Dark Waters of Self-Delusion: The crash of Transair flight 810
On the 2nd of July 2021, a Boeing 737–200 hauling cargo between the Hawaiian Islands lost power in one engine shortly after takeoff from Honolulu. As the pilots attempted to turn back toward the airport, they reported the unthinkable: their second engine was going too, and they weren’t going to make it. While the Coast Guard scrambled to respond, the crew carried out an extraordinary ditching at sea in the dark of night, successfully bringing their 737 down on the heaving waters of Mamala Bay, 3.3 kilometers off the coast of Oahu. Although the plane broke into two pieces on impact, both pilots managed to escape, and in a harrowing rescue they were plucked from the water just as the remains of the airplane slipped beneath the waves.
Two years later, the publication of the National Transportation Safety Board’s final report has confirmed what many long suspected: that the crash of Transair flight 810 was not a story of exemplary airmanship, but quite the opposite, as a relatively minor engine failure snowballed into a dangerous ditching that need never have been attempted. The unfortunate truth was that the pilots never properly addressed the emergency, and in their confusion, reduced power on their functioning engine — a tale as old as the very concept of multi-engine airplanes. The cockpit voice recording and interviews with the pilots revealed the factors which may or may not have contributed, from their muddled attempts to declare an emergency, to an incomplete control handover, to simple stress, as the captain delivered a heated and sometimes sexist 32-minute pre-flight monologue about a fellow pilot. In any case, the findings raised questions about the safety culture at Transair, a scrappy (and now defunct) cargo airline operating 50-year-old airplanes — and highlighted how a breakdown in communication and critical thinking can turn a minor failure into a potentially deadly crash.
In the archipelago of Hawaii, modern life depends on the fast and efficient transfer of goods between the state’s seven inhabited islands, especially by air. Numerous small companies have historically competed for this market, including — until recently — Rhoades Aviation, better known under its public-facing name Transair, which branded itself as “Hawaii’s leader in interisland air cargo.” Founded in 1982 by Iranian-born businessman Teimour Riahi, the airline slowly grew from a few small turboprops to a fleet of several first-generation Boeing 737–200 jets, surviving for decades despite its small size and even a failed attempt to expand into passenger services in 2005.
For Transair pilots, the pay was mediocre and the hours were unpredictable, but by the 2020s, Transair was one of at most two or three remaining operators of the ancient Boeing 737–200 left in the United States, and anyone who wanted to fly the classic jets would have had few other options. Others were simply attracted by the promise of working in Hawaii, including one of the main characters of this story, 58-year-old Captain Henry Okai. Born in the West African nation of Ghana, he came to the United States decades ago to pursue his dream of flying, which was met with success as he passed pilot training and got a job with regional carrier Allegheny Airlines. Over the years he flew for a variety of companies, both in the United States and abroad, until he finally landed with Transair, having been drawn to the airline in a spur-of-the-moment decision.
Just after midnight on the 2nd of July, 2021, Captain Okai reported for duty at Honolulu International Airport to fly Transair flight 810, a regular service from Hawaii’s capital and largest city, to Kahului, the largest town on the island of Maui. Joining him was 50-year-old First Officer Gregory Ryan, founder of the local Honolulu law firm Greg Ryan and Associates. Ryan first flew for commuter carrier Mesa Airlines from 1991 to 1995, before switching careers to become a divorce lawyer. In 2019, however, he decided to get back into flying, and for the last two years he had been splitting his time between Transair and his legal practice.
That night they would be flying a Boeing 737–200 built in 1975 and registered as N810TA (at Transair, the flight number was based on the registration number — any route that N810TA happened to be flying was “flight 810”). When they arrived at the ramp, cargo handlers were loading the plane with several tons of frozen seafood, pharmaceuticals, and other perishable items typically shipped by air in Hawaii. After performing the pre-flight checks, the pilots sat down in the cockpit to wait for the cargo loading to finish, at which point Captain Okai began to vent about an incident that had allegedly occurred on July 1st, less than 24 hours previously. First Officer Ryan appears to have been already aware of what happened, suggesting that the conversation may actually have begun earlier, but what is known is that the issue would come to dominate the cockpit conversation almost until the moment of takeoff.
Most of the information about what happened comes from Captain Okai’s own statements captured by the cockpit voice recorder, but what is known is that on the morning of the 1st, Okai had been rostered to fly with the airline’s sole female First Officer, identified as Gina Moore. After a fraught disagreement over procedures, the two apparently found themselves in a shouting match in the cockpit, at which point Moore announced that she would not fly with Captain Okai, and walked away from the flight in the middle of the after start checklist. A new first officer had to be found, and the flight was delayed. (According to Moore’s own testimony, which is very sparse in detail, she did not ask to be replaced — rather, the Chief Pilot replaced her as soon as she told him she was uncomfortable with Captain Okai. Okai may have been unaware of this.)
From the transcript, Captain Okai clearly had not mentally moved on from the incident. The conflict seemed to have arisen because Okai and Moore had different interpretations of the procedures in the manual, and neither was willing to compromise with the other, a hallmark of poor crew resource management. As First Officer Ryan listened, interjecting only occasionally to affirm his captain, Okai described his interpretation of the procedures, then discussed how Moore walked out in the middle of the checklist, which apparently prompted him to say a number of hostile words, including “what’s wrong with you,” “this is a joke,” and “you’re going to finish the checklist.” A shouting match ensued, which Ryan recognized as a safety issue, although neither pilot pointed out Okai’s own role in the altercation. In fact, he said, “This is the way we work when I am with her, you know, you have to yell at her to force her to do things.”
This incident had apparently been escalated all the way to the airline’s owner, but Okai accused the Chief Pilot of favoring Moore at his expense. He then professed a belief that First Officers needed to acquiesce to their captains regardless of what they thought “the book” said. Again, not a hallmark of an effective team player.
At around quarter past 1:00, the cargo loading concluded, and the pilots paused the conversation to conduct the departure briefing, complete the before start checklist, and start the engines — although Okai interrupted the checklist to mention that he was going to use his cell phone to send pictures of the wording in the manual to the Chief Pilot in order to prove Moore wrong.
Several minutes later, the flight was ready to taxi, and the pilots proceeded toward the runway — only for Okai’s mind to come back to Moore again. Spotting a pothole in the runway, Okai began to describe how he accidently ran through that same pothole during a landing rollout because he was distracted arguing with Moore. “This girl is driving me crazy, you know!” he said.
Moments later, he brought the rant to a new level, graduating from personal animosity to outright misogyny. “These are the kind of women you don’t wanna get married to,” he said. “You know, some men, they lose their temper and the next thing you know, the wife is dead, you know… they start punching them and kicking them, and they lost their minds, you know… they kill the woman… it’s the woman who can drive you to do crazy stuff, you know?”
(Public service announcement: if a husband murders his wife because he thinks she’s annoying, that’s the husband’s fault. I shouldn’t need to say this.)
Minutes later, at 1:33 a.m., flight 810 arrived at the head of the runway with takeoff clearance in hand, and Captain Okai handed over control to First Officer Ryan. Working together, they pushed the thrust levers to takeoff power, and the engine instruments responded normally. Okai observed that the exhaust gas temperatures, or EGTs, were hovering very close to the yellow “caution” zone on the gauge, but he had seen this indication many times before on multiple Transair planes, and he wasn’t concerned.
As the 737 accelerated down the runway, Okai made the standard callout, “Eighty knots,” followed by “V1,” or decision speed, and then “rotate.” Ryan pulled the nose back, and the plane lifted off, prompting Okai to call out, “positive rate.”
“Gear up,” Ryan ordered, and Okai complied.
Then, just as the gear finished retracting, a loud “thud” was heard, accompanied by vibrations and a long “whooshing” sound, like an engine rolling back.
“Oh shit,” Ryan exclaimed.
“Lost an engine, you got it?” Okai asked.
“Okay, I got it, yep,” Ryan said, instinctively stepping on the rudder to counteract the developing asymmetric thrust.
“Yep, you lost number…” Okai started to say, trying to determine which engine had failed.
“Number two, yep,” said Ryan, referring to the right engine.
“Number two,” Okai agreed.
The pilots’ assessment was correct. Inside the high pressure turbine within the right (№2) engine, corrosion had been eating away at two of the turbine blades from the inside, expanding outward around each blade’s internal lightening holes — voids in the material designed to reduce the weight of the blades. The corrosion steadily weakened the blades, until one or both failed under the stresses of normal operation. The broken blade tips were then sucked back through the low pressure turbine, causing further damage that reduced the engine’s ability to produce power. In fact, within seconds of the failure, the Engine Pressure Ratio, or EPR, for the right engine — a proxy for its power output — decreased from 1.97, which is approximately takeoff power, to 1.43, which is closer to cruise.
When an engine failure occurs on takeoff in a twin-engine jet like the 737, the procedure is to declare an emergency, climb to a safe altitude, level off, identify which engine has failed, complete the “engine failure or shutdown” checklist, and then return to the airport. Therefore, to start things off, Captain Okai jumped on the radio and said, “Rhoades eight ten, we have an emergency, stand by.”
“Rhoades Express eight ten, radar contact, fly heading of one one zero to join victor two, resume own navigation,” the controller said, having apparently missed the content of the transmission.
“Eight twenty [sic] has emergency, on a two twenty heading, stand by,” Okai repeated. Turning to his first officer, he added, “Okay, you can inch up to two thousand.” 2,000 feet would be an excellent safe altitude at which to level off while they completed the engine failure procedure.
About 12 seconds later, Okai said, “Okay, coming up on two thousand, we’ll level at two thousand… you have two twenty heading, right?”
In addition to flying with less power on the right side, First Officer Ryan was also navigating through a procedure turn to the right following takeoff, but he seemed to be handling it just fine, so he simply said, “Yes.”
Moments later, the flight reached 2,000 feet, and Ryan began leveling the plane. At the same time, the controller called them again to repeat her earlier clearance. “Rhoades Express eight ten, radar contact, turn left heading zero niner zero, join victor two, resume own navigation, climb and maintain one three thousand, say altitude,” she said.
Wondering whether the controller wasn’t able to hear them, Okai said, “Okay, Rhoaaades eight ten, radio check, how do you read?”
“Rhoades Express eight ten, loud and clear, how do you hear? Turn left heading one eight zero,” the controller replied, again without mentioning the emergency. The simple truth, which Okai would later realize, was that the controller was handling a large volume of traffic, and other planes were stepping on his transmissions, making them hard to understand. But in the moment, her failure to appreciate the emergency declaration was probably frustrating.
“Okay, Rhoades eight ten, we’ve lost an engine, we are on a two twenty heading, maintaining two thousand, declaring an emergency, how do you read?” Okai repeated.
But the controller was in the middle of talking to their sister aircraft, Transair flight 809, and when Okai stopped talking, he heard only the end of their conversation: “…say again, heading two four zero?”
“Okay, two four zero heading, Rhoades eight ten,” Okai replied, thinking the transmission was for him.
“No, Rhoades eight oh nine, Rhoades eight oh nine, left two four zero,” the controller clarified. Then, finally recognizing that flight 810 was in trouble, she added, “Rhoades Express eight ten, you are cleared visual approach runway four right, you can turn in towards the airport.”
“Okay, Rhoades eight ten, we’re gonna have to run a checklist, if we can get a delay vector and uh, we’ll let you know when we’re ready to come into the airport,” Okai replied.
“Just keep me advised and maintain two thousand if that’s the altitude you’d like,” said the controller.
“Okay, two thousand is good for now,” said Okai. “We’ll stay around fifteen miles from the airport and uh, maintaining two thousand, Rhoades eight ten.”
By the time the conversation concluded, a minute and forty seconds had passed with little to no discussion between the pilots. First Officer Ryan spent that time leveling off at 2,000 feet and trying to achieve the target airspeed for an engine-out scenario, which was about 220 knots. He initially overshot both, climbing to 2,100 feet and reaching a speed of 250 knots, so he began incrementally reducing power in both engines in order to slow down.
Returning his attention to the cockpit, Captain Okai now said, “Okay, let’s uh… two forty heading.” He appeared not to have understood that this heading was not for him. He then added a question: “You want me to take over, or you got it?”
“No, I’m okay, thank you,” said Ryan.
In an emergency, it’s normal for the First Officer to fly while the Captain develops a strategy and completes the abnormal checklists. This was not an official rule nor was it set in stone, but Okai’s offer contradicted it nonetheless.
At that moment, the controller called again. “Rhoades Express eight ten, uh, when you get a chance can I get the nature of the emergency, I know you said an engine out, which one? Uh, how many souls on board, and fuel?”
“Okay, all that is good, we’ll give you all that in a little bit, in a little bit, Rhoades eight ten,” Okai replied. Turning back to First Officer Ryan, he said, “Okay, so we’ll plan for two.. say two twenty speed, eh?”
“Kay,” said Ryan. By now, both thrust levers had been rolled all the way back to flight idle, the lowest flight setting, and the left and right EPRs had dropped to 1.05 and 1.09 respectively, indicating very little forward thrust. Their speed was dropping nicely toward 220 knots, which was what they wanted.
Now, about 45 seconds after his first offer to take control, Okai said, “Let me take over briefly, and you…”
“Okay,” First Officer Ryan agreed. He would later state that he perceived Okai’s statement as an order, so he agreed to hand over control, even though he was having no issues flying the plane. In fact, with both engines at idle, the asymmetric thrust had disappeared, and it was trivial to keep the plane straight and level.
“You set your things up, I have control,” said Captain Okai.
“Okay, you have control,” Ryan acknowledged.
Now that he was flying the plane, Okai immediately noticed that not all was as it should be. Their speed had dropped to the target of 220 knots, but they were losing altitude, having fallen from 2,100 down to 1,700 feet. Okai tried pitching up to regain their planned altitude, but as a result their speed dropped even more, to 196 knots, and the plane barely climbed. Of course, the reason was because First Officer Ryan had set both thrust levers to idle, and because of the control handover, no one pushed them back up again. But Okai didn’t realize that. Instead, he said, “Okay, let’s see what is the problem. Which one… what’s going on with the gauges? Read the gauges and see which one… who one… which… who has the EGT?”
Glancing over at the engine gauges, First Officer Ryan attempted to determine which engine had abnormal parameters, including but not limited to the exhaust gas temperature (EGT). But with both engines still running at idle power, it was quite difficult to tell. Out of the indicated parameters, engine pressure ratio (EPR) was usually the biggest clue, but the EPR for both engines was almost the same. Instead, Ryan attempted to recall what symptoms he had noticed when the engine first failed: he heard a sound which seemed to come from the left, and the plane yawed left — didn’t it? So it must have been the left engine. Its indicated EPR, slightly below that of the right engine, was consistent with such an interpretation. And so he said, “Yep, so it looks like the number one.”
“Number one is gone?” Okai asked.
“It’s gone, yep,” said Ryan. “So we have number two.”
“So we have number two, okay,” said Okai.
You might have already noticed what’s wrong with this picture. When the failure first happened, didn’t both pilots identify the problem as being with the right engine? First Officer Ryan even used the rudder to prevent the plane from yawing right! But, as it turns out, human memory is more fallible than we would sometimes like to admit, and in the intervening four minutes, both pilots had somehow entirely forgotten their initial impressions. First Officer Ryan even seemingly forgot that the left engine was at idle power because he put it there himself not even two minutes earlier. If at that moment some outside observer had asked Ryan why he thought the number one (left) engine was faulty, he might not even have been able to give a straight answer, and yet in the moment he expressed his determination with unquestioned conviction, and Captain Okai, believing Ryan to be a competent and trustworthy pilot, accepted his conclusion unconditionally.
Having concluded that the left engine was at fault, Okai advanced the right thrust lever in order to stabilize their flight path, then moved to their next priority: completing the engine failure checklist. His plan was to fly 15 miles out from the airport on their assigned heading before turning back, which would give them plenty of time to complete the procedure, so he said, “Alright, uh, two forty heading, I have control.”
“Okay, should we head back toward the airport though, before we get too far away?”
“Yeah, we’ll stay within fifteen… alright, I have controls, you run the checklist, let’s do the engine failure shutdown checklist.”
First Officer Ryan would later assert that he disagreed with the decision to spend so much time in the air, but that Okai was the captain, so he obeyed him. Besides, given their earlier conversation, he surely knew where arguing with Okai would get him (which was nowhere). Okai, for his part, would later note that he had been reprimanded by the Chief Pilot for landing without performing the checklist after a previous engine failure, and had promised not to do so again.
Some 30 seconds later, Okai asked air traffic control for permission to begin turning in, and received a new heading. Meanwhile, First Officer Ryan started reading off the conditions for performing the checklist. “Okay, engine failure or shutdown,” he recited. “When these occurs… engine failure, engine flameout, or another checklist directs an engine failure…”
At that moment, Ryan seemed to notice that the EGT on the right engine was abnormally high, almost inside the red “warning” zone on the gauge. If they let the exhaust gas temperature climb into the red zone, severe engine damage could occur. Of course, the reason for this was that the right engine was already damaged and was not running properly, causing its internal temperature to rise, but in the moment it appeared to First Officer Ryan that they were simply demanding too much of the old, somewhat underpowered engine. “We’re… we’re red line here, we should pull the right one back a little bit,” he said.
Captain Okai immediately recognized that this was a serious issue. He had already moved the right thrust lever to a reasonable power setting, but the EPR was much lower than it should have been, only about 1.22, which was not enough to keep them airborne for long. And yet even at this low power setting, the engine was overheating. His immediate conclusion was that they were about to lose thrust in both engines, and that they needed to get on the ground as soon as possible, so he said, “Okay, shoot, we should head towards the airport.”
As the gravity of the situation set in, First Officer Ryan began setting up for the approach, while Captain Okai informed air traffic control that they were turning in and did not have the airport in sight.
“Rhoades Express eight ten, fly heading of zero two zero and would you like to intercept the localizer or do you want vectors?” the controller asked.
“No, vectors straight to the airport,” Okai said. “We might lose the other engine too.”
Back in the cockpit, Okai asked, “We are clean, right?” His concern was that the flaps or landing gear might be extended, causing drag that was reducing their performance (a plane with no flaps or gear is referred to as “clean”). But they were in fact clean, so that wasn’t the problem.
“Okay,” said Ryan.“Just have to watch this though, the number two.”
By now they had fallen to 1,000 feet, their speed was down to 157 knots, and both parameters were still decreasing. “Damn,” Okai said. Suddenly, the stick shaker activated, warning that they were flying too slowly and could stall if they didn’t increase their airspeed. With their only working engine redlined — or so they thought — the only way to gain speed was by pitching down, but that would only hasten their already alarming descent.
“What’s this?” Okai exclaimed. “Hey man, we can’t keep going down!”
“We’re descending,” Ryan agreed.
Okai advanced the right thrust lever even more, and the EPR crept up to a still meager 1.37, but the temperature only continued rising into the red zone, until finally it reached the maximum that gauge could indicate.
“Okay, see, see if you can see the airport now,” Okay said, growing worried.
“Uh, we’re descending, we have to climb!” said Ryan.
“Double check the airplane is cleaned up,” said Okai.
“Yeah, flaps are up, speedbrakes…” Ryan replied.
“How is the EGT?” Okai asked.
“It’s max, it’s beyond max,” said Ryan.
“Okay, we’re barely holding altitude,” Okai said. “Okay, see what you can do in the checklist, finish as much as possible.”
“This says, uh, airframe vibrations, abnormal engines exist…” Ryan said, speed reading the checklist introductions. “It says do the engine shutdown only when flight conditions — we have to fly the airplane though.”
The full phrase was “when flight conditions allow” — and in Ryan’s view, that meant when their altitude and speed were stable, which they were not. And that meant flying the airplane had to come before finishing the checklist.
“Okay,” said Okai. “Damn.”
“We’re losing altitude,” Ryan repeated.
“Yeah. Fifteen miles out,” Okai said. They were on their way back to the airport now, but they were so low that it was difficult to make out the airport lights on the horizon, and they were still dropping. Unless they managed to find some more thrust, they weren’t going to make it. Of course, if someone had simply advanced the left thrust lever, all their problems would have been solved, but nobody even thought to try, so down they went.
Desperate now to avoid losing altitude, First Officer Ryan thought it was time to start deploying the flaps, knowing that while they would allow them to fly at a lower speed, they would also increase drag. “Do we go flaps, flaps one?” he asked.
“No no, not yet,” said Okai.
“Kay, we’re, we’re very slow though,” said Ryan. If they didn’t deploy the flaps, Okai would have to keep pitching down to avoid stalling.
“Shoot, okay, flaps one,” Okai agreed.
“Five hundred,” an automated voice called out, reciting their height above the water. It was followed by a callout from the Enhanced Ground Proximity Warning System, or EGPWS: “TOO LOW, GEAR!”
Keying his mic, Captain Okai said to air traffic control, “Okay, Rhoades eight ten, uh situation, we’ve lost number one engine and um, we’re coming straight to the airport… we’re gonna need the fire department, there’s a chance we’re gonna lose the other engine too, it’s running very hot. And um, speed is um, we’re pretty low on the speed and it doesn’t look good out here… you might want to let the Coast Guard know as well.” This request would probably end up being the best decision Captain Okai made during the entire emergency.
“TOO LOW, GEAR!” the EGPWS repeated.
“Just fly, fly the airplane please!” said Ryan.
“TOO LOW, TERRAIN,” said the EGPWS. “TOO LOW, GEAR! TERRAIN! TERRAIN!
“Do you have the airport?” Okai desperately asked.
“PULL UP,” the EGPWS blared.
“Pull up, we’re low!” Ryan repeated.
“PULL UP! PULL UP!”
“Rhoades Express eight ten, do you have the airport in sight?” the controller asked.
“Negative!” Ryan replied.
“And Rhoades Express eight ten, low altitude alert, are you able to climb at all?”
“No, negative,” Ryan again replied.
“Rhoades Express eight ten, roger, proceed direct to the airport and you are cleared to land any runway,” the controller said, followed by a heading. But they were running out of time.
As flight 810 dropped the last few hundred feet toward the ocean, the EGPWS continued to blare: “TOO LOW, TERRAIN! Three hundred! TOO LOW, GEAR!”
“Rhoades Express eight ten, the trucks are rolling,” said the controller.
Jumping on the radio again, Okai replied, “Roger, you wanna — you wanna let the Coast — Coast Guard know as well?
“Say that again?”
“Can you let the Coast Guard know, we cannot maintain altitude,” Okai repeated.
“We will,” said the controller.
At that moment, the EPR on the right engine increased to over 1.4, and for a brief moment the plane seemed to level off, before entering an extremely shallow climb. “Hold that please, it’s climbing, hold that, hold that,” First Officer Ryan exclaimed. “Pull back, we’ve got a climb! Pull back to the stick shaker!”
“Shoot, the three hundred feet…” Captain Okai started to say.
“It’s okay, we’re climbing — ” Ryan began, but at that moment the right engine started losing power again, and they began descending once more, having gained only 50 feet. “Oh, we’re not climbing, damn,” Ryan concluded.
“How’s the EGT?” Okai asked again.
“Hot, way over,” said Ryan.
“TOO LOW, TERRAIN!” said the EGPWS. “TOO LOW, GEAR! TOO LOW, GEAR! TOO LOW, GEAR!”
“Rhoades Express eight ten, the Coast Guard is on the way,” said the controller.
“TOO LOW, GEAR! TOO LOW, TERRAIN!”
“Pull back please!” said Ryan.
“Rhoades Express eight ten, if you can get to runway eight right or Kalaeloa, do you want Kalaeloa?” the controller asked, referring to a military airfield off their left side. It was closer than Honolulu International, but probably still too far away.
“We’d like the closest airport runway please,” Ryan replied.
“Anything we can land on,” Okai interjected.
“[Kalaeloa air]port is three miles north of you, uh, off your nine to ten o’clock,” said the controller.
“Wanna go there?” Ryan asked. The stick shaker stall warning activated for two seconds, prompting Okai to pitch down again.
“Can you get that, Rhoades Express eight ten, it’s three uh, to your left about three miles northwest of you,” the controller said.
“TOO LOW, GEAR! TOO LOW, GEAR!”
“Okay, give me a heading,” Captain Okai transmitted.
“TOO LOW, GEAR! TOO LOW, GEAR!” the EGPWS blared, followed again by the stick shaker.
“Rhoades Express eight ten, uh the airport is about a three one zero heading from you,” said the controller.
But it was too late even for this last-ditch effort. As Captain Okai turned left toward the airbase, the pace of the EGPWS alerts became even more frenetic: “TERRAIN! TERRAIN! PULL UP! PULL UP!”
“Three one zero, thank you,” Okai said to the controller. It would be the last transmission from flight 810.
“PULL UP,” the EGPWS screamed. “PULL UP! PULL UP! PULL UP! PULL UP!”
“You have control and you have control!” Okai exclaimed. It’s unclear what he meant, since he retained control of the plane and neither pilot would be able to recall the statement later.
“Okay,” said Ryan.
“Shoot, this is the water, we in the water,” Okai said, spotting the shining black waters of Mamala Bay rising beneath them.
“PULL UP!” The stick shaker rattled briefly again. “PULL UP! PULL UP! PULL UP! TOO LOW, TERRAIN!”
“Oh man, we’re in the water, we’re in the water, we can’t…” Okai said, on the verge of hyperventilation.
The stick shaker started rattling continuously now, punctuated by more EGPWS alerts: “TERRAIN! TERRAIN! PULL UP!”
“Damn!” Okai shouted.
The EGPWS mustered one last “pull up,” and then, with a tremendous shudder, the plane hit the water.
The impact was hard, and over quickly. Within seconds, the plane ground to a halt, but its fuselage had cracked in two just ahead of the wings, and water was pouring in. By the time Captain Okai managed to undo his seatbelt, the water outside the plane was half way up his window, and it came rushing into the cockpit when he slid it open. Fighting against the inflow, he forced his way out the window and into the heaving ocean. Meanwhile, First Officer Ryan’s seat had collapsed forward on impact, causing him to strike his head, but he too managed to open his window and clamber out into the watery darkness. Now only one objective remained: to survive.
In search of something to hang onto, Captain Okai swam toward the tail section, but no cargo or panels had come loose, so he simply grabbed the automatic direction finder antenna on the vertical stabilizer and hauled himself onto the top of the sinking empennage, where he clung to the tail as waves crashed over him. At the same time, First Officer Ryan held onto the nose section, but as it began to slip beneath the surface, he spotted a loose cargo pallet and climbed aboard, using it as a makeshift raft. He called his captain’s name, and Okai called his name in return, but Okai was in trouble, as waves repeatedly knocked him off his perch, forcing him to swim back again.
Suddenly, the roar of a helicopter overcame the rumble of the waves, and floodlights illuminated the desperate scene. The Coast Guard had arrived! At that moment, a wave again swept Captain Okai into the water, but this time he became disoriented; he could no longer find the tail, which was rapidly sinking. Floundering in the heaving sea, he began inhaling water and jet fuel. Realizing that his captain’s life was in danger, First Officer Ryan pointed the helicopter toward the tail section, and the rescuers got the message. An elite rescue swimmer jumped from the hovering helicopter and swam to Okai’s aid, pulling him back from the brink at the last possible moment. The swimmer and the unconscious captain were then winched back aboard — at which point the rescue swimmer jumped right back in again to save First Officer Ryan. With Captain Okai in apparently critical condition, the helicopter departed without them, but the Coast Guard had a plan B: a rescue boat, which was just now arriving at the scene. Grabbing onto the First Officer’s cargo pallet, the rescue swimmer swam through the ocean, pushing the improvised raft ahead of him, until they reached the boat and were hoisted aboard.
Against all odds, having ditched their plane in the ocean in the middle of the night, both pilots had been saved in the nick of time.
When National Transportation Safety Board investigators arrived in Hawaii later that day, they knew from the publicly available air traffic control tapes that the pilots of flight 810 reported an inability to maintain altitude and a possible dual engine failure, leading to a forced landing on water at night. Although it was clear that the pilots were lucky to be alive — in fact both were released from hospital within 48 hours — little else about the nature of the events was immediately obvious. And with the plane, and its black boxes, sitting somewhere on the bottom of Mamala Bay, the only way to find out what happened was to ask the two men who were there.
The interviews with the pilots, which have been publicly released, provide a glimpse into what the crew thought was going on during the emergency. Captain Okai reported believing that the number two (right) engine had failed, but that when First Officer Ryan told him the faulty engine was number one (left), he had no reason to disbelieve him. After all, Ryan was the one flying the plane, so he would have been in a better position to detect which side was lacking thrust. First Officer Ryan, for his part, stated in full confidence that the sound of the “thud” came from the left side, that the plane yawed to the left, and that he had always known it was the left engine that failed. Only after this did it become clear that the right engine was running very hot and was not producing enough thrust to keep them in the air. But both pilots agreed on one thing: they had no idea why the plane wouldn’t fly, and were eager to find out.
The recovery of the plane from under 110 to 130 meters (360 to 420 feet) of water ultimately took four months, but when the NTSB finally received the flight data and cockpit voice recordings, their contents underscored just how unreliable witness testimony can often be. In fact, the data showed that the right engine suddenly lost power about 7 seconds after liftoff, confirming Captain Okai’s initial impression that this engine had failed. Furthermore, the resulting yaw to the right was countered correctly by First Officer Ryan, showing that he knew which side had lost thrust. The cockpit voice recorder was even more unequivocal: in fact, both pilots explicitly stated that the right engine had failed. This was confirmed by metallurgical analysis, which showed that corrosion had led to at least one blade failure in the right engine’s high pressure turbine, but that no defects were present in the left engine until it hit the water.
The error chain began minutes after the initial failure, when First Officer Ryan began reducing thrust on both engines toward idle in order to slow the plane from 250 to 220 knots. After this occurred, the pilots again revisited the question of which engine had failed, and came to a startlingly different conclusion. In his interview, Ryan said that in addition to the symptoms described earlier, he saw that the left engine’s EPR and other parameters had fallen to idle, leading him to a conclusion that this engine had failed. But the left engine was at idle because he put it there! How was it possible for him to have become so confused? In the end, we may never know for sure — but it is possible to say a lot more about why Captain Okai failed to notice.
As pilot monitoring during the takeoff, it was Captain Okai’s primary responsibility to watch the instruments and note any abnormalities. But almost as soon as the failure occurred, he took it upon himself to declare an emergency to air traffic control, an effort which he admitted “became a project.” In fact, Okai spent one minute and 40 seconds in a confused exchange with the oversaturated controller before he finally returned his attention to the cockpit, demonstrating rather poor task prioritization. Ideally, he should have analyzed the situation first and declared an emergency second, and if the controller did not hear his emergency declaration, he could have used the transponder to “squawk” 7700, the universal emergency code, instead of wasting more time on the radio. But he did not.
By the time Captain Okai returned his attention to the cockpit, First Officer Ryan had already rolled back both engines to idle and leveled off at 2,000 feet, eliminating the most salient clues as to which engine had failed. At this point, they found themselves outside the boundaries of the assumptions built into their training scenarios and emergency checklists. The procedures for responding to an engine failure on takeoff assumed two things: first, that one engine would stop producing power entirely, resulting in warnings and zeroes on gauges; and second, that the adverse yaw from the asymmetric thrust would persist, providing a powerful clue about which engine had failed. But in this case, neither of these assumptions held, because the right engine only suffered a partial loss of power, and by the time the pilots got around to formally identifying the failed engine some four minutes after takeoff, both engines were producing the same amount of thrust (very little), so the adverse yaw was gone. At that point the only obvious difference between the two sets of gauges would have been a higher temperature on the right engine. As a result, there was nothing to obviously indicate to Captain Okai that First Officer Ryan’s conclusion about the failed engine was wrong. There was nothing to indicate that it was right, either, but Okai’s trust in Ryan was apparently good enough. Had he attempted to verify this by advancing both thrust levers in turn, which is a prescribed procedure for identifying a failed engine, he would have realized that the left engine was fine, but he never tried.
Because the pilots never increased power on the left engine, the plane did not have enough thrust to maintain altitude, even with the right thrust lever fully forward, because they were relying only on the damaged right engine. At any point, the pilots could have averted the accident by simply moving the left thrust lever forward, which would be a sensible thing to do when one is about to hit the water, even if one believes that that engine has failed. After all, the worst that can happen is it doesn’t work, and in the best case scenario, it could save lives. But when the NTSB conducted follow-up interviews in March 2022 to clarify why, among other points, the pilots did not move the left thrust lever, both replied that it simply never occurred to them. By the time it had become clear that they could not maintain altitude, both pilots were suffering from tunnel vision, and were singularly focused on flying the airplane to the end, rather than thinking outside the box for solutions. And with their focus so consumed by the task of flying, no one even looked at the thrust levers, let alone considered moving them.
Had the pilots completed the engine failure and shutdown checklist, which required moving the affected thrust lever to idle before cutting fuel, the pilots might have noticed that the left thrust lever had been at idle the whole time, and might have tried advancing it. But in the event, they never actually started the checklist, because by the time they got around to it, their flight path was no longer stable, and First Officer Ryan had decided that flying the plane was a higher priority. Captain Okai, for his part, told the NTSB that he thought the checklist would be useless once the second engine started to fail, so he didn’t order Ryan to finish it.
In the end, the fact that the pilots rolled back the wrong engine was attributed to poor communication and insufficient procedural discipline. The flight operations manual included the following prescient warning: “Any time an engine shutdown is required in flight, good crew coordination is essential. Airplane incidents have turned into airplane accidents as a result of the flight crew shutting down the incorrect engine. When the flight path is under complete control, the crew should proceed with a deliberate, systematic process that identifies the correct engine and ensures that the operating engine is not shut down.” In the event, the flight path was stable at 2,000 feet for several minutes, but no “deliberate” or “systematic” attempt to identify the correct engine was ever carried out. Ultimately, this was the pilots’ biggest and most unfortunate mistake.
The NTSB also criticized Captain Okai for demonstrating poor task prioritization (communicating with ATC instead of analyzing the situation, failing to ensure that the checklist was performed in a timely manner); poor crew resource management (failing to trust but verify, failing to monitor his First Officer’s actions); and poor leadership (failing to establish a plan, failing to enforce adherence to procedures). However, investigators also wrote that many of his mistakes could have been influenced by stress, which is known to have effects similar to fatigue, including inhibited decision-making and reduced ability to conduct critical thinking.
Although the NTSB pointed to the nature of the emergency itself as the possible source of his stress, it’s also worth noting that the cockpit voice recorder transcript supports a hypothesis that Captain Okai was already stressed before the flight even took off. He had been in a shouting match with another pilot less than 24 hours earlier and may have felt hurt or insulted by her refusal to fly with him. The salience of this event was clear, given that Okai spent a total of 32 minutes before the flight talking about his experiences with First Officer Moore, including after starting the engines and during taxi, in violation of the sterile cockpit rule, which prohibits off-topic conversations between engine start and 10,000 feet. This violation almost certainly had no effect on the course of events, but it did suggest that Okai was having difficulty focusing on the task at hand. In the end, the NTSB declined to mention these conversations in its final report, which is normal — most of the time, the agency doesn’t wade into pilots’ personal disputes — but when taken in context, it’s difficult to ignore.
Although the crash was the direct result of the flight crew’s actions, it’s worth summarizing the mechanical aspects before bowing out. The final report and its supporting documentation are light on details, but the cause of the failure seems to have been simple corrosion of either one or two high pressure turbine blades. The question of whether this corrosion was detectable during routine inspections, and why the corrosion appeared in the first place, don’t seem to have been addressed. However, given that the corrosion was internal to the blades, it’s possible that it was difficult to detect, which is supported by the NTSB’s explicit conclusion, stated in its report, that “maintenance was not a factor in this accident.” Furthermore, corrosion is an inevitability on airplanes and engines operating in Hawaii’s humid, salty climate, especially over long timeframes. The engine that failed was built in 1968 and was 53 years old at the time of the crash, plenty long enough to develop all manner of problems, especially if the maintenance was not always up to par.
There was plenty of circumstantial evidence to suggest that maintenance was a major problem area for Transair. Captain Okai said he had experienced five engine failures while flying 737s for Transair, which is a lot, and issues like high engine temperatures on takeoff were common. The airline’s chief maintenance inspector had also resigned two weeks before the crash, citing insufficient staffing, time, and experience. And according to a colleague, First Officer Ryan had previously called the airline’s safety culture “screwed up” and “beyond help.” These problems had been brewing in the background for some time, and in May 2022, the Federal Aviation Administration revoked Rhoades Aviation’s air operator certificate, permanently grounding Transair, after an investigation found numerous maintenance violations, including 33 flights performed with unairworthy engines. However, the investigation and its findings were said to have nothing to do with the accident, which was caused by an apparently undetectable issue.
With Transair having ceased to exist by the time the investigation concluded, and with very few Boeing 737–200s remaining in service in the United States, the NTSB did not issue any safety recommendations as a result of the accident. Nevertheless, as the latest example in a series of crashes involving shutdown of an incorrect engine, it’s worth extracting some lessons anyway. The crash of Transair flight 810 in particular evokes the 1989 disaster involving British Midland flight 92, another Boeing 737 that suffered a partial engine failure, only to crash short of the airport after the pilots mistakenly shut down the wrong engine. The reasons for the engine failures and for the pilots’ mistakes in both crashes were different — for instance, the British Midland investigation cited poorly designed gauges that were not installed on earlier 737–200s like that involved in the Transair crash. However, both cases were characterized by a lack of due care in determining the failed engine, including captains who uncritically believed their first officers’ unsupported and incorrect determinations.
The fact that the same mistakes could occur again after 32 years underscores the need for pilots to double and triple check which engine has failed, but it also highlights the limitations of better training and words of caution in manuals as a solution to this recurring issue. As I mentioned in my article on the British Midland crash, the most effective way to prevent this kind of accident is by fitting airplanes with an Engine Indicating and Crew Alerting System, known as EICAS, or similar equipment. These systems automatically monitor engine performance and, should an engine fail, will produce a message informing the pilots which engine is the cause of the problem, dramatically reducing the probability of an incorrect identification. However, retrofitting the systems onto older 737s, which are most at risk, is not required and may be impractical or impossible. For that reason, as long as first and second generation 737s continue to fly, a safety risk still exists, and now that the findings of the Transair investigation have been released, that fact bears repeating: as long as pilots rely on context clues to determine which engine has failed, the opportunity for this type of error will remain. Let us merely be thankful that this latest warning did not come to us at the cost of lives — and let us not squander it.
Support me on Patreon (Note: I do not earn money from views on Medium!)
Visit r/admiralcloudberg to read and discuss over 240 similar articles