De Havilland DHC-6 Safety Record

The failure of maintenance personnel to correctly diagnose and correct a reoccurring nose gear steering problem, and the improperly tensioned nose wheel steering actuator cables which provided the pilot with an erroneous cockpit indication that the nose gear was centered when it was cocked.

the pilot's inadequate en route fuel consumption calculations, which led to his failure to recognize a deteriorating fuel duration versus time-to-go situation in a more timely way.

THE PARACHUTIST'S FAILURE TO FOLLOW PROCEDURES ON EXITING THE AIRCRAFT. A FACTOR WAS THE PARACHUTIST'S INCAPACITATION DUE TO HITTING HIS HEAD ON THE DOORWAY FLOOR.

Intentional ditching due to the flightcrew's failure to properly manage the fuel system, and operation of the airplane in an excessively overweight condition.

THE PILOT-IN-COMMAND'S INADVERTENT FEATHERING OF THE WRONG PROPELLER FOLLOWING AN ENGINE POWER LOSS, AND THE FAILURE OF THE OPERATOR TO ASSURE THAT THE PILOT WAS PROVIDED WITH ADEQUATE TRAINING IN THE AIRPLANE. FACTORS RELATED TO THE ACCIDENT WERE: WATER CONTAMINATION OF FUEL IN THE AIRPORT STORAGE TANKS, THE OPERATOR'S LACK OF FUEL QUALITY CONTROL PROCEDURES, IMPROPER FUEL SERVICING, IMPROPER PREFLIGHT BY THE PILOT(S), AND EXCEEDING THE GROSS WEIGHT/FORWARD CG LIMITS OF THE AIRPLANE.

THE HIGH CROSSWIND CONDITION, THE PILOT IN COMMANDS INABILITY TO COMPENSATE FOR THE WIND CONDITIONS, AND HIS FAILURE TO FOLLOW COMPANY PROCEDURES AND THE PROCEDURES RECOMMENDED IN THE AIRCRAFT FLIGHT MANUAL. FACTOR RELATING TO THE ACCIDENT WAS THE CAPTAIN'S OVERCONFIDENCE IN HIS PERSONAL ABILITY.

A LOSS OF POWER ON THE LEFT ENGINE DUE TO A FATIGUE FAILURE OF A COMPRESSOR TURBINE BLADE LEADING TO FURTHER COMPRESSOR BLADE DAMAGE; A WORN POWER TURBINE GOVERNOR THROTTLE CAM ASSEMBLY WHICH LED TO LOSS OF POWER ON THE RIGHT ENGINE; AND INADEQUATE MAINTENANCE AND INSPECTION BY THE OPERATOR.

THE AIRPLANE'S CONTROLLED FLIGHT INTO TERRAIN AS A RESULT OF THE DECISION OF THE CAPTAIN TO CONTINUE FLIGHT UNDER VISUAL FLIGHT RULES AT NIGHT INTO INSTRUMENT METEOROLOGICAL CONDITIONS (IMC), WHICH OBSCURED RISING MOUNTAINOUS TERRAIN. CONTRIBUTING TO THE ACCIDENT WAS: THE INADEQUATE SUPERVISION OF PERSONNEL, TRAINING, AND OPERATIONS BY ALOHA ISLANDAIR MANAGEMENT AND INSUFFICIENT OVERSIGHT OF ALOHA ISLANDAIR BY THE FEDERAL AVIATION ADMINISTRATION PARTICULARILY DURING A PERIOD OF RAPID OPERATIONAL EXPANSION. (REF: NTSB/AAR-90/05)

THE PILOT INADVERTENTLY MISUSED THE FLAPS, BY FAILING TO SET THE FLAPS TO THE PROPER SETTING. THE FLAPS WERE SET FULL DOWN. THIS CAUSED THE AIRCRAFT TO PITCH UP STEEPLY AFTER LIFTOFF. ADDITIONALLY, THE FLIGHT CONTROL LOCK WAS PROBABLY INSTALLED DURING SOME PORTION, IF NOT THE ENTIRE FLIGHT, WHICH PREVENTED FLIGHT CONTROL OPERATION. THE PILOT SUBSEQUENTLY FAILED TO MAINTAIN ADEQUATE FLYING SPEED AND THE AIRCRAFT STALLED. CONTRIBUTING FACTORS ARE THE PILOT'S INATTENTION AND HIS FAILURE TO ADEQUATELY USE THE CHECKLIST.