Stall / Spin · NTSB WPR19MA177
Beech 65-A90 — Mokuleia, HI
| Date | June 22, 2019 |
| Location | Mokuleia, HI |
| Aircraft | Beech 65-A90 |
| Purpose of flight | Skydiving |
| Conditions | Day · Visual Meteorological Cond |
| Phase / occurrence | Takeoff Aerodynamic stall/spin |
| Pilot age | 42 |
| Pilot total time | 1,086 hrs · Experienced |
| Time in type | 214 hrs |
| Fatalities | 11 |
Probable cause
The 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.
NTSB findings
- Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot
- Personnel issues-Experience/knowledge-Training-Type/qual of instruct/training-Pilot
- Personnel issues-Psychological-Personality/attitude-Self confidence-Pilot
- Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Angle of attack-Capability exceeded
- Aircraft-Aircraft oper/perf/capability-Aircraft capability-CG/weight distribution-Capability exceeded
- Aircraft-Aircraft structures-Wing structure-Main frame (on wing)-Damaged/degraded
- Organizational issues-Management-Policy/procedure-Adequacy of policy/proc-Operator
- Organizational issues-Management-Culture-Safety-Operator
- Aircraft-Aircraft handling/service-Maintenance/inspections-(general)-Inadequate inspection
- Aircraft-Aircraft handling/service-Maintenance/inspections-(general)-Incorrect service/maintenance
- Aircraft-Aircraft handling/service-Maintenance/inspections-(general)-Related records
- Personnel issues-Task performance-Inspection-Scheduled/routine inspection-Maintenance personnel
- Personnel issues-Task performance-Maintenance-Scheduled/routine maintenance-Maintenance personnel
- Organizational issues-Support/oversight/monitoring-Oversight-Oversight of operation-FAA/Regulator
- Organizational issues-Support/oversight/monitoring-Oversight-Oversight of maintenance-FAA/Regulator
- Organizational issues-Support/oversight/monitoring-Training-Initial training-FAA/Regulator
- Personnel issues-Action/decision-Info processing/decision-Decision making/judgment-Instructor/check pilot
- Personnel issues-Action/decision-Info processing/decision-Decision making/judgment-Other
- Personnel issues-Psychological-Personality/attitude-(general)-Instructor/check pilot
What happened
Analysis pending