Thursday, June 7, 2018

Beech 19A Musketeer Sport, N6142N: Fatal accident occurred July 28, 2017 in Waipi'o, Hawaii

Dean "Dingo" Hutton, private pilot 

Alexis Aaron, passenger

 Heather Riley and Gerrit Evensen, passengers

The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Honolulu, Hawaii
Lycoming Engines; Chandler, Arizona
Textron Aviation; Wichita, Kansas

Aviation Accident Factual Report - National Transportation Safety Board:

Investigation Docket - National Transportation Safety Board:
Location: Waipi'o, HI
Accident Number: WPR17FA170
Date & Time: 07/28/2017, 1852 HST
Registration: N6142N
Aircraft: BEECH 19A
Aircraft Damage: Substantial
Defining Event: Controlled flight into terr/obj (CFIT)
Injuries: 4 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On 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 

Pilot Information

Certificate: Private
Age: 29, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 1 Without Waivers/Limitations
Last FAA Medical Exam: 08/22/2012
Occupational Pilot: No
Last Flight Review or Equivalent: 05/04/2017
Flight Time:  (Estimated) 127.5 hours (Total, all aircraft), 6.3 hours (Total, this make and model), 60 hours (Pilot In Command, all aircraft), 10 hours (Last 90 days, all aircraft), 5 hours (Last 30 days, all aircraft)

A 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 and Owner/Operator Information

Aircraft Manufacturer: BEECH
Registration: N6142N
Model/Series: 19A
Aircraft Category: Airplane
Year of Manufacture: 1969
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: MB-413
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: 02/01/2017, Annual
Certified Max Gross Wt.: 2250 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 5072 Hours as of last inspection
Engine Manufacturer: LYCOMING
ELT: Installed, activated, aided in locating accident
Engine Model/Series: O-320 SERIES
Registered Owner: On file
Rated Power: 150 hp
Operator: On file
Operating Certificate(s) Held: None 

The 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.

Dean "Dingo" Hutton, pilot 

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 Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: PHNL, 13 ft msl
Observation Time: 1853 MST
Distance from Accident Site: 13 Nautical Miles
Direction from Accident Site: 40°
Lowest Cloud Condition: Few / 2500 ft agl
Temperature/Dew Point: 27°C / 20°C
Lowest Ceiling: None
Visibility:  10 Miles
Wind Speed/Gusts, Direction: 12 knots/ 23 knots, 60°
Visibility (RVR):
Altimeter Setting: 29.96 inches Hg
Visibility (RVV):
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Honolulu, HI (PHNL)
Type of Flight Plan Filed: None
Destination: Honolulu, HI (PHNL)
Type of Clearance: None
Departure Time: 1837 HST
Type of Airspace: 

An 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. 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: 3 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 4 Fatal
Latitude, Longitude:  21.427222, -158.084722 (est) 

The 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. 

Medical And Pathological Information

The 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. 

Additional Information

FAA-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.

NTSB Identification: WPR17FA170 
14 CFR Part 91: General Aviation
Accident occurred Friday, July 28, 2017 in Waipi'o, HI
Aircraft: BEECH 19A, registration: N6142N
Injuries: 4 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On July 28, 2017, about 1852 Hawaii standard time (HST), a Beech BE-19A, N6142N, collided with terrain near Waipi'o, Hawaii. The airplane was registered to a private individual and operated by Aircraft Maintenance Hawaii as a 14 Code of Federal Regulations Part 91 personal flight. The private pilot and three passengers sustained fatal injuries; the airplane sustained substantial damage. Visual meteorological conditions prevailed, and no flight plan had been filed. The local flight departed Honolulu International Airport (HNL), Honolulu, Hawaii, about 1837 HST.

The Federal Aviation Administration issued an alert notice (ALNOT) at 1322 HST, July 29, when family members reported that the flight was overdue. The US Coast Guard located the wreckage later that day on steep, mountainous terrain at the last identified latitude and longitude .

A review of recorded air traffic control communications indicated that the airplane departed HNL runway 04R. Recorded radar data displayed the airplane's secondary beacon code as it departed and made a left turn to the northwest. After flying about 9 minutes along that course, the target made a left turn, and was at a mode C reported altitude of 1,800 feet mean sea level (msl). It made descending and climbing turns during the next 6 minutes. During the last minute, it climbed and was at a maximum mode C altitude of 2,000 feet when the target disappeared.


Anonymous said...

Another smart ass punk killing people

Jim B said...

Another avoidable accident. Lives lost.

Anonymous said...

Thinking with the wrong head.

Anonymous said...

^^ Agree with above comments.

808pilot said...

Stuffing four fully grown adults into a Beech 19 and then trying to fly it in hot and humid Hawaiian weather...

I should think you wouldn't even need to do a W&B to know that's a stupid idea. Sadly though, there are just as many dumb pilots as there are dumb drivers, but now we have one less...