WPR10FA107

The pilot's continued visual flight into instrument meteorological conditions at an altitude insufficient to ensure adequate terrain clearance. Contributing to the accident was the air traffic controller's failure to issue a safety alert after observing the pilot's navigational deviation toward high terrain.

The non-instrument-rated pilot was on the return leg of his regular 63-nautical-mile commute between two islands. He was cleared for a visual flight rules arrival, which entailed passing over a very high frequency omni-directional radio aid (VORTAC), continuing over a golf course, and then following a freeway before entering the traffic pattern. The approach controller told the pilot to proceed to the VORTAC, but the pilot replied that he wanted a vector. The controller provided a vector and the pilot said that he did not have the island in sight. The controller told the pilot to resume his own navigation. The airplane flight path crossed over the VORTAC and proceeded north into mountainous terrain instead of the cleared arrival path. While the pilot said that he was in the rain at the golf course, radar data indicate that he was actually about 2.5 miles to the east of that location. About 1 minute 20 seconds later, the pilot said that he was inbound for landing, and the controller told him that he was heading toward the mountains. The pilot immediately requested a vector "to intercept landing," which was the last transmission he made. The controller told the pilot to make either a left or right turn southbound to a 180-degree heading. The airplane was substantially off course for almost 1 minute 30 seconds before impact. A group of hikers who were near the accident site heard the airplane operating in the clouds prior to impact. Weather at the time of the accident included light to moderate rain showers and reduced visibility that would have been encountered by the airplane. A postaccident examination revealed no evidence of a mechanical malfunction or failure with the airframe or engine prior to impact. Despite the pilot’s two radio calls suggesting disorientation during the flight’s final 90 seconds, the controller did not issue a safety alert to the pilot. Although the responsibility for flight navigation rests with the pilot, Federal Aviation Administration Order 7110.65, paragraph 2-1-6, directs controllers, in part, to “Issue a safety alert to an aircraft if you are aware the aircraft is in a position/altitude which, in your judgment, places it in unsafe proximity to terrain, obstructions, or other aircraft.” The investigation concluded that the controller had sufficient information to determine that a low altitude alert was necessary, as evidenced by her attempt to turn the airplane. A timely low altitude alert may have enabled the pilot to climb and avoid the accident. When the controller recognized that there was a problem with the airplane, she concentrated on correcting his lateral track rather than helping him immediately climb to a safe altitude.

HISTORY OF FLIGHT On January 10, 2010, about 1345 Hawaiian standard time, a Piper PA-32-300, N8934N, impacted the southeast side of a ridge while approaching the Honolulu International Airport, Honolulu, Hawaii. The pilot, who was additionally the owner, was operating the airplane under the provisions of 14 Code of Federal Regulations Part 91. The non-instrument rated private pilot and one passenger were killed. The airplane was substantially damaged during the impact and subsequent on-ground fire. The personal cross-country flight originated from Lanai Airport on the island of Lanai, Hawaii, about 1315, with a planned destination of Honolulu on the island of Oahu. Instrument meteorological conditions prevailed in the area surrounding the accident site, and the pilot was receiving visual flight rules (VFR) flight following; he had not filed a flight plan. A group of hikers were near the accident site and observed the airplane just prior to impact. One hiker reported that in "very cloudy, poor visibility," conditions he heard an airplane crash into a ridge about 50 yards from his location. He recalled that he could "hear the engine all the way," and that the airplane did not make a sound consistent with turning or pulling up. He further stated that visibility was so bad that he was not able to see the airplane. Another hiker reported that the ridge was obscured by clouds and he heard the engine "running the whole time," prior to the airplane crashing. Another hiker stated that she heard an airplane flying low and briefly observed it pass by before it disappeared in the cloud layer. A different hiker recalled that he was almost at the peak of the ridge when he noticed an airplane flying low in the mountains; he observed it crash into an adjacent ridge. Shortly thereafter, he observed the clouds move in and he could no longer see the wreckage. He stated that when the airplane impacted, there were "heavy clouds and the mountain was hard to see." Another hiker stated that she heard the airplane as it came closer and the noise became louder. It was flying toward the ocean and then suddenly turned into the mountain. An additional hiker observed the airplane flying at eye-level to him. It veered to the right and he heard it crash into the ridge. The direct route of flight from Lanai to Honolulu is about 63 nautical miles (nm) on a course of 300 degrees true. The pilot was on the Kona Arrival to Honolulu Airport at the time of the accident, which is an arrival procedure for VFR aircraft. As published, the arrival procedure is to proceed to KoKo Head very high frequency omni-directional radio range tactical air navigation aid (VORTAC) and then continue to the Waialae Golf Course. Thereafter, the pilot is to follow the H-1 Freeway to enter the left base of the traffic pattern for runway 22L. During the investigation, the recorded voice channels from the Honolulu Air Traffic Control Facility, and recorded radar data, were obtained and reviewed by a National Transportation Safety Board investigator. While the airplane was en route to Honolulu, the pilot was in communication with Honolulu air traffic controllers and receiving flight following services. At 1332:51, the approach controller directed the pilot to proceed to KoKo Head, to which the pilot replied that he would like to receive a vector. The controller provided a vector of 290 degrees, and at 1335:20, the pilot reported, "no joy on Oahu." The controller directed the pilot to resume his own navigation to runway 22L via the Kona Arrival. At 1339:10, the pilot reported that he was abeam KoKo Head and the controller replied that after passing Koko Head the pilot could descend at his discretion. Several minutes later, at 1342:40, the pilot reported that he was "in the rain at golf course [and] proceeding to Punchbowl." At 1344:00, the pilot reported that he was at Punchbowl at an altitude of 1,900 feet mean sea level (msl), and proceeding inbound for landing on runway 22L. The controller responded by stating that the airplane was in actuality "heading toward the mountains, toward the other side of the island," and that he was going into Ana Hina. The pilot immediately requested for the controller to vector him "to intercept landing," which was the last transition he made. The controller instructed the pilot to make either a left or right turn southbound to a suggested heading of 180 degrees. Recorded radar data covering the area of the accident was examined for the time frame, and a discreet secondary beacon code target was observed that matched the anticipated flight track of the airplane en route from Lanai to Honolulu. A review of the data disclosed that at 1339:10, when the pilot reported that he was abeam KoKo Head, the target at the corresponding time was located about 5 miles from the VORTAC to the east-southeast. Several minutes later, when the pilot reported he was at the golf course, the target was about 0.5 miles off the shoreline and about 2.5 miles east of the golf course. As the radar track reached land, the altitude remained at 1,700 feet until reaching the rising terrain, where the last recorded altitudes were 1,800 feet. The majority of these radar returns were spaced uniformly, and followed a track of about 330 degrees true. The last radar return was recorded at 1344:23, and located about 0.5 miles southeast of the accident site. PERSONNEL INFORMATION According to the Federal Aviation Administration (FAA) Airman and Medical records, the 81-year-old pilot held a private pilot certificate with single and multi engine land airplane ratings. A third-class airman medical certificate was issued on June 20, 2009, with the limitation that he must wear corrective lenses while exercising the privileges of his airman certificate. No personal flight records were recovered for the pilot. On the application for his last medical certificate, the pilot stated that his total flight experience was 5,900 hours. He was a member of the local United Flying Octogenarians chapter. Family members reported that the purpose of the accident flight was for the pilot, a veterinarian, to return from working on Lanai. As on almost every Sunday, the pilot commuted from Honolulu to Lanai to see veterinary patients, with his work hours ending around 1200. The pilot had a history flying on the island and had performed "thousands" of flights between Lanai and Honolulu. Although the passenger did not hold a pilot certificate, he would often fly with the pilot, his father. AIRCRAFT INFORMATION A review was conducted of the material maintained by the FAA in the Aircraft and Registry files for this airplane. The Piper PA-32-300 single-engine airplane, serial number 32-40734, was manufactured in 1969, and purchased by the pilot in February 2000. According to the airworthiness documents, the airplane was originally equipped with a Lycoming IO-540-K1A5 engine. No airplane or engine maintenance records were located in the wreckage, or submitted to the Safety Board. METEOROLOGICAL INFORMATION A routine aviation weather report (METAR) for Honolulu recorded at 1353 stated: sky condition 1,800 feet scattered, 2,400 feet broken; visibility 7 statute miles (sm) with light rain; temperature 23 degrees Celsius; dew point 21 degrees Celsius; altimeter 29.91 inches of mercury; visibility to the west 1.5 sm. Approximately 25 minutes after the accident, Honolulu reported lowered ceilings to 2,200 feet, with few clouds at 1,200 feet, in heavy rain. Analysis of Doppler weather radar at the time of the accident identified light to moderate rain showers around the southeastern edge of Oahu. Weather radar imagery also indicated Honolulu likely did not observe similar rain conditions at the time of the accident. Tops of the highest clouds reached 8,000 feet msl. An advancing, but weakening cold front pushing through the area was the cause of the inclement weather and forecast. WREC