N13GZ

HISTORY OF FLIGHTOn December 15, 2022, about 2114 Hawaii-Aleutian standard time, a Raytheon Aircraft Company (formerly Beech) C90A, twin-engine, turbine-powered airplane, N13GZ, sustained substantial damage when it was involved in an accident near Kaupo, Hawaii. The airline transport pilot, flight paramedic, and flight nurse were fatally injured. The airplane was operated as a Title 14 CFR Part 91 air ambulance positioning flight.

The flight, operated by Guardian Flight LLC, dba Hawaii Life Flight, departed the Kahului Airport (OGG) on the Island of Maui, Hawaii, about 2053, on an instrument flight rules (IFR) flight plan. The accident airplane was destined for the Waimea-Kohala Airport (MUE), a 21-minute flight, on the Island of Hawaii to pick up a patient to be transported to Honolulu, Hawaii.

A review of the Appareo Vision 1000 recorded images and audio data, archived voice communication information, and ADS-B data revealed that the pilot engaged the autopilot shortly after takeoff at about 160 ft msl. He retracted the landing gear about 700 ft above ground level and reduced propeller pitch. After departure from OGG about 2055, the pilot contacted the departure ATC specialist on duty, indicating the flight was at 1,000 ft msl climbing to 11,000 ft msl.

After the airplane departed OGG, it initially proceeded north, then it turned eastbound, which is consistent with the Onohi Two standard instrument departure procedure.

As the airplane climbed through 1,400 ft msl, the pilot passed money to a medical flight crewmember seated in the cabin.

About 2056, the pilot opened a music app on his cell phone and set it down in the right seat as the airplane climbed through 4,500 ft msl. The pilot looked at an approach plate on the iPad and entered approach frequencies.

About 2100, as the airplane climbed through 8,000 ft msl, the pilot repeatedly manipulated the buttons on the Collins MFD, but the screen remained blank and unresponsive. Review of previous flights revealed the Collins MFD was not working in the last four flights of recorded video. According to the Daily Maintenance Records there were no entries for the MFD being inoperative in the two weeks prior to the accident.

About 2102, the departure ATC specialist instructed the pilot to contact Honolulu Air Route Traffic Control Center (ARTCC).

About 2103, the pilot contacted the ARTCC specialist on duty and reported level at 11,000 ft msl, and the pilot requested the RNAV 4 instrument approach at MUE.

About 2104, the ARTCC specialist asked if the pilot could climb to 13,000 ft msl, and the pilot responded that he could.

The flight proceeded on an east-southeasterly heading and along the northern shoreline of the Island of Maui, and then it turned southbound along the predetermined flight route.

About 2106, the autopilot disconnect alert tone sounded, and the autopilot disconnect light illuminated. The pilot’s Electric Attitude Director Indicator (EADI) did not display artificial horizon information for the duration of the flight, red warnings flashed several times, and then remained lit (see Figure 1). The flight nurse asked the pilot if the autopilot had disconnected, and the pilot confirmed to the flight nurse that it had.

Figure 1. Google Earth image of portion of the flight path.

About 2107, the copilot side attitude indicator indicated a 30° bank angle to the right and then returned to level flight. The altimeter alert sounded, and the altimeter read 13,220 ft. The pilot adjusted the pitch trim, and the attitude indicator indicated a steepening right bank, and then a left turn.

About 2108, as the flight continued on a southeasterly heading, the ARTCC specialist initially instructed the pilot to turn right to a heading of 180°, and then to an amended heading of 200°; the pilot acknowledged the 200° heading. The attitude indicator indicated a descending and deepening right bank turn.

About 2109, as the flight continued on a 200° heading at 13,000 ft msl, the ARTCC specialist instructed the pilot to descend to 12,000 ft msl, and the pilot accepted.

About 2110, the ARTCC specialist instructed the pilot to descend to 8,000 ft msl, and the pilot acknowledged.

About 2111, ATC issued a traffic advisory and the airplane leveled off and began a left turn. Immediately following the pilot’s response to the traffic advisory, the airplane began an increasingly rapid descent through 12,000 ft msl and leveled off at 11,120 ft msl.

About 2112, the ARTCC specialist instructed the pilot to fly a heading of 180°, and he cleared the flight to fly direct to TAMMI, the initial approach fix for the RNAV (GPS) 4 approach to MUE, and the pilot acknowledged the instructions. The airplane was in a slight left, descending turn. The pilot manipulated the GPS and selected direct TAMMI. The attitude indicator indicated an increasing right bank, and the airplane was descending at 1,000 ft per minute. The airplane continued to descend through 10,180 ft msl, and the rate of descent increased as the roll increased to 65° angle of bank to the right.

At 2113:22, the ARTCC specialist contacted the pilot of N13GZ, asking him to verify that he was flying “direct to Tammi” as previously instructed.

At 2113:40, the pilot replied: “Uhh, 13GZ is off navigation here… we’re gonna… we’re gonna give it a try.” The vertical speed indicator was pegged at -3,500 fpm (see Figure 2).

Figure 2. Google Earth image of a portion of the flight track.

At 2113:32, the ARTCC specialist acknowledged the pilot’s last statement and instructed him to turn right to a 170° heading and to maintain 8,000 ft msl. The copilot attitude indicator displayed 90° angle of bank. The airspeed indicator needle was at the maximum operating speed of 226 knots.

At 21:13:41 the attitude indicator showed an inverted descending right turn.

At 2113:43, as the airplane passed through 7,700 ft msl, a final radio transmission, believed to be from the accident pilot, is heard saying “Hang on.” The altimeter was showing a very rapid descent. The engine gauges were within normal range.

At 21:13:51, the airplane passed through 4,000 ft msl and was rapidly decreasing. The yoke seemed to move quickly forward and then aft in a jolt like manner. As the movement towards the aft position of the yoke occurred, a sound similar to a loud metallic bang was audible. The camera recorded a rapid jolt, and the field of view of the recorded image noticeably changed. The control panel illumination appeared to be extinguished, consistent with the airplane main power bus failing, and switching over to battery power.

The last recorded frame of the video and end of audio recording at 21:14:06 showed the altimeter indicating about 400 ft msl.

There were no further communications with the accident flight. The pilot did not declare an emergency, report the instrumentation failure, or report that the autopilot was disengaged. The ADS-B data stopped about 10 miles south of Kaupo, near where a witness observed the accident airplane impact the water. (Figure 3)

Figure 3. Google Earth image of the flight path from the departure airport, and depecting the destination airport.

A witness, who was flying a low-wing Piper PA-44 airplane from Hilo, Hawaii, to Honolulu, reported seeing the accident airplane well above and to the north of his flight path. The ARTCC specialist reported that N13GZ was at the PA-44 pilot’s 3 o’clock position at 12,000 ft msl, descending to 8,000 ft msl. The witness continued watching the lights of the airplane and said that as the airplane continued southbound it began a right turn. Then it entered a spiraling right descending turn, which steepened as the descent increased. The airplane continued to descend until it impacted the surface of the water. He lost sight of the airplane’s lights shortly after the airplane impacted the water. The red flight track represents the accident airplane, and the yellow flight track represents the eyewitness airplane (see Figure 4).

Figure 4. Google Earth image of the accident flight path and the witness’s airplane flight path. PERSONNEL INFORMATIONThe pilot held an Airline Transport Pilot (ATP) certificate with a rating for multiengine land and Rotorcraft-helicopter, with commercial pilot privileges for airplane single-engine land and airplane single-engine sea, and type ratings on the B-737, EMB-145, and LR-60. The pilot’s ratings included limitation of B-737, EMB145 Circling approach – VMC only, EMB-145 is subject to pilot-in-command limitation(s), LR-60 SIC privileges only, and English proficient. He held a flight instructor certificate with ratings for rotorcraft-helicopter and instrument helicopter, and a remote pilot certificate with a rating for small, unmanned aircraft system. He held an FAA second-class medical certificate dated April 21, 2022, with limitation of must have available glasses for near vision. At the time of the accident, he was based at OGG.

When he was hired by Hawaii Life Flight on December 2, 2019, he had 7,668 total hours of flight time, about 950 of which were in fixed-wing airplanes. Before being hired at Guardian Flight, from 2009 to 2019, pilot had six Notice of Disapproval entries on his certification records: three for rotorcraft and three for fixed-wing — each one the culmination of multiple unsatisfactory training events. Of the three fixed-wing notices, two were issued when the applicant was applying for an ATP multiengine land airplane certificate. The third and most recent notice of disapproval was when the applicant was applying for an additional type rating to his ATP certificate. A review of the unsatisfactory items in the three most recent notices of disapproval indicated, in part: “poor automation management especially as to the FMS and lateral nav[igation] situational awareness;” “applicant did not demonstrate proper recovery for clean stall;” and various other reasons including, but not limited to, airplane performance procedures. The records detailed consistent def...