Event WPR17FA170

Factual narrative

HISTORY OF FLIGHTOn July 28, 2017, about 1852 Hawaii-Aleutian standard time, a Beech BE-19A airplane, N6142N, collided with terrain near Waipi'o, Hawaii. The private pilot and three passengers were fatally injured. The airplane was substantially damaged. The airplane was privately owned and operated under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the local personal flight, which departed Daniel K. Inouye International Airport (HNL), Honolulu, Hawaii, about 1837. A review of recorded air traffic control communications indicated that the airplane departed HNL runway 04R. Although the airplane was not in contact with air traffic control after departure from HNL, recorded radar data displayed the airplane's secondary transponder beacon code as it departed and made a left turn to the northwest. At 1843, radar data showed the airplane at 1,800 ft mean sea level (msl) about 4 miles north of the airport and on a northwesterly heading (see figure 1). For the next 2 minutes, the airplane's altitude varied and descended to 1,500 ft when it turned west. About 1 minute later, the airplane started the first of three 360° turns. The first was a right turn at 1,200 ft. At the completion of the turn, the airplane resumed a westerly heading at 1,100 ft. Shortly thereafter, the airplane began the second 360° turn to the left, maintaining an altitude of 1,100 ft. At the completion of the turn, the airplane resumed a northerly heading and climbed to 1,600 ft. About 3 minutes after the completion of the second 360° turn, the airplane turned to the west toward a ridgeline. The airplane climbed to 1,800 ft and, about 1 minute later, began the third 360° turn to the left. At the completion of the turn, the airplane climbed to 2,000 ft on a westerly heading as it approached a ridgeline that ran perpendicular to its flight path. About 10 seconds later, the airplane initiated a descending left turn. The last target, at 1852, depicted the airplane at 1,900 ft. A witness located 1/2-mile east of the accident site reported that he saw the airplane flying "very low." He added that the airplane was making a turn and eventually went out of view. The witness reported that he heard the engine producing power then heard a "boom," followed by silence. At 1859, the Federal Aviation Administration (FAA) Honolulu Control Facility (HCF) Front Line Manager (FLM) contacted the Coast Guard to report that aircraft in the vicinity of BOOKE intersection, west of O'ahu, were receiving a strong emergency locator transmitter (ELT) signal. The Coast Guard reported that they had no active signals and advised that they did not have any further information but asked the HCF to pass on any additional reports. At 0844 the following morning, the FLM reported to the Coast Guard that the strongest signal was being received 5 nautical miles northwest of HNL. The Coast Guard reported that they had a C130 airplane returning to HNL and would do a shoreline pass. At 1239, the owner of the accident airplane reported to the HCF that his airplane was missing; an alert notice (ALNOT) was issued at 1322. The Coast Guard subsequently located the wreckage in the vicinity of the last recorded radar return on the east side of steep, mountainous terrain at an elevation of 1,900 ft. Figure 1. Radar Tracking PERSONNEL INFORMATIONA review of FAA airman records revealed that the 29-year-old pilot held a private pilot certificate with a rating for airplane single-engine land, which was issued on May 4, 2017. The pilot held an FAA first-class medical certificate issued in August 2012 with no waivers or limitations. The logbook indicated that his first flight in the Beech 19A was a checkout flight with a flight instructor on June 8, 2017, for a total of 1.3 hours. The airplane flight time log indicated that this flight was actually recorded on July 8, 2017. Three other flights in the Beech 19A were identified in the pilot's logbook, with the last logged flight on July 19, 2017. The airplane flight time log indicated that the pilot also flew on July 21, 2017 for a total time of 0.9 hour; this flight was not logged in the pilot's logbook. Based on the entries in both logbooks, the pilot had accumulated about 6.3 hours in the Beech 19A. The pilot's total flight experience was about 127.5 hours. He logged 9.1 hours in the previous 90 days, and 5.1 hours in the previous 30 days. AIRCRAFT INFORMATIONThe 4-seat, low-wing, fixed-gear airplane, serial number MB-413, was manufactured in 1969 and was powered by a 150-horsepower Lycoming O-320-E2A engine, serial number L-24212-27A. A review of the maintenance logbooks showed that the airplane had accumulated a total airframe and engine time of 5,072.11 hours at the most recent annual inspection, dated February 1, 2017. The engine time since major overhaul was 1,613.51 hours, with 153.61 hours since top overhaul. Weight and Balance A current weight and balance calculation form was located within the wreckage. The form indicated a maximum gross weight of 2,250 lbs, and an empty weight of 1,436.40 lbs. Additional paperwork located within the wreckage addressed the fuel capacity for the airplane. A highlighted section of the Beechcraft Shop Manual indicated that each of the 2 fuel tanks contained a visual measuring tab in the filler neck; the lower tab indicated 15 gallons, and the upper tab indicated 20 gallons. The owner of the airplane reported that he checked the fuel level before the accident flight and that each tank indicated about 17.5 gallons of fuel. The occupant seating locations and their weights were verified by an investigator for the Department of the Medical Examiner. The gross weight at the time of departure was estimated at 2,311 lbs, 61 lbs over the airplane's maximum certificated gross weight. Per the center of gravity envelope graph for the airplane, it was loaded near its forward center-of-gravity (CG) limit at takeoff. METEOROLOGICAL INFORMATIONAn automated surface weather observation at HNL (elevation 13 ft msl, 12 miles southeast of accident site) was issued 1 minute after the accident. It indicated wind from 060° at 12 knots gusting to 23 knots, 10 miles visibility, few clouds at 2,500 ft and 3,600 ft, scattered clouds at 7,500 ft and 20,000 ft, temperature 27°C, dew point 20°C, and an altimeter setting of 29.96 inches of mercury. An automated surface weather observation at Wheeler Army Airfield (HHI), Wahiawa, Hawaii (elevation 843 ft msl, 5 miles northeast of accident site), was issued 1 minute after the accident. It indicated wind from 070° at 3 knots, 10 miles visibility, scattered clouds at 2,000 ft, temperature 25°C, dew point 21°C, and an altimeter setting of 29.97 inches of mercury. AIRPORT INFORMATIONThe 4-seat, low-wing, fixed-gear airplane, serial number MB-413, was manufactured in 1969 and was powered by a 150-horsepower Lycoming O-320-E2A engine, serial number L-24212-27A. A review of the maintenance logbooks showed that the airplane had accumulated a total airframe and engine time of 5,072.11 hours at the most recent annual inspection, dated February 1, 2017. The engine time since major overhaul was 1,613.51 hours, with 153.61 hours since top overhaul. Weight and Balance A current weight and balance calculation form was located within the wreckage. The form indicated a maximum gross weight of 2,250 lbs, and an empty weight of 1,436.40 lbs. Additional paperwork located within the wreckage addressed the fuel capacity for the airplane. A highlighted section of the Beechcraft Shop Manual indicated that each of the 2 fuel tanks contained a visual measuring tab in the filler neck; the lower tab indicated 15 gallons, and the upper tab indicated 20 gallons. The owner of the airplane reported that he checked the fuel level before the accident flight and that each tank indicated about 17.5 gallons of fuel. The occupant seating locations and their weights were verified by an investigator for the Department of the Medical Examiner. The gross weight at the time of departure was estimated at 2,311 lbs, 61 lbs over the airplane's maximum certificated gross weight. Per the center of gravity envelope graph for the airplane, it was loaded near its forward center-of-gravity (CG) limit at takeoff. WRECKAGE AND IMPACT INFORMATIONThe wreckage was located on steep mountainous terrain at an elevation of about 1,900 ft. The airplane collided with densely-vegetated terrain in a nearly wings-level attitude about 50 ft below a ridge that ran perpendicular to the main north/south-running ridgeline. The highest point of the ridge line near the accident site was about 2,800 ft. The accident site was located south of Pohakea Pass (2,100 ft), an area commonly used by pilots to transition the inland mountains of O'ahu (see figure 2). Figure 2. Accident Site Location All major components of the airplane were located and identified in the immediate area of the main wreckage. The outboard section of the right wing, with aileron attached, separated from the inboard section at the aileron/flap junction and was located about 30 ft below the main wreckage. The inboard section of the right wing remained attached at the wing root. The right flap separated from the inboard wing section and was also located below the main wreckage. The left wing remained attached to the airframe wing root, and the aileron and flap remained intact and attached to the wing. Extensive compression-like impact damage was noted to the outboard section of the wing assembly. The tail cone was compressed and buckled to the left. The vertical stabilizer, rudder, horizontal stabilizers, and elevators remained attached to the tail. The elevator control cables and rudder cables remained attached to the flight control surfaces in the tail. Extensive impact-related damage was noted to the cockpit and cabin area. The inboard attachment points of the two front seats were impact-separated from the floor assembly. The engine remained attached to the airframe by the engine mount and was displaced upward and aft toward the firewall. The vacuum pump and drive coupler were visible from the top rear section of the engine. The carburetor was not visible due to the engine positioning and surrounding terrain. The spark plugs were secure, and their respective leads were attached. The top spark plugs were removed. The spark plug electrodes remained undamaged and displayed normal operating signatures when compared to the Champion Spark Plugs "Check-a-Plug" chart AV-27. Both magnetos appeared to be securely mounted at their respective mounting pads with their harnesses secured. The rocker box covers at cylinder Nos. 1, 2, and 4 were removed. The No. 3 cover was not removed due to corrosion of the cover screws. The rocker boxes and valve train components appeared undamaged with no evidence of oil contamination or foreign objects. The combustion chamber of each cylinder was examined through the spark plug holes via a lighted borescope. The chambers remained mechanically undamaged with no evidence of foreign object ingestion or detonation. The valves were intact and undamaged. The fixed-pitch, metal propeller blades remained partially attached to the crankshaft flange. Complete rotation of the crankshaft was not possible due to the engine position; however, partial rotation was obtained, and continuity to the vacuum pump drive was confirmed. The propeller blades displayed leading edge gouging, torsional twisting, chordwise striations across the cambered surface, and trailing edge "S" bending. The signatures were consistent with rotational forces applied at the crankshaft at the time of impact. The wreckage was not recovered and remained at the accident site. ADDITIONAL INFORMATIONFAA-H-8083-25B (2016), Pilot's Handbook of Aeronautical Knowledge, stated: The detrimental effects of overloading on performance are not limited to the immediate hazards involved with takeoffs and landings. Overloading has an adverse effect on all climb and cruise performance, which leads to overheating during climbs, added wear on engine parts, increased fuel consumption, slower cruising speeds, and reduced range. MEDICAL AND PATHOLOGICAL INFORMATIONThe Department of the Medical Examiner, Honolulu, Hawaii completed an autopsy of the pilot and concluded that the cause of death was blunt impact to the torso. The Federal Aviation Administration's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing on specimens recovered from the pilot. The results of the testing were negative for carbon monoxide, volatiles, and tested drugs. The laboratory did not perform tests for cyanide. The private pilot and three passengers departed on a local flight in day visual meteorological conditions. Radar data identified the flight shortly after takeoff at 1,800 ft mean sea level (msl), traveling on a northwesterly heading. As the flight continued, the altitude varied between about 1,100 ft and 1,800 ft as the airplane conducted three 360° turns. Following the third turn, the airplane was heading west, climbing from 1,800 ft to 2,000 ft msl as it approached a ridgeline that ran perpendicular to its flight path. Data indicated that the airplane then entered a left turn; the data ended in the vicinity of the accident site at an altitude about 1,900 ft msl. The wreckage was located on steep, mountainous terrain at an elevation about 1,900 ft msl. The airplane collided with the densely-vegetated terrain in a nearly wings-level attitude about 50 ft below a ridge that ran perpendicular to the main north/south running ridgeline. The highest point of the ridge line near the accident site was about 2,800 ft.  The accident site was located south of a pass in an area commonly used by pilots to transition the inland mountains of the island. The lowest point of the pass was about 2,100 ft. Postaccident examination of the wreckage did not reveal evidence of any mechanical failures or malfunctions that would have precluded normal operation, and a witness reported that the engine was producing power until impact. It is unknown if the pilot was attempting to cross the ridge through the pass, was planning to fly along the ridgeline when the impact occurred, or was going to attempt to climb over the higher ridge. Regardless, the pilot decided to fly at low altitude, providing him little margin for error and he failed to maintain sufficient altitude above the mountainous terrain. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12

NTSB Findings

Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).

• C Not determined-Not determined-(general)-(general)-Unknown/Not determined - C
• F Personnel issues-Action/decision-Info processing/decision-Decision making/judgment-Pilot - F
• F Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Altitude-Not attained/maintained - F
• — Environmental issues-Physical environment-Terrain-Mountainous/hilly terrain-Contributed to outcome