The National Transportation Safety Board has determined that pilot error was the likely cause of the crash of a Hawaii Air Ambulance aircraft on the Big Island in January 2004 that killed all three occupants on the plane.

The NTSB released the results of its probable cause investigation yesterday and said there were "no anomalies with the airplane or engines" on the Cessna 414A that crashed Jan. 31. The report points to several actions taken by the pilot during poor weather as contributing factors in the crash.

Killed were pilot Ron Laubacher, 38; Honolulu firefighter Joseph "Danny" Villiaros, 39; and Emergency Medical Services district supervisor Mandy Shiraki, 47. The Air Ambulance plane went down in dense forest 25 miles northwest of Hilo early Jan. 31, but the wreckage was not discovered until two days later.

The aircraft was on its way to Hilo to pick up a patient for transport back to Honolulu when it crashed.

The NTSB is still investigating the March 8 crash of a Hawaii Air Ambulance plane on Maui that killed three crew members. In the meantime, the company has halted operations pending the outcome of inspections of its aircraft.

In its report of the 2004 crash, the NTSB said that Laubacher was operating by visual flight rules, or VFR, rather than instrument flight rules, or IFR. Hawaii Air Ambulance had told NTSB investigators that VFR was normal, even at night or during bad weather, and that IFR clearance could be picked up during the flight.

The company said IFR flights often are held up in Honolulu and Kona and flying under VFR "helped them get under way to their patients faster," the NTSB report said. Laubacher had flown under VFR the entire flight, the NTSB said.

"The normal visual approach into Hilo was to fly over 'Upolu Point at 9,500 feet and then begin the descent about 15-20 miles later," the report said. "The accident flight path was not normal."

As the plane approached 'Upolu Point, the NTSB said, radar showed it at about 7,400 feet.

A witness said he heard an aircraft fly over his home in 'Umikoa Village at about 1:30 a.m. He went outside and saw a plane flying about 500 feet above his home, which is at the 3,526-foot level and about 50 miles from 'Upolu Point, the NTSB said.

The Cessna crashed about three miles away after it hit a tree branch and then slammed into the ground.

The NTSB report said probable causes of the accident were Laubacher's "disregard for an in-flight weather advisory" and the likely encounter with "marginal" visual flight rules weather.

"His decision to continue flight into those conditions, and failure to maintain an adequate terrain clearance altitude (resulted) in an in-flight collision with trees and mountainous terrain," the NTSB reported. "A contributing factor was the pilot's failure to adhere to the VFR weather minimum procedures in the company's operations manual."

"We are saddened and surprised by this news," Andrew Kluger, Hawaii Air Ambulance chairman and chief executive officer, said yesterday in a statement. "Ron was an exceptional friend and pilot who flew a great many successful missions. We still miss him dearly."

Ruth Laubacher, the pilot's mother, declined comment.

Dominica Villiaros, mother of Danny Villiaros, said she was not surprised or angered.

"I thought if it was pilot error what would I do? I'm going to be mad with the pilot? I'm going to sue the pilot? His mother is grieving, too. That was her only son," Villiaros said. "My son's dead. There's nothing that I can do. But I have to tell you it has been difficult."

The NTSB said Laubacher had more than 8,200 hours of flight time and that other emergency medical personnel who had flown with him said they were "very confident" with his abilities.

But Laubacher did have several blemishes on his flying record before he was hired by Hawaii Air Ambulance in 2000.

Federal Aviation Administration records showed that Laubacher had his pilot's license suspended for 180 days on Sept. 29, 1999, because he had two convictions for drunken driving within three years, and because he had failed to report the second DUI conviction within 60 days, which he was required to do under federal regulations.

His FAA medical certificate was revoked the same year for making "an incorrect statement" to the agency on his application to renew the certificate.

But the FAA said Laubacher's pilot's license and medical certificate were later restored, and both were valid at the time of the crash.

An autopsy revealed that Laubacher had an antihistamine in his system, but the NTSB did not say if it played a role in the crash. One side effect of the medication is drowsiness.

Reach Curtis Lum at culum@honoluluadvertiser.com.