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FROM YOUR LINK - PASSENGER REPORTS

SURVIVAL FACTORS
The airplane was configured with two flight crew seats and nine passenger seats. The pilot occupied the left flight crew seat, and the right flight crew seat was not occupied. There were four passenger seats on the left side of the airplane, which were numbered from front to back as seats 1, 3, 5, and 7, and five passenger seats on the right side of the airplane, which were numbered from front to back
as seats 2, 4, 6, 8, and 9. All the passenger seats except seat 9, which was located aft of the passenger door at the rear of the cabin, were occupied. For purposes of this report, the passengers will be identified by their seat numbers; for example, passenger 1 was the person seated in seat 1 during the accident flight.

The pilot reported that he hit his head on the instrument panel during the water impact, and was “bleeding badly” as a result. He unstrapped his harness, yelled at the passengers to get out, and started to grab seat cushions to use as floatation devices. He looked for life vests, saw one, and gave it to a passenger who said his wife did not have one. He did not take time to look for his own
life vest as the airplane was filling with water. After checking to see that the cabin was empty, he exited through the door at the rear of the cabin. He told the passengers to swim away from the airplane because he was concerned that it would sink rapidly and drag them down. The current and waves, which he estimated to be 6 to 8 feet high, gradually separated the group. The pilot’s reported
weight was 240 pounds.

Passengers 1 and 2, a married couple, both sustained serious injuries. Their daughter reported that
her father (passenger 1) sustained broken ribs and a gash on his head, and her mother (passenger 2)
sustained broken ribs and a broken sternum. She further reported that her father said they received a passenger briefing for the morning flight from Honolulu to Kalaupapa, however, did not receive a briefing for the accident flight. Passenger 1’s reported weight was 200 pounds and passenger 2’s reported weight was 175 pounds.

Review of the video, recorded by passenger 8, indicated that the fatally injured passenger, passenger
3, exited the airplane under her own power while wearing an inflated life vest. Passenger 3’s life vest was examined, and determined to be an infant life vest. One of the two CO2 cartridges installed in the vest was punctured and empty, and the other cartridge was full, consistent with a partially inflated life vest. Passenger 3’s reported weight was 220 pounds.

Passenger 4, who was traveling with passenger 3, reported that the pilot did not give a safety briefing before takeoff. He said that after the airplane impacted the water, he saw other passengers with life vests, and asked where they were located. Someone told him they were in the seat pockets, and he found one, put it on, and went to the back of the airplane.

WPR14FA068
12/11/2013
Accident
1b
This space for binding
National Transportation Safety Board
FACTUAL REPORT
AVIATION
NTSB ID:
Occurrence Date:
Occurrence Type:
FACTUAL REPORT - AVIATION Page

Narrative (Continued)
Passenger 4 further stated that he was at the rear door passing seat cushions out to passengers who were already in the water when passenger 3 came to the door; she was wearing a life vest, and she inflated the vest. They got into the water, and he inflated his life vest. Passenger 4 stayed with passenger 3 as they drifted away from the airplane. He noted that passenger 3 was “not really saying
anything but was breathing very hard and fast.” Later, he noticed that passenger 3’s eyes were closed, and she was no longer breathing hard.

Passenger 4 added that the pouch that the life vest was stored in was difficult to open and that the
vest was “very tight” on his neck and difficult to remove when he got on shore. He said that “even with the life vest on I was surprised [at] how much effort was needed to keep my head above the waves and to avoid swallowing water.” He did not use the life vest’s waist strap. Passenger 4’s life vest was examined, and determined to be an adult life vest. Passenger 4’s reported weight was 175 pounds.

Passengers 5 and 6, a married couple, reported that the pilot assigned them seats, but did not provide
a safety briefing prior to the flight. The pilot asked them how many of them had flown over that morning, and then said, “you know the procedures.” After the water impact, passenger 6 opened the door at the rear of the cabin, and immediately jumped into the water without a life vest. Passenger 5 jumped out behind him, and she also did not have a life vest. Someone was throwing life vests out of
the airplane, and passenger 6 grabbed two of them. He inflated a life vest without putting it on, and
held onto it. He assisted his wife (passenger 5) in putting on and inflating a life vest; she did not use the life vest’s waist strap. She reported that the life vest “pushed up around her head and was choking her.” The life vests worn by passengers 5 and 6 were examined, and determined to be adult life vests. Passenger 5’s reported weight was 210 pounds and passenger 6’s reported weight was 200 pounds.

Passenger 7 reported that everyone exited the airplane without difficulty. He recalled helping an older couple put on their life vests before they exited the airplane. He said that they were having difficulty opening the pouches that the vests were stored in so he opened the pouches for them, helped them put the vests on, and inflated one CO2 cartridge on each vest. After exiting the airplane, he
swam to shore. He later found that he had inadvertently put on an infant life vest, which he said seemed “small or tight” although it “worked fine.” Passenger 7’s reported weight was 160 pounds.

Passenger 8 reported that it took a few minutes for everyone to exit the airplane and that he did not
notice anyone having a problem. His video showed that he obtained a life vest from the seat pocket in
front of his seat. Passenger 8’s reported weight was 160 pounds.

An autopsy of the fatally injured passenger was conducted by Pan Pacific Pathologists, LLC, of
Wailuku, Hawaii, under the authority of the Maui Police Department. The findings listed in the autopsy
report included “acute cardiac arrhythmia” and “no significant traumatic injuries.” The report noted
that she was observed by another passenger “to be fearful and hyperventilating shortly before losing consciousness.” According to the autopsy report, her cause of death was “acute cardiac arrhythmia due
to hyperventilation.”

Review of 14 CFR 135.117, briefing of passengers before flight, revealed that section A states in part
“…Before each takeoff each pilot in command of an aircraft carrying passengers shall ensure that all
passengers have been orally briefed on…Location and means for opening the passenger entry door and emergency exits…Location of survival equipment…If the flight involves extended overwater operation, ditching procedures and the use of required flotation equipment.”
Item 9 states that “before each takeoff the pilot in command shall ensure that each person who may
need the assistance of another person to move expeditiously to an exit if an emergency occurs and that person’s attendant, if any, has received a briefing as to the procedures to be followed if anevacuation occurs. This paragraph does not apply to a person who has been given a briefing before a previous leg of a flight in the same aircraft.”