The NTSB has released the final report on the May 23, 2016 fatal Cessna 182 crash at Skydive Kauai.

Read the NTSB report.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:

The pilot’s failure to maintain airspeed following a partial loss of engine power for reasons that could not be determined during postaccident examination, which resulted in the airplane exceeding its critical angle of attack and experiencing an aerodynamic stall.

The NTSB says the low time pilot was the cause by allowing the aircraft to slow, stall and spin after a partial engine failure. What is not answered is: why did the engine fail? The facts of the case include a discussion about an Autogas STC to use automobile gas instead of 100LL aviation gas. Fuel was purchased at a nearby gas station without regard for whether it was ethanol free. The state of Hawaii does not require markings at pumps warning of ethanol if it has less than 1% ethanol in the fuel. And yet, even though 12 gallons of gas was recovered from the accident aircraft and tested for the presence of water it was never tested for the presence of ethanol. There is no mention of testing for ethanol in the hand containers that transported the fuel and filled the aircraft. The report brings up the question by referencing an EASA paper on Autogas in aircraft but makes no correlation. The report discusses the atmospheric conditions for the formation of carburetor icing as being severe at idle that day but then says carburetor icing is unlikely due to the aircraft being at high power during takeoff. But what if carburetor ice formed on the previous descent? Jump planes descend at near idle power for long periods normally. No account for how much time in between loads is stated.

With respect to the pilot’s experience the report states he held a US commercial license single engine land (appropriate for the operation). However, zero information is provided other than total flight hours as to the pilot’s experience. The pilot’s logbook does not show any experience in a Cessna 182 and the last entry was about two months prior to the accident. The amount of time in type is not provided at all in the report nor does it seem the operator of Skydive Kauai was asked to provide an estimate from time of employment. No account is given for what training in the operation was given. Questions remain:

  • How did the operation train the pilot to fly for them?
  • What topics were covered?
  • Did the topic of engine failure on departing runway 9 (towards open ocean) get discussed?
  • What was expected?

Flying skydivers is not like other flying even if you are rated to fly the aircraft to be used. This pilot did not have an instructor rating and in the U S only the Certified Flight Instructor rating is required to have spin training.

Were any of the occupants wearing flotation devices in the event of a water landing? According to previous pilots at Skydive Kauai none were ever provided despite the proximity to open ocean.

In the discussion of the video recording it was stated the stall horn never sounded. But there is zero explanation as to why. Is it a result of a right spin or an inoperative component?

It has been a year and half since the accident and the NTSB has reverted to the ready standby result of “pilot error.” Comparatively, when a fatal accident occurs in charter or airline flying great scrutiny is given to the corporate environment the accident happened in. Detailed explanations of training, experience and expectations are laid out. And none of that is provided here nor does there seem to be any effort to do so. The only “lesson” that seems to come from this report is “don’t mess up” with the reference to the FAA Airplane Flying Handbook to “establish a glide straight ahead.” So why no critical thinking of why this pilot might not have chosen to do that? The right turn seems to be intentional. The video report says after the reduction in power the left aileron trailing edge is observed deflected down in a right roll position. Is this because the pilot was faced with ditching in open ocean with no flotation devices? Why turn right instead of left?

What I take from this accident and NTSB report is that if skydiving aircraft operations are to improve it is up to us to make it happen. We can not expect, nor do I think we should wish for, government intervention with increased regulation. The resources are there. Decades of effort to provide easy and free information on how to safely fly skydivers is readily available through USPA, DiverDriver.com, FAA AC-105E and online forums. Skydivers and pilots together must learn what a “good” operation looks like. And if what they see does not conform to that standard they need to walk away. In fact, several pilots had already walked away from Skydive Kauai.