Beech 65-A90Oahu Parachute Center
Mokuleia, HI, USA · 2019-06-22·N256TA
What happened
NTSB summary, verbatimAnalysis pending
Probable cause
the Board's determinationThe pilot’s aggressive takeoff maneuver, which resulted in an accelerated stall and subsequent loss of control at an altitude that was too low for recovery. Contributing to the accident were (1) the operation of the airplane near its aft center of gravity limit and the pilot’s lack of training and experience with the handling qualities of the airplane in this flight regime; (2) the failure of Oahu Parachute Center and its contract mechanic to maintain the airplane in an airworthy condition and to detect and repair the airplane’s twisted left wing, which reduced the airplane’s stall margin; and (3) the Federal Aviation Administration’s (FAA) insufficient regulatory framework for overseeing parachute jump operations. Contributing to the pilot’s training deficiencies was the FAA’s lack of awareness that the pilot’s flight instructor was providing substandard training.
Occurrence sequence
3 stepsNTSB coding · CICTT taxonomy- 1 · TakeoffAbrupt maneuverdefining event
- 2 · TakeoffAerodynamic stall/spin
- 3 · Uncontrolled descentCollision with terr/obj (non-CFIT)
Findings
13 causal · 6 contributing- CAUSEPersonnel issues › Task performance › Use of equip/info › Aircraft control — Pilot
- CAUSEPersonnel issues › Experience/knowledge › Training › Type/qual of instruct/training — Pilot
- CAUSEPersonnel issues › Psychological › Personality/attitude › Self confidence — Pilot
- CAUSEAircraft › Aircraft oper/perf/capability › Performance/control parameters › Angle of attack — Capability exceeded
- CAUSEAircraft › Aircraft oper/perf/capability › Aircraft capability › CG/weight distribution — Capability exceeded
- CAUSEAircraft › Aircraft structures › Wing structure › Main frame (on wing) — Damaged/degraded
- CAUSEAircraft › Aircraft handling/service › Maintenance/inspections — Inadequate inspection
- CAUSEAircraft › Aircraft handling/service › Maintenance/inspections — Incorrect service/maintenance
- CAUSEOrganizational issues › Support/oversight/monitoring › Oversight › Oversight of operation — FAA/Regulator
- CAUSEOrganizational issues › Support/oversight/monitoring › Oversight › Oversight of maintenance — FAA/Regulator
- CAUSEOrganizational issues › Support/oversight/monitoring › Training › Initial training — FAA/Regulator
- CAUSEPersonnel issues › Task performance › Inspection › Scheduled/routine inspection — Maintenance personnel
- CAUSEPersonnel issues › Task performance › Maintenance › Scheduled/routine maintenance — Maintenance personnel
- FACTOROrganizational issues › Management › Policy/procedure › Adequacy of policy/proc — Operator
- FACTOROrganizational issues › Management › Culture › Safety — Operator
- FACTORAircraft › Aircraft handling/service › Maintenance/inspections — Related records
- FACTORPersonnel issues › Action/decision › Info processing/decision › Decision making/judgment — Instructor/check pilot
- FACTORPersonnel issues › Action/decision › Info processing/decision › Decision making/judgment — Other
- FACTORPersonnel issues › Psychological › Personality/attitude — Instructor/check pilot
Safety recommendations
3 issuedwhat changed because of this accidentTO THE FEDERAL AVIATION ADMINISTRATION: Develop a system to automatically notify your inspectors of those flight instructors (within each inspector’s geographic area of responsibility) whose student pass rate in the Program Tracking and Reporting Subsystem has become substandard so that the inspectors can perform additional surveillance according to the guidance in Order 8900.1, Flight Standards Information Management System, volume 6, chapter 1, section 5, “Surveillance of a Certificated Flight Instructor.”
TO THE FEDERAL AVIATION ADMINISTRATION: Until the system proposed in Safety Recommendation A-20-40 is implemented, direct your inspectors to (1) review the Program Tracking and Reporting Subsystem on an ongoing basis to identify those flight instructors (within each inspector’s geographic area of responsibility) with a substandard student pass rate and (2) provide additional surveillance of those instructors according to the guidance in Order 8900.1, Flight Standards Information Management System, volume 6, chapter 1, section 5, “Surveillance of a Certificated Flight Instructor.”
TO THE FEDERAL AVIATION ADMINISTRATION: Revise Order 8900.1, Flight Standards Information Management System, volume 6, chapter 1, section 5, “Surveillance of a Certificated Flight Instructor,” to include flight instructors with a substandard student pass rate as one of the criteria necessitating additional surveillance of a flight instructor.
NTSB analysis
from the final reportAnalysis pending