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B190, vicinity Lihue Hawaii, 2008

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Summary
On 14 January 2008, a single pilot Beech 1900C on a non scheduled mail flight which had departed from Honolulu disappeared during a visual dark night approach at its destination. The Investigation concluded that the pilot had become spatially disoriented and lost control of the aircraft.
Event Details
When January 2008
Actual or Potential
Event Type
Human Factors, Loss of Control
Day/Night Night
Flight Conditions VMC
Flight Details
Aircraft BEECH 1900
Operator Alpine Aviation
Domicile United States
Type of Flight Public Transport (Cargo)
Origin Honolulu International Airport
Intended Destination Lihue
Take off Commenced Yes
Flight Airborne Yes
Flight Completed No
Flight Phase Descent
ENR / APR
Location - Airport
Airport vicinity Lihue
HF
Tag(s) Distraction,
Manual Handling,
Spatial Disorientation
LOC
Tag(s) Flight Control Error"Flight Control Error" is not in the list (Airframe Structural Failure, Significant Systems or Systems Control Failure, Degraded flight instrument display, Uncommanded AP disconnect, AP Status Awareness, Non-normal FBW flight control status, Loss of Engine Power, Flight Management Error, Environmental Factors, Bird or Animal Strike, ...) of allowed values for the "LOC" property.
Outcome
Damage or injury No
Aircraft damage Hull loss
Injuries Most or all occupants
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) None Made
Investigation Type
Type Independent

Description

On 14 January 2008, a Hawker Beechcraft Corporation 1900C being operated by Alpine Air on a non-scheduled mail flight from Honolulu to Lihue on the island of Kauai as AP 253 and on an IFR flight plan in night VMC disappeared from radar on final approach to destination shortly after a related MSAW alert had been annunciated. The aircraft was subsequently found to have crashed.

Investigation

The NTSB carried out an investigation, It was found that during descent to 2000 feet QNH at pilot's discretion, the controller had advised that other traffic would be overtaking him and that he should expect a visual approach at Lihue number 2 to the other aircraft. The flight was then transferred to advisory frequency and was subsequently lost from radar about 6.5 miles south-southeast of the airport. The aircraft was destroyed by impact forces and the pilot presumed killed. It was concluded that the 38 year-old pilot had become spatially disoriented and had lost control of the aircraft.

The formal determination of Probable Cause was "the pilot's spatial disorientation and loss of situational awareness.

Two Contributory Factors were also identified:

  • the dark night conditions
  • the task requirements of simultaneously monitoring the cockpit instruments and the (position of the) other airplane.

The Final Report of the Investigation was adopted on 6 May 2009.

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