Hang On

“N13GZ verify going direct TAMMI?”

“13GZ is off navigation here…we’re gonna…we’re gonna give it a try.”

Air traffic control, responding to the pilot’s odd transmission, simplified the clearance, issuing just a heading and an altitude. There was a pause on frequency. Then the pilot said:

“Hang on.”

After more silence, Honolulu Center gave a new heading and a lower altitude. There was no answer. ATC announced loss of transponder data. A Piper Seminole on frequency spoke up, saying he saw a plane spiraling down before its lights disappeared. That pilot circled the approximate area but reported seeing nothing but water.

An extensive Coast Guard search operation was launched. It found only a few airplane parts floating on the waves. The King Air had hit the water at high speed. The pilot and both nurses on board had died on impact. The King Air was eventually located by a specialized deep-water survey and salvage vessel at a depth of 6,400 feet. It was inverted, mostly intact, although missing its wingtips and empennage. 

Most crashes like this remain somewhat mysterious forever. An experienced pilot in a well-equipped plane on a clear night—then “hang on” and it was over. 

But this accident was different. Among the wreckage pulled up from the depths was a cockpit video recorder. The operator had installed an Appareo Vision 1000 airborne image recording system (AIRS) that captured the instrumentation for both seats, as well as the center pedestal and overhead panel. The National Transportation Safety Board (NTSB) was able to use the recordings, along with a lot of interviews, to determine what happened over the dark waters 10 miles south of Kaupō, Hawaii, on December 15, 2022.

We’ll start just before the crash and work backward. Descending through 4,000 feet, the yoke moved quickly forward then aft in a “jolt-like manner.” There was a sound that investigators described as “similar to a loud metallic bang.” It was the tail separating from the fuselage. Fifteen seconds later, the remaining airframe impacted the water. This mechanical failure was the defining point of no return. But why did the empennage break off?

When ATC gave the clearance direct to the TAMMI intersection, the pilot reached over to the GPS unit and pressed several buttons. The plane had been in a slight left descending turn, but now it rolled to the right. The roll was not checked by the pilot and continued past 60 degrees of bank and the descent rate increased. When the controller asked to “verify going direct TAMMI,” the plane was descending at 3,500 fpm in an increasingly steep spiral. 

The bank angle reached 90 degrees, the airspeed showed 226 kias with the engine gauges still all normal. The plane rolled inverted. Extreme aerodynamic stresses of the out-of-control descent eventually caused the tail to separate. 

Takeoff from Kahului Airport (PHOG) looked routine. Beautiful weather for a 21-minute flight around Maui and south to Waimea–Kohala Airport (PHMU). The autopilot was engaged at 160 feet. As the King Air was climbing through 1,400 feet, the pilot passed money to a nurse seated in the cabin. As the flight climbed through 4,500 feet, the pilot opened a music app on his cell phone and placed it in the empty copilot seat. 

On the way through 8,000 feet, the pilot repeatedly played with the multifunction display (MFD) that handled primary navigation duties. The screen was blank and unresponsive. NTSB review of cockpit video showed the MFD wasn’t working on the last four flights. This issue had not been recorded in the daily maintenance records. 

Cruising at 11,000 feet, the autopilot disconnected, its alert tone sounding as warning lights illuminated. The airplane’s main vertical gyro had failed, which in turn failed the pilot’s electric attitude director indicator (EADI, or artificial horizon). This avionics failure was a serious problem. They were over the ocean, off the dark east side of Maui, with the moon still below the horizon. Without an attitude indicator, in conditions with no natural horizon, it’s scary easy to lose control.

The King Air, a workhorse used by commercial operations worldwide, has a backup to the main gyro instruments. The copilot panel has an independent mechanical attitude indicator that provides pitch and bank information. It’s smaller than the main EADI, and the pilot has to awkwardly look across the cockpit to use it, but it should have got them home. They didn’t, however, head for home.

The pilot did not declare an emergency, or make any of the required reports of equipment malfunction. He was now hand-flying at night over the ocean, looking across the cockpit to the copilot attitude indicator. He was navigating using the secondary GPS because the main MFD was not working. A sharp pilot should be able to handle this workload without losing control. However, the NTSB uncovered another layer in this accident.

The pilot was experienced, with more than 7,000 hours total time and several jet type ratings, as well as being instructor certificated in airplanes and helicopters. He also held a master dive license and a Coast Guard ship captain’s license. A snowboarder, surfer, mountain biker, and sailor, he’d been on adventures all around the world. 

Yet he also had a troubled training record. The NTSB notes that “from 2009 to 2019, pilot had six Notice of Disapproval entries on his certification records: three for rotorcraft and three for fixed-wing—each one the culmination of multiple unsatisfactory training events.” Anyone can fail a check ride. I have. But six? Training records “detailed consistent deficiencies in use of navigational systems, instruments, and multiengine aircraft maneuvering.”

Hired in 2019 by the air ambulance company, the pilot was scheduled for six King Air simulator training sessions. He received five unsatisfactory ratings. He was given two extra sim sessions and in 2020 judged ready for line flying. In three years of employment, he had the normal schedule of a training event about every six months. He failed three of the six check rides on the first attempt.

The NTSB interviewed several management pilots. More than 1,500 pages of transcripts reveal that the company was surprised when confronted with these training records, unable to recall details, and expressed concern about the breakdown in intra-company communication. Corporate seemed to point to this being a Hawaii assistant chief pilot issue, along with “communities are so tight-knit out there that I think that there is community pressure for flying at times.”

The NTSB has recently released its final report. The crash was indeed spatial disorientation after loss of the primary attitude indicator, leading to loss of control. But the agency primarily considers this a breakdown of our larger-scale aviation system. The probable cause was the air carrier’s “inadequate pilot training and performance tracking, which failed to identify and correct the pilot’s consistent lack of skill.”