LAX04FA113 · Cessna 414A
Hawaii Air Ambulance Cessna 414A · Accident: in flight encounter with weather en route
From Daniel K. Inouye International Airport (HNL) to Hilo International Airport (ITO)
Event
- NTSB case
- LAX04FA113
- Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
- Accident
- InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
- Completed
- API-reported fatalities
- 3 · all aircraft and ground
- Ground fatalities
- Unknown
- OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
- General aviation
- WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
- Instrument Meteorological Cond
Cessna 414A
- Aircraft type
- Cessna 414
- Category
- Airplane
- RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
- N5637C
- Operator
- Hawaii Air Ambulance
- Onboard fatalities
- Unknown
- Route
- From Daniel K. Inouye International Airport (HNL), Honolulu, HITo Hilo International Airport (ITO), Hilo, HI
- Aircraft age
- Not recorded
- Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
- Part 91: General Aviation
- Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
- En route · cruise
- First occurrenceThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
- In flight encounter with weather
- Also codedOther events the NTSB coded in the sequence, such as a wire strike after a loss of power. Flight Findings uses them for its kinds of event. Glossary
- Visual flight rules (VFR) flight into instrument meteorological conditions (IMC)
- DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
- Destroyed
Cause areas
- Pilot in command › In-flight weather advisories, disregarded
- Pilot in command › VFR flight into imc, continued
Approximate · Coordinates from the NTSB case API, which marks them as estimated or does not say; no uncertainty radius is established.
NTSB narrative
The airplane collided with trees and mountainous terrain at the 3,600-foot-level of Mauna Kea Volcano during an en route cruise descent toward the destination airport that was 21 miles east of the accident site. The flight departed Honolulu VFR at 0032 to pickup a patient in Hilo, on the Island of Hawaii. The inter island cruising altitude was 9,500 feet and the flight was obtaining VFR flight advisories. At 0113, just before the flight crossed the northwestern coast of Hawaii, the controller provided the pilot with the current Hilo weather, which was reporting a visibility of 1 3/4 miles in heavy rain and mist with ceiling 1,700 feet broken, 2,300 overcast. Recorded radar data showed that the flight crossed the coast of Hawaii at 0122, descending through 7,400 feet tracking southeast bound toward the northern slopes of Mauna Kea and Hilo beyond. The last recorded position of the aircraft was about 26 miles northwest of the accident site at a mode C reported altitude of 6,400 feet. At 0130, the controller informed the pilot that radar contact was lost and also said that at the airplane's altitude, radar coverage would not be available inbound to Hilo. The controller terminated radar services. A witness who lived in the immediate area of the accident site reported that around 0130 he heard a low-flying airplane coming from the north. He walked outside his residence and observed an airplane fly over about 500 feet above ground level (agl) traveling in the direction of the accident site about 3 miles east. The witness said that light rain was falling and he could see a half moon, which he thought provided fair illumination. The area forecast in effect at the time of the flight's departure called for broken to overcast layers from 1,000 to 2,000 feet, with merging layers to 30,000 feet and isolated cumulonimbus clouds with tops to 40,000 feet. It also indicated that the visibility could temporarily go below 3 statute miles. The debris path extended about 500 feet along a magnetic bearing of 100 degrees with debris scattered both on the ground and in tree branches. Investigators found no anomalies with the airplane or engines that would have precluded normal operation. Pilots for the operator typically departed under VFR, even in night conditions or with expectations of encountering adverse weather, to preclude ground holding delays. The pilots would then pickup their instrument flight rules (IFR) clearance en route. The forecast and actual weather conditions at Hilo were below the minimums specified in the company Operations Manual for VFR operations.
Probable cause
the pilot's disregard for an in-flight weather advisory, his likely encounter with marginal VFR or IMC weather conditions, his decision to continue flight into those conditions, and failure to maintain an adequate terrain clearance altitude resulting in an in-flight collision with trees and mountainous terrain. A contributing factor was the pilot's failure to adhere to the VFR weather minimum procedures in the company's Operations Manual.
Verbatim NTSB analysis and probable cause from the NTSB dataset
Sources
NTSB record LAX04FA113
- Event ID
- 20040213X00192
- Case number
- LAX04FA113
- Dataset
- historical-pre2008
- Source SHA-256
- 89e2df6d848e7ab3b42e7d7c7a03ff403303057a26ca04c95b3ea67201c3ce74
Source notes (4)
- Unreviewed is an editorial label, not an investigation status. API-sourced is not report-checked or human-reviewed. Explicit event totals are used without summing aircraft injury tables; onboard allocation is withheld. Unknown values remain unknown. The operation category is mapped from the NTSB-reported FAR part and has not been reviewed.
- Filled from the NTSB case API where the bulk record had no value: investigation status, coordinates. Values present in the bulk record are kept.
- The date is the local date, which is the same as the UTC date the NTSB stores.
- API snapshot SHA-256: a6c6e19b073402a471b58f466040708f66f2431a1fbf719b6befc168aaef516a; retrieved 2026-09-20T18:35:11.505Z.