Replies

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.”

From your link:

YAMAMOTO REPORT:

A. My Observations Before the Accident
1 buckled my seat belt and was talking with Loretta about some of the Issues that came up during our visit to Kalaupapa. 1 remember the pilot saying something about-the test was who remembered his name-someone said Clyde. We then took off -a few minutes into the flight I remember hearing a loud beeping sound and saw the plane started to go down. I could see that the plane was getting closer to the water~we then hit the water. I then remember seeing water coming Into the front part of the plane.

B. My Observations During the Accident
1 remember hearing people saying get the door open. I then saw people with their life vest on -and asked where were the life vests and someone said in the seat pocket. I put the life vest on and went to the back of the plane I then tried to blow up the vest. I was at the plane door and was passing seat cushions out to people, Loretta came out of the plane with her life vest on I started to blow up her vest-she then pulled the cord that filled her vest. I saw the pilot and he was bleeding from his head - he said we needed to get away from the plane. We got in the water -and I pulled the cord and fully inflated my vest. I remember seeing the pilot swim by he kept saying stay together. When we got in the water it started to get rough and the group got separated. I had lost my glasses and was having a hard
time seeing - we were trying to swim and stay close to the group. Loretta was not really saying anything but was breathing very hard and fast- I saw that her eyes were open and her legs were moving~ - I kept saying be calm and float We kept swimming for a while toward the others and tried to stay above the waves and avoid swallowing water. I then thought I saw a boat in the distance and I remember saving a boat was coming- and we tried to swim toward the boat -1 then realized that I may have been seeing things and a boat was not coming. I then realized that Loretta’s eyes were closed and she was no longer breathing hard- 1 remember seeing her hand floating in the water and she was no longer holding on to me-l kept saying we will be ok and to keep calm. I then realized that I needed to do something to get help. The shore looked close so I decided to swim to shore. I took off my shoes, socks and pants then tried to swim to shore but the life vest kept pullfng me upward -1 then started to get cramps in my right leg. I realized that 1 was not going to make it to shore and that the current and waves had pulled Loretta away. The waves were getting higher and I kept trying to keep my head above the waves and to avoid swallowing water. I then remember seeing planes and helicopters flying above. Then a helicopter with a rescue basket and diver arrived and pulled me out of the water and put me on shore.

C. Observations After the Accident
When the diver pulled me out of the water I remember my leg cramping up again he then asked myname. I asked him If they had gotten Loretta-he said they were still working on getting people out.
Several staff and patlents·from Kalaupapa were on shore they gave me blankets and I told them that the Director was still out there. Two other passengers were on shore- we were taken to the airport where nurses and rescue staff were helping people. They asked If I was hurt -1 said I was ok -only had a c:ramp In my leg. I then saw a women covered in blankets and thought she was Loretta and asked her if she
was ok -1 realized that it was not her. I then saw Mark Miller the Kalaupapa administrator and asked if
Loretta was ok -he said that they were still rescuing people and he did not k.now, he then later told me
that she was ok and was being flown to Honolulu. One of the Kalaupapa residents got me some dry clothes. Then a few minutes later Mark told me that Loretta did not make it. I asked Mark if he know where she was and I needed to see her-I also asked to see the Kalaupapa Catholic: priest. I spoke wfth the Catholic priest and told him that Loretta did not make it and that she was a devote catholic and
would he please do last rites. Mark then took me to the Kalaupapa facility-the staff where working on cleaning loretta and the priest was giving the last rites. The staff gave me Loretta’s person items. Mark drove me to airport and I returned to Honoh.llo.

D. Other Observations
I do not remember the pilot giving us any safety instruction prior to take off. The package that the life
vest was in was difficult to open. The life vest was very tight on my neck and I was surprised how difficult it was to remove when I got on shore. The next day I realized that my lower jaw and collar area was sore from the pressure of the life vest. Even with the life vest on 1 was surprised how much effort was needed to keep my head above the waves and to avoid swallowing water. 1 also realized that 1 did
not have the life vest belt during most of the time in the water.