N687MA

HISTORY OF FLIGHT

On December 11, 2013, about 1522 Hawaiian standard time, a Cessna 208B, N687MA, was destroyed following a loss of engine power and ditching into the Pacific Ocean near Kalaupapa, Hawaii. One passenger was fatally injured, the airline transport pilot and two passengers were seriously injured, and five passengers received minor injuries. The airplane was registered to Leis Air LLC, and operated by Makani Kai Air under the provisions of 14 Code of Federal Regulations (CFR) Part 135. Visual meteorological conditions prevailed for the cross-country flight, and a company flight plan had been filed. The flight departed from the Kalaupapa Airport on the island of Molokai, about 2 minutes prior to the accident, with an intended destination of the Honolulu International Airport on the island of Oahu.

In a written statement, the pilot reported that shortly after takeoff from runway 05, at an altitude of about 400 feet above ground level (agl), he began a left turn for a downwind departure. Shortly after passing 500 feet agl, the pilot motioned toward the power lever to reduce power for the climb when he heard a loud "bang" followed by an immediate loss of engine power. The pilot continued the turn toward land, verified the fuel valves were on, and observed all engine gauges displaying "zero." The pilot realized the airplane was not going to make it to land, and rolled the wings level while broadcasting a mayday distress call. Shortly after, the airplane landed within open ocean water in a flat or slightly nose up attitude.

All the passengers and the pilot exited the airplane through the rear right door, and the airplane remained on the water surface for approximately 25 minutes before it sank. One passenger swam to shore, and United States Coast Guard and Maui Fire and Rescue helicopters recovered the pilot and 7 passengers from the water about 80 minutes after the ditching.

Review of video taken by one of the passengers (which started with the airplane descending toward the water, showed the impact, and continued for about 15 minutes) indicated that the airplane impacted the water in a wings level, slightly nose-high attitude. The video showed that the airplane remained intact after contacting the water, and remained afloat throughout the video.

PERSONNEL INFORMATION

The pilot, age 60, held an airline transport pilot certificate with a multiengine land rating and type ratings in the Boeing 737 and 777. He had commercial privileges in single-engine land airplanes and gliders, and he held a flight instructor certificate with multiengine airplane, single-engine airplane, and glider ratings. His most recent first class medical certificate was issued on December 9, 2013, with the limitation "must wear corrective lenses."

According to the operator, the pilot satisfactorily completed his most recent Part 135 proficiency/competency check on May 9, 2013. The pilot reported that he had accumulated a total flight time of about 16,000 hours of which 250 hours were in Cessna 208Bs. In the past 90 days, 30 days, and 24 hours, the pilot had flown 150, 50, and 10 hours, respectively, all in Cessna 208Bs.

AIRCRAFT INFORMATION

The airplane, a Cessna 208B, was manufactured in 2002 and equipped with a Pratt and Whitney Canada PT6A-114A 675-horsepower turbo-prop engine, serial number PCE-PC1021, which had accumulated 4,899.6 hours and 9,303 cycles since new at the time of the accident.

Review of the engine and airframe logbooks revealed that in July 2012 the engine had reached Pratt & Whitney Canada's (P&WC) recommended time between overhaul (TBO) of 3,600 hours, however, the operator obtained a factory authorized 200-hour TBO extension, which was subsequently approved by the FAA.

On July 23, 2012, at a total time since new of 3,752.3 hours total time, the engine was placed onto the Maintenance on Reliable Engines (MORE) STC, which extended the TBO from 3,600 hours to 8,000 hours, which was subsequently approved by the FAA. The MORE STC literature states that the MORE Instructions for Continued Airworthiness (ICA) is not a stand-alone document but is only a supplement to the PW&C engine maintenance program requiring that all the inspection and maintenance specified in the PW&C manual must be performed in addition to inspections and maintenance specified by the MORE program, such as a more frequent borescope inspection of the hot section, periodic inspection of the compressor and exhaust duct areas, and periodic Power Plant Adjustment/Tests.

In conflict with the P&WC guidance, which requires engine condition trend monitoring (ECTM), a method of continuously monitoring engine health, the MORE STC does not recommend ECTM. The operator elected to follow the MORE program guidance and did not conduct ECTM.

According to the airframe and engine records, when the engine was placed onto the MORE STC, an engine hot section inspection (HSI) was performed. Guidance for managing and performing an HSI is contained in the P&WC applicable engine maintenance manual and service bulletin (SB), No. 1703 titled "Operating Time Between Overhauls and Hot Section Inspection Frequency Recommendations". Revision 6 of the P&WC SB 1703 was applicable at the time. The maintenance manual and SB required a compressor turbine (CT) blade metallurgical evaluation, which consisted of selecting two random pre-SB1669 CT blades, sectioning them and evaluating the samples in a materials laboratory. The tests destroy the two samples. No documentation was located to show that this inspection was complied with.

According to the operator, the combined guidance documentation between the MORE literature, P&WC Maintenance Manual and the P&WC SB was confusing. They further stated that they interpreted the P&WC guidance recommending the destructive blade testing if a TBO extension was being requested from P&WC, however, since the TBO extension was granted via the MORE STC, which did not contain blade sectioning instructions, they deemed that this task was not necessary because they believed the increased inspection intervals required in MORE STC guidance, would effectively manage the CT blades.

Two other HSI tasks, a combustion liner cooling ring gap check and a trim thermocouple verification, which are recommended by the P&WC maintenance manual, but not required under the MORE STC, were not accomplished. The MORE STC documentation also does not reference the P&WC publication service information letter (SIL) PT6A-116R3 "Borescope Inspection in Conjunction with Fuel Nozzle Check" which better illustrates the borescope examination of the trailing edges of the CT blades.

At the time of the accident, the engine had been operating under the MORE STC for about 1,137.3 hours. The most recent inspection performed on the engine prior to the accident was conducted 3.9 hours prior, and consisted of the MORE STC 100, 200, and 400-hour inspections. The MORE STC program 400-hour inspection included a hot-section inspection, which only required inspection of the compressor blades via a borescope.

METEOROLOGICAL INFORMATION

At 1454, the reported weather conditions at the Molokai Airport, Kaunakakai, Hawaii, located about 8 nautical miles southwest of the accident site, were wind from 040 degrees at 15 knots gusting to 26 knots, visibility 10 miles, sky clear, temperature 27 degrees C, dew point 19 degrees C, and altimeter setting 29.95 inches of mercury.

WRECKAGE AND IMPACT INFORMATION

The airplane was recovered from the ocean on December 18, 2013, 7 days after the accident, and transported to Honolulu, Hawaii, on a barge. It was examined under the supervision of the NTSB investigator-in-charge in Honolulu on December 19, 2013. The airframe was fragmented into numerous pieces, which were crushed and battered in a manner consistent with being repeatedly rolled over on a hard, uneven surface by wave action. The engine had separated from the airframe, and the propeller remained attached to the engine. The three propeller blades remained intact, were bent, and appeared to be in the feather position. The engine was subsequently shipped to P&WC for further examination.

SURVIVAL FACTORS

The airplane was configured with two flight crew seats and nine passenger seats. The pilot occupied the left flight crew seat, and the right flight crew seat was not occupied. There were four passenger seats on the left side of the airplane, which were numbered from front to back as seats 1, 3, 5, and 7, and five passenger seats on the right side of the airplane, which were numbered from front to back as seats 2, 4, 6, 8, and 9. All the passenger seats except seat 9, which was located aft of the passenger door at the rear of the cabin, were occupied. For purposes of this report, the passengers will be identified by their seat numbers; for example, passenger 1 was the person seated in seat 1 during the accident flight.

The pilot reported that he hit his head on the instrument panel during the water impact, and was "bleeding badly" as a result. He unstrapped his harness, yelled at the passengers to get out, and started to grab seat cushions to use as floatation devices. He looked for life vests, saw one, and gave it to a passenger who said his wife did not have one. He did not take time to look for his own life vest as the airplane was filling with water. After checking to see that the cabin was empty, he exited through the door at the rear of the cabin. He told the passengers to swim away from the airplane because he was concerned that it would sink rapidly and drag them down. The current and waves, which he estimated to be 6 to 8 feet high, gradually separated the group. The pilot's reported weight was 240 pounds.

Passengers 1 and 2, a married couple, both sustained serious injuries. Their daughter reported that her father (passenger 1) sustained broken ribs and a gash on his head, and her mother (passenger 2) sustained broken ribs and a broken sternum. She fur...