ASN Aircraft accident de Havilland Canada DHC-6 Twin Otter 300 N707PV Hoolehua-Molokai Airport, HI (MKK)

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Accident description

Last updated: 20 June 2013

Status:	Final
Date:	28 OCT 1989
Time:	18:37 HST
Type:	de Havilland Canada DHC-6 Twin Otter 300
Operator:	Aloha IslandAir
Registration:	N707PV
C/n / msn:	400
First flight:	1973
Total airframe hrs:	19875
Cycles:	30139
Engines:	2 Pratt & Whitney Canada PT6A-27
Crew:	Fatalities: 2 / Occupants: 2
Passengers:	Fatalities: 18 / Occupants: 18
Total:	Fatalities: 20 / Occupants: 20
Airplane damage:	Destroyed
Airplane fate:	Written off (damaged beyond repair)
Location:	near Hoolehua-Molokai Airport, HI (MKK) (United States of America)
Phase:	Approach (APR)
Nature:	Domestic Scheduled Passenger
Departure airport:	Kahului Airport, HI (OGG/PHOG), United States of America
Destination airport:	Molokai/Kaunakakai Airport, HI (MKK/PHMK), United States of America
Flightnumber:	1712

Narrative:
Flight 1712 departed Kahului at 18:25 for a 25-minute VFR flight to Kaunakakai. The aircraft climbed to 1000 feet and descended to 500 feet at 18:30. The plane struck a 27deg rocky slope on the north-eastern slopes of the coastal mountains on the island of Molokai at around 600 feet.

PROBABLE CAUSE: "The decision of the captain to continue flight under visual flight rules at night into instrument meteorological conditions (IMC), which obscured rising mountainous terrain. Contributing to the accident was the inadequate supervision of personnel, training, and operations by Aloha IslandAir management. Also contributing to the accident was the insufficient oversight during a period of rapid operational expansion and corporate growth."
Board member Jim Burnett filed the following dissenting statement on the Probable Cause: "I would add to the statement of probable cause the following additional language: Also contributing to the accident was the failure of the Federal Aviation Administration to require a Ground Proximity Warning System for Part 135 aircraft."

Events:

Sources:
» NTSB/AAR-90/05

Official accident investigation report

investigating agency:	National Transport Safety Bureau (NTSB) - USA
report status:	Final
report number:	NTSB/AAR-90-05
report released:	25-SEP-1990
duration of investigation:	332 days (11.1 months)
download report:	Aloha IslandAir, Inc., Flight 1712 DeHavilland Twin Otter, DHC-6-300, N707PV, Halawa Point, Molokai, Hawaii, October 28, 1989. (NTSB/AAR-90-05)

Follow-up / safety actions

NTSB issued 11 Safety Recommendations

Issued: 21-NOV-1990	To: FAA	A-90-135
REQUIRE THAT SCHEDULED 14 CFR PART 135 OPERATORS DEVELOP AND USE COCKPIT RESOURCE MANAGEMENT PROGRAMS IN THEIR TRAINING METHODOLOGY BY A SPECIFIED DATE. (Closed - Acceptable Action)
Issued: 21-NOV-1990	To: FAA	A-90-136
PERFORM A SPECIAL STUDY OF THE ADEQUACY OF FLIGHT STANDARDS DISTRICT OFFICE STAFFING CONSIDERING THE AVAILABILITY OF WORK HOURS, THE GEOGRAPHIC AREA OF RESPONSIBILITY, AND THE SIZE AND COMPLEXITY OF THE ASSIGNED OPERATION. (Closed - Acceptable Action)
Issued: 21-NOV-1990	To: FAA	A-90-137
REQUIRE THAT SCHEDULED 14 CFR PART 135 OPERATIONS OF TURBINE-POWERED OR MULTIENGINE AIRPLANES BE CONDUCTED UNDER INSTRUMENT FLIGHT RULES DURING HOURS OF DARKNESS OR WHENEVER VISIBILITIES LESS THAN 3 MILES OR CEILINGS LESS THAN 1,000 FEET ARE FORECAST, REPORTED, OR ENCOUNTERED. (Closed - Acceptable Action)
Issued: 21-NOV-1990	To: FAA	A-90-138
ESTABLISH PROCEDURES WHEREBY EXISTING FAA AND US MILITARY GROUND-BASED RADAR FACILITIES ARE INCORPORATED INTO THE HAWAIIAN ISLANDS REPORTING SERVICE AREA. (Closed - Reconsidered)
Issued: 21-NOV-1990	To: FAA	A-90-139
REQUIRE THE HONOLULU FLIGHT STANDARDS DISTRICT OFFICE (FSDO-13) TO DISTRIBUTE A BULLETIN TO GENERAL AVIATION OPERATORS (14 CFR PART 91) OF THE FACTS AND CIRCUMSTANCES OF THIS ACCIDENT AND ENCOURAGE THOSE OPERATORS TO USE IFR SERVICES OR RADAR FLIGHT FOLLOWING DURING PERIODS OF DARKNESS AND MARGINAL VFR WEATHER. (Closed - Acceptable Action)
Issued: 21-NOV-1990	To: FAA	A-90-140
REQUIRE THAT SCHEDULED 14 CFR PART 135 OPERATORS PROVIDE COMPREHENSIVE INSTRUMENT PROFICIENCY TRAINING TO ALL COMPANY FLIGHT CREWMEMBERS, USING A VIEW-LIMITING DEVICE WHEN VFR CONDITIONS EXIST. (Closed - Acceptable Action)
Issued: 21-NOV-1990	To: FAA	A-90-141
REQUIRE COMMERCIAL OPERATORS TO CONDUCT SUBSTANTIVE BACKGROUND CHECKS OF PILOT APPLICANTS, WHICH INCLUDE VERIFICATION OF PERSONAL FLIGHT RECORDS AND EXAMINATION OF TRAINING, PERFORMANCE, AND DISCIPLINARY AND OTHER RECORDS OF PREVIOUS EMPLOYERS, THE FEDERAL AVIATION ADMINISTRATION SAFETY AND ENFORCEMENT RECORDS, AND THE NATIONAL DRIVERS REGISTER. (Closed - Unacceptable Action)
Issued: 21-NOV-1990	To: National Weather Service	A-90-142
REQUIRE THAT WEATHER FORECASTS NOTE THE POSSIBLE FORMATION OF OROGRAPHIC CLOUDS AND PRECIPITATION WHEN CONDITIONS EXIST THAT WOULD CREATE SUCH CLOUDS. (Closed - Reconsidered)
Issued: 21-NOV-1990	To: Aloha IslandAir	A-90-143
MODIFY FLIGHT SCHEDULES, OPERATIONS, AND FLIGHTCREW DUTIES TO ACCOMODATE OPERATIONS UNDER INSTRUMENT FLIGHT RULES. (Closed - Acceptable Action)
Issued: 21-NOV-1990	To: Aloha IslandAir	A-90-144
IMPLEMENT PROCEDURES TO CONDUCT BACKGROUND CHECKS OF PILOT APPLICANTS TO INCLUDE THE VERIFICATION OF PERSONAL FLIGHT RECORDS, THE EXAMINATION OF TRAINING PERFORMANCE, DISCIPLINARY AND OTHER RECORDS OF PREVIOUS EMPLOYERS, AND FEDERAL AVIATION ADMINISTRATION SAFETY AND ENFORCEMENT RECORDS. (Closed - Acceptable Action)
Issued: 21-NOV-1990	To: Regional Airline Association and AOPA	A-90-145
ADVISE YOUR MEMBERS OF THE CIRCUMSTANCES OF THE ALOHA ISLANDAIR ACCIDENT AND THE SAFETY RECOMMENDATIONS ISSUED AS A CONSEQUENCE THEREOF. (Closed - Acceptable Action)

Show all AD's and Safety Recommendations

Photos

Map

This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Kahului Airport, HI to Molokai/Kaunakakai Airport, HI as the crow flies is 74 km (46 miles).

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DHC-6 Twin Otter

146^th loss
844 built
6^th worst accident (at the time)
10^th worst accident (currently)

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United States of America

145^th worst accident (at the time)
168^th worst accident (currently)

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