacceptable Response-Superseded.’

 

“The Safety Board maintains that passengers on board scheduled 14 DFR Part 135 flights are entitled to the additional safety margin provided by IFRE requirements. Currently, 14 CFR Part 135 requires that the airplanes used in these operations are to be equipped for IFR flight and the pilots to be IFER rated. Therefore, there is no reason that scheduled 14 CFR Part 135 flights could not be operated IFR…. [p. 4]

 

“The Safety Board believes that the accident involving flight 1712 dramatically indicates how quickly instrument flying skills and procedures can deteriorate when not used regularly.

 

“The Safety Board finds that these considerations influenced the daily operational decisionmaking processes of Aloha IslandAir pilots, including those of this captain, to the detriment of flight safety. The Safety Board believes that 14 CFR 135 should require appropriate IFR recurrent training, using vision-restricting devices. [end of p. 5]

 

“The investigation disclosed that the company placed little emphasis on crew coordination or CRM in its training. Although Aloha IslandAir believed that it addressed some elements of CRM in training, only the procedural mechanisms of crew interaction were addressed. The behavioral aspects of crew interaction were not discussed, and the investigation disclosed little awareness or understanding of the principles of CRM at Aloha IslandAir. The Safety Board notes that Aloha IslandAir has recognized this deficiency and has adopted the formal CFR program used by Aloha Airlines.

 

“In summary, the Safety Board concludes that Aloha IslandAir management provided inadequate supervision of its personnel, training, and flight operations. The numerous deficiencies evident during the investigation relative to the IFR training of the pilots, the reduced ground school training, the lack of CRM training, the captain’s known behavioral traits, and the policy of not using the weather radar systems installed on the airplanes, were the responsibility of the airline’s management to correct. The failure of the management personnel to correct these deficiencies contributed to the events that led to this accident.

 

“The investigation noted that N707PU was not equipped, nor was it required to be equipped, with a ground proximity warning system (GPWS). However, the possible benefit of a GPWS aboard flight 1712 was considered. Calculations show that a GPWS designed for commuter aircraft, such as the Twin-Otter would have given the warning ‘Too Low – Terrain’ about 0.7 seconds after the airplane crossed the coastline or about 7 seconds prior to impact. Assuming a 3-second pilot recognition and response time to this warning, a wings-level pull up with a 1.5 G load factor would have allowed the flight to clear the terrain vertically…. [p. 6]

 

“The Safety Board believes that if the flightcrew had elected to remain on its assigned ATC frequency and had continued the VFR radar traffic advisory service, the controller would have been alerted by the Minimum Safe Altitude Warning (MSAW) system that the flight was approaching an unsafe terrain situation. A controller’s observance of such a situation would have required the issuance of a safety alert to the flight regarding its situation…. [p. 7]

 

“…as a result of this accident, the National Transportation Safety Board recommends that the Regional Airline Association (RAA) and the Aircraft Owners and Pilots Association (AOPA):

 

Advise your members of the circumstances of the Aloha IslandAir accident and the safety recommendations issued as a consequence thereof. (Class II, Priority Action) (A-90-145)

 

“Also, the Safety Board issued Safety Recommendations A-90-135 through -141 to the Federal Aviation Administration; A-90-142 to the National Weather Service; and A-90-143 through -144 to Aloha IslandAir….” (NTSB. Safety Recommendation A-90-145. 11-21-1990.)

 

Sources

 

National Transportation Safety Board. Aircraft Accident Report. Aloha Island Air Inc., Flight 1712, De Havilland Twin Otter, DHC-6-300, N707PV, Halawa Point, Molokai, HI, Oct 28, 1989. Washington, DC:  NTSB (NTSB/AAR-90/05), September 25, 1990, 44 pages. Accessed 5-11-2016 at: http://libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-reports/AAR90-05.pdf

 

National Transportation Safety Board. Safety Recommendation A-90-145 (sent to President of the Regional Airline Association and the President of the Aircraft Owners and Pilots Association). Washington, DC: NTSB, 11-21-1990. Accessed 5-11-2016 at: http://www.ntsb.gov/safety/safety-recs/recletters/A90_145.pdf