NTSB CAROL · Event
Event LAX95FA031
Aircraft involved
Probable cause & findings
Improper loading of the airplane. Contributing to the accident was the pilot's failure to maintain minimum control airspeed.
Factual narrative
HISTORY OF FLIGHT
On November 4, 1994, at 1130 hours Hawaiian standard time, a Piper PA-28-140, N3198Q, was destroyed after descending into a commercial building during the initial climb at the Honolulu International Airport, Honolulu, Hawaii. According to the communications tapes at Honolulu Air Traffic Control Tower (ACTC), the pilot had declared an emergency and was returning to the airport. The accident occurred about 1/4-mile north of the airport. Visual meteorological conditions prevailed for the personal cross-country flight, and a VFR Hawaiian Island Reporting Service (IRS) flight plan had been filed. Both the pilot and passenger received fatal injuries. The airplane departed runway 4L, destined for Lihue Airport on the island of Kauai. The pilot obtained a preflight weather briefing prior to departure. At 1126:48, Aloha Airlines flight 354 (AAH354), a Boeing 737, was cleared for takeoff on runway 8L from intersection "Lima" with 7,500 feet of runway remaining. At 1127:23, while the accident airplane was still on taxiway "Charlie", the Honolulu ACTC cleared the airplane to "cross runway 4R and runway 4L cleared for takeoff caution wake turbulence for the departing Boeing." The clearance was repeated again at 1127:35 to the accident airplane. The pilot read back the clearance except for the caution wake turbulence. According to radar data, at 1128:05, AAH354 was passing through 2,000 feet msl. At 1129:12, the pilot of the Piper was requested (and he acknowledged) a left turn direct to Tripler Hospital, and resume the Redhill 3 departure at pilot's discretion. At 1129:52, the pilot was requested to contact departure. Five seconds later, the pilot stated that "we need to return to the airport uh we're declaring an emergency." According to the radar data the accident airplane did not climb above 200 feet msl.
LEFT SEAT PERSONNEL INFORMATION
Both of the pilots were partners in the accident airplane's ownership according to an FAA aircraft registration application dated May 9, 1992,. According to the previous owner of the airplane who helped load the plane for the trip, the owner in the right front seat was not flying, nor did he have a valid medical certificate. The left seat pilot's last flight physical was conducted on April 28,1994. At that time, he reported a total flight time of 300 hours, with 30 hours in the last 6 months. According to limited logbook information, the left seat pilot received a biennial flight review on June 5, 1993, in the accident airplane. The last logbook entry was on October 3, 1994, for a flight in the accident airplane. A voice tape was obtained from the FAA ATCT. According to a family member who listened to the voice on the tape, it was that of the left seat pilot.
RIGHT SEAT PERSONNEL INFORMATION
The right seat pilot/partner reported a total flight time of 600 hours at his last flight physical conducted on October 24, 1991. The limited logbook information that was recovered documents an entry indicating a total flight time of 713.9 hours, with two other untotaled pages of about 30 additional hours. The last documented log entry was on September 15, 1993.
AIRCRAFT INFORMATION
The records for the airplane were not recovered. According to the maintenance technician who performed the last annual inspection on November 13, 1993, the airplane had accumulated about 3,330.56 hours of flight time. The weights of the two occupants were obtained from the medical examiner, plus the weight of 26 pounds of personal items that the coroner had recovered. The baggage/cargo that had not been consumed in the postcrash fire was recovered and weighed. It included masonry tools, skill saw, 6 and 12-inch tiles, clothes, toiletries, bookkeeping records, mail, a life raft and a large ice chest, among other things. This weight combined with the aircraft empty weight, less the weight of the removed rear seat, was 2,391 pounds. According to the Piper Aircraft's Pilot Operator Handbook, the aircraft maximum gross weight is 2,150 pounds.
METEOROLOGICAL INFORMATION
The Honolulu scheduled weather observation at 1055 hours was reporting: 2,400 feet scattered; 3,900 feet scattered, estimated 7,000 feet broken, 23,000 broken; visibility 20 miles, temperature 83 degrees Fahrenheit, dew point 69 degrees Fahrenheit, wind 060 degrees at 14 knots; and the altimeter was 30.01 inches of mercury. The Honolulu airport has 5 wind sensors located at various points on the airport. The wind direction and speeds are automatically averaged by the system. That information is then provided to the pilots. At 0824, the pilot had called the Honolulu FSS by telephone and filed a VFR, Hawaiian Island Reporting Service (IRS) flight plan. The pilot requested and received an abbreviated preflight pilot brief for his route of flight from Honolulu to Lihue.
AIRPORT INFORMATION
AAH354 departed from runway 8L at intersection "LIMA" with about 7,500 feet remaining. According to the Aloha chief pilot, AAH354 should have rotated at about intersection "INDIA". The accident aircraft departed from runway 4L, a 6,952-foot- long runway which intersects runway 8L at a 40-degree angle. Maintenance work on the approach end of 8L had been notamed (notice to airmen) for about 2 weeks prior to the accident.
WRECKAGE AND IMPACT INFORMATION
Postcrash examination of the accident site revealed that the airplane had collided with the corrugated sheet metal roof of a commercial warehouse building about 1/4-mile northeast of the departure runway. Examination of the roof structure revealed four parallel slash marks spaced about 12 inches apart. The fourth slash had transected a steel purlin in the roof structure. Three large squirrel cage type cooling vents were damaged during the collision, two were knocked from the roof. Examination of the right wing revealed that the right landing gear had penetrated the sheet metal roof. The main upper casting of the gear remained attached to the wing structure. The oleo and wheel assembly had separated. The right wing tip was noted to be damaged. Midspan upward bending of the wing structure was noted. The left wing was found inverted with the landing gear assembly severed from the wing. The two wings were separated by a hole in the roof, which was measured to be about 4 to 5 feet in diameter. The left wing tip was noted to be damaged with corresponding paint transfer to a squirrel cage. The wing was damaged by the postaccident fire. The aft fuselage and empennage was destroyed by the postaccident fire, with only the steel components recovered. The stabilator trim barrel was recovered, and measured at 2 degrees of nose-up trim. The maximum nose-up trim is 12 degrees. The front seats, with some floor structure including the engine and propeller, were found inside the building on the floor about 20 feet below the roof.
MEDICAL AND PATHOLOGICAL INFORMATION
On November 7, 1994, the Honolulu Medical Examiner performed autopsies on both pilots. According to the autopsy reports, the cause of death was attributed to multiple traumatic injuries for both occupants. No preexisting conditions were noted during the autopsies that would have adversely affected the decedents abilities to pilot an airplane. Samples were obtained from both pilots for toxicological analysis by the FAA Civil Aeromedical Institute in Oklahoma City, Oklahoma. The results of the toxicological analysis were negative for all screened drug substances and alcohol.
ADDITIONAL INFORMATION
According to the FAA Controllers Handbook 7110.65H, a wake turbulence advisory and a 2-minute separation is required from heavy jet departures of 300,000 pounds or more. The Boeing 737, is less than 300,000 pounds. A wake turbulence advisory was not required to be given to the accident pilot. On November 15, 1994, Mrs. Annie Geerin, widow of an owner of the accident airplane, was contacted by telephone regarding the release of wreckage, NTSB Form 6120.15. She stated that she did not want to sign the form, nor have anything to do with the airplane wreckage or its contents. According to insurance coverage sources, there was no insurance coverage for the airplane at the time of the accident. The wreckage was left hangared, in the care custody and control of the Honolulu Airport management. THE PIPER PA-28-140, AIRCRAFT OWNER/PILOTS WERE DEPARTING FOR THE ISLAND OF KAUAI TO PERFORM SOME MASONRY WORK. THE ACCIDENT SITE WAS LOCATED ABOUT 1/2-MILE FROM THE RUNWAY END. THE AIRPLANE WAS LOADED WITH MASONRY TOOLS, TILES, CLOTHES, A LIFE RAFT AND A LARGE ICE CHEST. THE BAGGAGE/CARGO THAT HAD NOT BEEN CONSUMED IN THE POSTCRASH FIRE WAS WEIGHED. THE AIRPLANE WAS OVER MAXIMUM ALLOWABLE GROSS WEIGHT BY ABOUT 241 POUNDS. THE REAR SEAT HAD BEEN REMOVED AND ITS WEIGHT SUBTRACTED FROM THE LOAD WHICH WAS NOT SECURED. WITNESSES SAW THE AIRPLANE FLYING LOW AND SLOW WITH A NOSE-HIGH ATTITUDE. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_1994_LAX95FA031.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (wake turbulence, turbulence, maintenance). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
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The paper reviews NASA's efforts on wake vortex turbulence minimization by aerodynamic design or retrofit modifications to large transport aircraft.
- NASA NTRS 2019 · Conference Paper
Wake Turbulence Mitigation for Arrivals (WTMA)
The preliminary Wake Turbulence Mitigation for Arrivals (WTMA) concept of operations is described in this paper. The WTMA concept provides further detail to work initiated by the Wake Vortex Avoidance…
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Aircraft wake turbulence avoidance
Aircraft wake turbulence /trailing vortex systems/ avoidance during flight, describing procedures for pilots and tower operators
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- Embry-Riddle Scholarly Commons 2025 · Journal article (JAAER)
Political Turbulence and Aviation Safety: A Cross-National Analysis of Political Stability's Effects on Aviation Accidents
To what extent does political stability affect aviation safety? This research aims to link domestic political conditions and public safety through the consideration of aviation accident frequency.
- SKYbrary (Eurocontrol) 2023 · SKYbrary article
Wake Vortex Turbulence — SKYbrary Knowledge Base
SKYbrary wake vortex turbulence comprehensive article — generation mechanics, dissipation factors, separation standards (ICAO LIGHT/MEDIUM/HEAVY/SUPER + recategorisation RECAT-EU).
Browse the full corpus — academia portal ↗