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Routine practice flight fatal for two

By NTSB · March 1, 2024 ·

The accident site.

On March 20, 2022, a Cessna 172N was destroyed when it was involved in an accident about 13 miles north of Kekaha, Hawaii, on the island of Kauai. The two pilots were fatally injured.

The 172, owned by the Civil Air Patrol, was conducting a routine hurricane/tsunami practice flight.

Witnesses reported to the Kauai Police Department that just before the accident they saw an airplane flying low and close to the mountain in poor weather conditions, then heard a loud crashing noise.

A search and rescue helicopter, operated by the Kauai Fire Department, located the fragmented airplane wreckage in an area of steep mountainous terrain and confirmed that there were no survivors.

According to FAA ADS-B data, after the airplane departed the Lihue Airport, it initially proceeded southwest, then it turned north as it neared the northwest side of the island. The standard flight route was to fly inland, passing the radar dome at Barking Sands PMRF before turning west toward the coast.

Once over the water, they were to maintain about 1/2 mile off the coast, at 1,000 feet above ground level (AGL), and fly around the island. The starting altitude was 1,500 feet AGL.

ADS-B data shows the airplane never made the turn and continued over land and up the ridgeline, until hitting the mountain at about 3,600 feet. The ADS-B data stops near where the wreckage was found.

Two witnesses at the Kalalau lookout, near the accident site, heard an aircraft flying towards them and then hitting the mountain. They were unable to see the aircraft due to poor weather conditions.

One of the witnesses recalled that they could only see about 20 feet because of fog.

A Blue Hawaiian helicopter was operating in the vicinity near the accident site. The pilot recalled the weather was getting worse on the Napali coast. He said the clouds were about 2,000 feet to 2,500 feet in the valley leading to the overlook.

The pilot saw an airplane that was flying straight and level, about 500 feet above him, and watched it appear to go into the clouds while flying to the north.

The airplane hit a near-vertical mountain side in a nose-up, wings-level attitude. After impact, the airplane fell about 1,100 feet, scattering debris on the side of the mountain.

The wreckage.

Toxicology testing of the pilot performed by the FAA Forensic Sciences Laboratory identified gabapentin in the liver and in the muscle. Based on the gabapentin level in the pilot’s liver, it is possible that his blood gabapentin level may have been in a range capable of producing impairing effects, such as sleepiness, dizziness, and/or diminished coordination at the time of the accident.

Gabapentin is used for seizure disorders, neuropathies, and restless leg syndrome (RLS). It has a high rate of impairing side effects, including dizziness, drowsiness, blurred vision, and sedation. Regular use for any reason is disqualifying.

This medication was not reported at the pilot’s most recent medical exam.

Probable Cause: The pilot’s improper decision to continue the visual-flight-rules flight into low visibility conditions, which resulted in controlled flight into terrain.

NTSB Identification: 104805

To download the final report. Click here. This will trigger a PDF download to your device.

This March 2022 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.

About NTSB

The National Transportation Safety Board is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant events in the other modes of transportation, including railroad, transit, highway, marine, pipeline, and commercial space. It determines the probable causes of accidents and issues safety recommendations aimed at preventing future occurrences.

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Comments

  1. scott k patterson says

    March 4, 2024 at 5:52 am

    The more I think about the simple repetitive flight plan, the obvious cloud condition, the known topography, the easy failsafe exit to an ocean, two pilots on board….think this may have been a suicide, perhaps joint, mission.

    • Wylbur Wrong says

      March 4, 2024 at 6:21 am

      I got that same feeling as I read the NTSB report, toxicology, etc. and saw that the one pilot was an ATP the other was an instructor. BOTH of them had instrument ratings and knew better than to fly into IMC and not have an IFR plan on file, and have gotten their IFR clearance before entering IMC.
      So the pilot in the left seat was the one on the proscribed drug or was it the right seat? I think the assumption was that it was the left seat pilot flying. But we don’t know if the right seat pilot took over (CFI….). But both were older pilots. Maybe this was their idea, to go out still flying. Old pilots like these two should have been very much aware of the CFIT/IMC issues.

      Meanwhile, I read what JimH said, and while I’ve not crossed the 70 line (there’s a sign post on the road up ahead…. ), I still prefer to fly at night when doing XCs. Smother, fewer aircraft flying — everyone has lights on that can be seen…. And I always file IFR.

      • Tom Curran says

        March 4, 2024 at 10:45 am

        I don’t know what CAP’s rules are for conducting these flights. As per the “Probable Cause”; sounds as if they were trying to stay VFR and scud run in deteriorating VMC.

        OTOH, they can fly in IMC, under IFR, with no ATC clearance, in uncontrolled Class G airspace…all day.

        As far as a “Second Hand Lions”-suicide scenario: Not sure about the “nose high, wings level” attitude at impact. Maybe they attempted to pull up at the last second?

  2. James Brian Potter says

    March 4, 2024 at 5:22 am

    Sounds like insufficient pre-flight planning and ignorance of local weather conditions gave the Grim Reaper two more victims. Plus the pilot’s toxicology mixed with get-there-itis in a last-minute fatal panic. An accident waiting to happen. RIP to both of them.
    Regards/J

  3. Sam says

    March 1, 2024 at 6:46 pm

    While touring the island our regular stops are at the Waimea Canyon lookouts. More often we see helicopters flying near the canyon sides and this time of year we see clouds scattered and it seems stupid IMO to play “Dodge Clouds” while sightseeing with visitors who are not familiar with good and bad cloudy days. As vehicle tours we often have to cut our tours shorts bc of clouds saturating the areas.
    I have flown as a passenger in the helicopters and would never fly once I saw the mountains covered with clouds.
    IMO, be smart and No Fly if too cloudy.
    Mahalo’s

    • JimH in CA says

      March 2, 2024 at 11:13 am

      Thanks for the insights on flying in Hawaii with clouds near the mountains.

      In Northern California, we have a similar situation this time of year where the Sierra Nevada Mountain peaks are obscured with the rain/snow clouds . In addition the icing is another high risk. So, there is no GA flying over the Sierras now.
      Right now the Sierras have a strong storm that could drop 10 feet of new snow over the next 2 days.
      The are a number of closed Sierra roads because CalTrans can’t keep up with the rate of snow accumulating on the highways.!

  4. JimH in CA says

    March 1, 2024 at 5:32 pm

    The CAP needs to review allowing two 77 year old pilots to fly a CAP aircraft…and not in marginal weather. Maybe put a 50 YO guy in the left or right seat.? [sarc]
    I’m 76 and I limit myself to day, VFR weather, mainly because I’m retired and don’t have any reason to fly at night.!

    • Scott Patterson says

      March 4, 2024 at 5:08 am

      And I’m 76, still operate a semi doing heavy haul, current medical, operate and repair heavy machinery. No weather condition issue limits on flying.
      Age, like hours, are routinely used to judge what is not known by facts.

      • Jack says

        March 4, 2024 at 8:02 am

        Good point, Scott. Still, there comes a time when one has to “hang them up.” It can be hard to tell, especially if one’s faculties are slowly diminishing. Also, one has to watch the medication side effects! Best wishes, Jack from PA

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