LAX03FA077
LAX03FA077

HISTORY OF FLIGHT

On January 25, 2003, at 1222 Hawaiian standard time, a single engine Cessna 172N airplane, N911FC, was destroyed when it impacted mountainous terrain while maneuvering approximately 5 miles east of the town of Kalaupapa on the island of Molokai, Hawaii. The student pilot, who was the sole occupant, was fatally injured. The airplane was registered to a private individual and was operated by George's Aviation Service, Inc., of Honolulu, Hawaii. The solo instructional flight was being conducted under the provisions of 14 CFR Part 91. The cross-country flight originated from the Honolulu International Airport (HNL), Honolulu, approximately 1140, and was destined for the Kahului Airport (OGG) on Maui Island, Hawaii. Instrument meteorological conditions (IMC) prevailed at the accident site at the time of the accident, and the student pilot had filed a visual flight rules (VFR) flight plan for the flight.

According to the student's flight instructor, the student was to fly from Oahu to Maui by flying over the north shore of Molokai at 3,500 feet msl. The student was utilizing an island reporting method to report his current and forecast positions to air traffic controllers and flight service stations (FSS). Reports from the Federal Aviation Administration (FAA) indicate that the student spoke with the Molokai air traffic control tower. The student was instructed to contact Honolulu radio after leaving the Molokai control area; however, the Honolulu (HNL) FSS never received the pilot's next position report (which was supposed to be over Cape Halawa on the east side of the island).

When the FSS did not receive the next radio call from the student, they issued an "alert notice (ALNOT)" for a missing aircraft. The U.S. Coast Guard started search and rescue mission flights approximately 1400. Interviews with the Coast Guard pilots, who executed the initial search efforts, revealed they encountered visual meteorological conditions (VMC) from Honolulu to the west side of Molokai. They observed hazier visibility conditions when they neared the northwest side of the island. The pilots reported encountering instrument meteorological conditions (IMC) once they passed halfway over the island, with cloud ceilings around 500 feet and visibility between 1-2 miles.

Weather hampered search efforts until January 27, 2003, when a Maui Fire Department helicopter spotted the wreckage on the west slope of the Manuahi Ridge. The burned remains of the wreckage were located approximately 1,500 feet above sea level, approximately 75 feet below the crest of the ridge.

PERSONNEL INFORMATION

The pilot obtained his third-class medical certificate and student pilot certificate on November 20, 2002. His medical certificate had no limitations placed upon it. The pilot's logbook, endorsements, and medical certificate were not located during the investigation, and were presumed burned in the wreckage. The flight school's records and flight instructor's logbook were utilized to determine the student's flight history.

The student had accumulated approximately 33 total flight hours. Of those 33 hours, the student had flown 1.2 hours of simulated instrument flight time, and 1.7 hours of pilot-in-command solo time. According to his flight instructor, this was his first solo cross-country flight. He had flown two cross-country flights with his flight instructor prior to the solo, one of which was along the same route of flight as the one the student was flying the day of the accident. The similar dual cross-country flight was conducted on January 18, 2003.

Review of the student's pre solo written examination revealed he was asked to, "Explain student pilot limitations concerning visibility and flight above the clouds." The student answered, "you can't be pilot-in-command if visibility is less than 3 statute miles during daylight or 5 statute miles at night [or] when the flight can't be made with visual references to surface."

During an interview with the flight instructor conducted by the National Transportation Safety Board investigator-in-charge (IIC), she indicated she was confident in the student's cross-country flying ability, and reported he was comfortable using navigation aides during his flights. When asked about the student's diversion training, the flight instructor reported she instructed her student to turn around and return to the departure airport if at anytime he could not visually locate the next checkpoint.

AIRCRAFT INFORMATION

The four-seat, high-wing airplane was powered by a 160-horsepower Lycoming O-320-H2AD engine. The airplane and engine underwent their last 100-hour inspection on January 19, 2003, at an aircraft total time of 8,763.5 hours, and a total time since engine overhaul of 323.7 hours. The aircraft underwent its last annual inspection on October 29, 2002, at an aircraft total time of 8,476.7 hours and a time since engine overhaul of 36.9 hours. The engine was last overhauled on October 6, 2002.

AIR TRAFFIC CONTROL AND RADAR DATA

The student filed a flight plan with the HNL FSS. According to the flight instructor, the student's planned route of flight was from Honolulu International Airport (Oahu) to Kahului Airport (Maui) via the north shore of Molokai, then return from Kahului, land at Molokai Airport, and finish back at Honolulu. The instructor added the student was to fly at an elevation of 3,500 feet on the way to Maui and 3,000 feet on the way back.

Review of unclassified radar data provided by the U.S. Army, revealed the accident airplane was at an altitude of 2,200 feet as it initially crossed the channel eastbound between Oahu and Molokai. Approximately midway over the channel, the radar data depicted the airplane at 1,700 feet. As the accident aircraft neared the east end of the channel, radar data depicted its altitude as 2,600 feet; however, as the airplane approached Ilio Point (on the northwest corner of Molokai), radar data depicted the airplane descending to 1,000 feet. The airplane proceeded eastbound along the north shore of Molokai and remained between 1,000 and 1,200 feet. As the airplane crossed over the Kalaupapa Peninsula, the radar data depicted the airplane at 1,300 feet. The last four radar returns provided by the Army radar service depicted the airplane level at 1,500 feet as it turned south towards the north coast of Molokai. The last radar return was in the vicinity of the accident site at 1221:07.

METEOROLOGICAL INFORMATION

According to the flight instructor, the student visited the HNL FSS between 0824 and 0900, for a personal weather briefing. The flight instructor then called the HNL FSS and obtained a weather briefing for the student's planned route of flight. The flight instructor met with the student at the airport approximately 1030, to review the weather printout and flight plan information.

The printed material, utilized for both the student's and the instructor's briefings, was provided to the Safety Board IIC. It should be noted that the island of Hawaii is referred to as the Big Island in the provided weather information.

Printed Weather Used for Student Briefing:

Review of the weather briefing material for the student revealed an area summary indicating a frontal shower band had just cleared the island of Molokai and was arriving over the Big Island. The summary continued by indicating the islands of Maui and Lanai would be clearing later in the morning.

An AIRMET for mountain obscurement over the islands of Lanai, Maui, and the Big Island was issued for temporary mountain obscurement above 2,000 feet in clouds and showers. The mountain obscurement conditions were forecast to end over the islands of Lanai and Maui after 1100.

An AIRMET for turbulence over the islands of Oahu, Molokai, Lanai, Maui, and Big Island was issued indicating temporary moderate turbulence was expected below 7,000 feet with the condition ending on Oahu and Molokai after 1000.

The current weather conditions provided to the student were as follows:

At 0753, in Honolulu, the wind was reported from 360 degrees at 4 knots; visibility was 10 statute miles; there were broken clouds at 7,000 feet agl; and the temperature was 20 degrees Celsius with a dew point of 18 degrees Celsius; and the altimeter setting was 29.97 inches of mercury.

At 0754, the Molokai Airport weather observation facility reported the wind from 010 degrees at 4 knots; visibility 10 statute miles; few clouds at 1,500 feet; temperature and dew point of 20 degrees Celsius; and an altimeter setting of 29.99 inches of mercury.

At 0754, the Kahului Airport (Maui) weather observation facility reported the wind from 090 degrees at 3 knots; visibility 10 statute miles; broken clouds at 4,500 feet agl; and an altimeter setting of 29.98 inches of mercury.

One of the pilot reports (PIREP) listed on the student's briefing information was provided by a Cessna 150 at 0830, between Koko Head (on the island of Oahu) and the Lanai Airport at 1,500 feet. The PIREP indicated the sky conditions as scattered between 2,000 and 2,500 feet, and broken at 7,000 feet, and a flight visibility of 10 statute miles. Another PIREP was issued at 0845 by the pilot of a Cessna 150 over the Koko Head/Molokai channel, which indicated the sky conditions were clear and the flight visibility was 10 statute miles. The remarks of that PIREP indicated "beautiful VFR conditions."

The Honolulu Area Forecast had a synopsis of the front dissipating over the Big Island moving east at 15 knots. The forecast for Oahu and Molokai was for scattered clouds at 4,000 feet agl, and temporarily scattered clouds at 3,000 feet and 4,000 feet with cloud tops at 5,000 feet. There was a chance of isolated clouds at 2,500 feet and light rain showers. The area forecast outlook called for VFR conditions.

The area forecast for south and west facing slopes, the coast, and adjacent waters of Lanai and Maui was for scattered clouds at 3,000 feet, broken to scattered clouds at 4,000 feet with cloud tops at 6,000 feet. There was also a chance for isolated broken clouds at 2,000 feet with cloud tops at 12,000 feet and visibilities between 1 - 2 statute miles in rain showers. At 1000, the forecast for the same area called for scattered clouds at 3,000 feet, broken to scattered clouds at 4,000 feet with cloud tops at 6,000 feet. There was also a chance of isolated broken clouds at 2,000 feet with cloud tops at 12,000 feet with visibilities of 3 statute miles in rain showers. At 1200, the forecast called for scattered clouds at 4,000 feet, with temporary cloud conditions scattered at 3,000 feet and broken clouds at 4,000 feet with cloud tops at 5,000 feet. There was also an isolated chance of broken clouds at 2,500 feet with light rain showers. The area forecast outlook for this area was VFR.

The terminal forecasts provided to the student pilot were as follows:

The Honolulu forecast at 0800, called for the wind from 320 at 3 knots; visibility greater than 6 statute miles; and a few clouds at 5,000 feet. At 1000, the forecast called for the wind from 150 degrees at 3 knots; visibility greater than 6 statute miles; and scattered clouds at 5,000 feet.

The Molokai Airport forecast at 0800, called for the wind out of the north at 4 knots with visibilities greater than 6 statute miles, and a few clouds at 1,500 feet and broken clouds at 5,000 feet. At 1100, the forecast called for the wind from 030 degrees at 7 knots; visibility greater than 6 statute miles; scattered clouds at 2,500 feet and 5,000 feet.
The Lahaina terminal forecast (on the west corner of Maui) for 0800, was for the wind out of the north at 5 knots; visibility greater than 6 statute miles; a few clouds at 3,000 feet; and scattered clouds at 6,000 feet. After 1000, the forecast called for the wind from 320 degrees at 5 knots and scattered clouds at 3,000 feet and broken clouds at 5,000 feet.

The Kahului terminal forecast (on the north central section of Maui) for 0800, was for the wind from 010 degrees at 5 knots; visibility greater than 6 statute miles; and scattered clouds at 2,000 feet and broken clouds at 5,000 feet. The terminal forecast called for temporary conditions of broken clouds at 2,000 feet. At 1000, the forecast called for the wind from 030 at 8 knots; visibility 6 statute miles, with scattered clouds at 2,000 feet, and scattered clouds at 5,000 feet.

The winds aloft information provided to the student for 3,000 feet over Honolulu and Kahului were 270 degrees at 10 knots and 220 degrees at 10 knots, respectively.

Weather Provided to Flight Instructor:

The tape recorded weather briefing given to the flight instructor was reviewed by the Safety Board IIC. The flight instructor requested a standard weather briefing for the flight. The briefer asked if they were planning on flying by the north shore or the south shore of Molokai. The instructor responded that they would be flying the north shore over and the south shore on the way back.

The weather briefer provided the instructor with the AIRMET for moderate turbulence below 7,000 feet, and indicated the AIRMET would be ending at 1200. The weather briefer then informed the instructor the front had passed over Maui and Lanai, leaving light and variable winds across the state and stable low clouds across the islands. The weather briefer did not state that VFR flight was not recommended.

The instructor was given the current weather at Honolulu and Kahului, which reported 3-knot winds and 10 statute miles visibility at both locations, scattered clouds at 7,500 feet over Honolulu, and a few clouds at 2,000 feet, scattered clouds at 3,000 feet, and broken clouds at 4,500 feet over Kahului. The temperature and dew point at Kahului were reported as 23 and 21 degrees Celsius, respectively.

The instructor asked for the current weather at Molokai and was given a special weather report indicating the winds were from 010 degrees at 7 knots; visibility was 10 statute miles; the clouds were broken at 2,300 and 4,900 feet; and the temperature and dew point were 23 and 20 degrees Celsius, respectively.

The instructor was also provided the PIREP in which the pilot reported "beautiful VFR conditions."

The area forecast for Oahu and Molokai was then provided to the instructor. The forecast called for scattered clouds, with occasional broken clouds at 4,000 feet with cloud tops at 5,000 feet, and isolated cloud conditions at 2,500 feet and 3 miles visibility in light rain showers.

The area forecast for Lanai and Maui south and west facing slopes called for scatted clouds at 3,000 feet and 4,000 feet with tops at 6,000 feet. Isolated broken clouds at 2,500 feet with tops at 12,000 feet and 3 miles visibility in rain was also issued in the forecast.

The weather briefer then told the instructor that after noon local time, the conditions were improving to scattered clouds at 4,000 feet, with occasional scattered clouds at 3,000 feet and broken clouds at 4,000 feet, with cloud tops at 5,000 feet. Isolated conditions called for broken clouds at 2,500 feet with light rain showers.

The briefer told the instructor that the conditions were expected to improve as the flight "headed that way." The weather briefer then told the instructor that the north and east slopes of Lanai and Maui were expecting scattered clouds at 3,000 feet, with occasional broken clouds at 4,000 feet with cloud tops at 5,000 feet. Isolated conditions continued to call for broken clouds at 2,500 feet with light rain showers.

The terminal aerodrome forecast for Kahului was given as wind from 030 degrees at 8 knots; visibility greater than 6 statute miles; and scattered clouds at 2,000 and 5,000 feet.

The flight instructor then asked for the forecast for Molokai. The weather briefer told the instructor that after 1100, the weather was forecast as wind from 030 at 7 knots; visibility greater than 6 miles; and two layers of scattered clouds at 2,500 and 5,000 feet.

The flight instructor was then given the forecast for Honolulu, which called for VFR conditions, winds aloft information for Honolulu and Kahului, and notices to airmen. The weather briefer asked if the instructor needed any additional information. The flight instructor responded in the negative and thanked the briefer.

Molokai Weather Information:

Review of the recorded weather observations for the Molokai Airport (located approximately 11 miles west of the accident site) between 1001 and the time of departure revealed VFR conditions with a few clouds between 1,600 and 1,800 feet agl, and scattered to broken clouds between 2,400 feet and 4,400 agl.

At 1154, the weather observation facility located at the Molokai Airport reported the wind from 040 degrees at 9 knots; visibility 10 statute miles; a few clouds at 800 feet agl; scattered clouds at 2,400 feet agl; and broken clouds at 5,500 feet agl. The temperature and dew point were reported as 23 and 21 degrees Celsius, respectively, and the altimeter setting was 30.00 inches of mercury.

It should be noted the Molokai Airport is separated from the accident site by 11 miles of mountainous terrain. The Molokai Airport sits at an elevation of 454 feet, and the terrain rises to the east to a peak elevation of 4,961 feet. There are no weather reporting capabilities east of the airport.

Witness Weather Reports:

A written statement provided by active military helicopter pilots belonging to the 25th Aviation Brigade indicated they were a flight of two OH-58D helicopters. They departed on their flight from Maui at 1145, and were en route at 400 feet msl to Oahu via the north shore of Molokai. According to their written statement and discussions with one of the pilots, they issued a PIREP to the Island Report System (FSS) when they were over Cape Halawa ( on the northeast corner of Molokai), and reported the weather as scattered clouds at 700 feet agl and broken clouds at 1,000 feet agl with precipitation and visibilities between 3 - 5 miles. The military pilots indicated they were monitoring the Molokai air traffic control tower frequency while they were issuing the PIREP and heard the tower talking with the accident airplane. Later, the military helicopters switched to the Molokai tower frequency, and were given a traffic advisory indicating the accident airplane was near the Kalaupapa peninsula at 1,000 feet. The second helicopter reported the airplane in sight. The helicopter pilot reported to the Safety Board IIC that this took place approximately 1225, and that he thought to himself, "At that altitude, [the airplane] is going to encounter some bad weather." The helicopter pilot further reported that as they reached Ilio Point (on the northwest corner of Molokai), the "weather improved to almost clear skies and unlimited visibility."

WRECKAGE AND IMPACT INFORMATION

The airplane wreckage was located on the side of an 80-degree mountain slope. The north shore of Molokai contains some of the highest sea cliffs in the world, which jut out of the Pacific Ocean almost 4,000 feet. The cliffs are covered with thick vegetation. The accident site was inaccessible by the Safety Board IIC; however, visual examination of the accident site and wreckage was accomplished via a helicopter. The wreckage was later reached by crash/fire and rescue personnel by rappelling down the slope. The wreckage was separated and bundled for transport to a temporary staging area, where the wreckage was examined by the Safety Board IIC and a representative from Cessna Aircraft Company.

Visual examination of the accident site revealed the airplane came to rest with its belly resting along the 80-degree sloping mountain. A horizontal linear impression in the vegetation and dirt, which was consistent with the length of the airplane's wingspan, was observed approximately 40 feet above the airplane's final resting position. Vegetation below the linear impression and above the airplane's final position was bent and broken in a downward direction. The right wing was fragmented and found on the right side of the wreckage pile. The left wing was relatively intact, but came to rest inverted on the left side of the wreckage. The empennage was upright and lying against the slope of the mountain. The engine was observed in the center of the cockpit/cabin area with its propeller flange facing aft. The cockpit and cabin area was completely destroyed by fire.

The engine, with the propeller attached, was the first component brought to the temporary staging area. The propeller spinner was crushed aft. One of the propeller blades was found twisted toward low pitch near its hub and was torn off approximately 10 inches from its hub. The other propeller blade was melted away with only approximately 10 inches remaining attached to the hub. The engine sustained extensive heat damage with all of the fuel lines found burned away. None of the accessory housings remained intact, and only their internal components were identified. The vacuum pump stator and two of its vanes remained intact, its drive was melted and the other vanes were not located. The magneto drive was intact and its teeth did not display any unusual wear marks. The oil filter remained intact and attached to the engine; however, its internal filter was destroyed by heat damage. The engine exhaust manifold was flattened.

The spark plugs, with the exception of one, which was covered by resolidified molten metal, were removed and examined. They all displayed normal wear and combustion signatures when compared with the Champion Spark Plug Check-A-Plug Chart. The number 2 cylinder's rocker arm cover was melted away, and the remaining three covers were removed. None of the rocker arms displayed any anomalies. The carburetor remained intact and attached to the engine. The engine control cables remained attached to their respective control arms; however, the cables were cut by recovery personnel for transport. The carburetor filter was removed and was found clear. The gascolator filter was found in the engine rubble and was destroyed.

Manual rotation of the propeller was attempted; however, the rusted accessory section and rocker arms, along with the extent of impact damage prevented its rotation.

The left wing was brought down to the staging area and was examined. The left wing was burned from the root outboard to the last 1/3 of the flap. The remainder of the wing sustained little to no fire damage. The lift strut remained attached to the wing. The left wing leading edge was crushed aft to the wing spar. The pitot tube remained attached and was bent outboard. The left aileron control cable remained attached to the bell crank but was cut by recovery personnel. The left flap cable was also cut by the recovery crew.

The empennage, along with the rudder controls, was brought to the staging area. The empennage remained intact, sustained fire damage aft to the horizontal stabilizer, and was separated from the fuselage from fire damage. The control cables remained attached to the control surfaces; however, the cables were cut near the fuselage area by recovery personnel.

Remnants of the right wing and fuselage were then examined. The right aileron cables remained connected to the aileron bell crank, but were separated by recovery personnel. The right wing was fractured at the aileron-flap junction.

The flap actuator was measured and found to be in the retracted position. The fuel selector valve was located in the wreckage and its fuel lines were melted away. The fuel selector was found selected to the right fuel tank and its internal components operated normally when the lever was rotated.

PATHOLOGICAL INFORMATION

The Maui Memorial Medical Center's Department of Pathology conducted an autopsy on the pilot. According to the coroner's report, the pilot died as a result of multiple traumatic injuries, and no preaccident conditions were noted.

Toxicology tests for ethanol and drugs were negative.

ADDITIONAL INFORMATION

The Hawaii Department of Transportation published a Hawaii Airports and Flying Safety Guide, which depicted the Hawaiian island reporting service checkpoints. The guide depicted the route of flight the student planned on flying (north route over Molokai; Honolulu - Mid-Channel - Ilio Point - Cape Halawa - Kahului), as well as other routes available throughout the island system, and provides instructions on how to use the island reporting system.


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