Kaupo, HI, USA
N13GZ
RAYTHEON AIRCRAFT COMPANY C90A
The medical transport flight was en route to pick up a patient on a neighboring island on an instrument flight rules (IFR) flight plan in dark night conditions over the ocean. About 13 minutes after departure, at 13,000 ft mean sea level (msl), the airplane’s vertical gyro failed, which subsequently failed the pilot’s Electric Attitude Director Indicator (EADI), which also caused the autopilot to disconnect. The failure of the EADI and autopilot disconnect required the pilot to manually fly the airplane using the copilot’s attitude gyro for his horizon information (bank angle and pitch attitude) for the duration of the flight. The pilot did not declare an emergency, nor did he inform air traffic control (ATC) that his electric attitude indicator had failed and that his autopilot had disengaged. After the instrumentation failure and autopilot disconnect, the airplane entered a series of right banks before being brought back to level, followed by a left turn, and then subsequent right banks. ATC asked the pilot to change course and the pilot agreed. The copilot attitude indicator indicated that the airplane entered a descending, steep right bank turn. Over the next 5 minutes, ATC issued varying instructions to the pilot. During this time, the airplane entered several right- and left-hand banks and rolls and descended 1,000 ft per minute (fpm), which increased to -3,500 fpm as the airplane’s airspeed increased. About 7 minutes after the instrumentation failure, the airplane was in a 65° bank angle when ATC asked the pilot to verify his heading. As the pilot responded, the airplane bank angle increased to 90° and the airspeed exceeded 260 knots. The bank angle and airspeed continued to increase; a loud metallic bang was recorded that was consistent with an in-flight separation of the empennage from the fuselage before impacting with the water. After an extensive underwater search, the main wreckage was located on the seabed at a depth of about 6,420 ft. The wreckage was recovered and transported to a facility for examination. A postaccident examination of the engines and airframe revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The engines exhibited contact signatures consistent with the engines developing power at the time of impact. The examination of the vertical gyro was unable to determine the reason for its failure due to the damage incurred by the unit during the accident sequence and the subsequent saltwater contamination. The operator had installed an Appareo Vision 1000 airborne image recording system (AIRS) in the airplane in 2018. The camera was mounted in a position that captured the entire instrumentation for both the left and right seats, as well as the center pedestal and overhead panel. During the accident flight, the Appareo video recording showed the pilot using his cell phone to listen to music shortly after takeoff, and the pilot talking to and passing money back to a medical flight crewmember as the airplane climbed through 1,400 ft msl. Both of these actions took place during a critical phase of flight and were in direct conflict with Guardian Flight’s Standard Operating Procedures. The Appareo video recording revealed that the airplane’s Collins multi-function display (MFD) was inoperative for the duration of the flight, and on the last four flights of recorded video. It also captured the EADI on the captain’s side (or left side), going black, or inoperative, approximately 13 minutes into the flight. Additionally, the video recording captured audible sounds including the autopilot disconnect, master caution warning, altitude alert tones, and the sound of a loud metallic bang shortly before water impact. Although this flight was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 flight, upon landing and loading the patient for transport to Honolulu the flight at that point would be operated under 14 CFR Part 135. Guardian Flight was allowed in their Operation Specifications to operate the Part 135 flight with a single pilot; however, those flights with only one pilot were required to have an operating autopilot. Therefore, in the airplane’s condition, with the autopilot and EADI inoperative due to the vertical gyro failure, they would not have been able to transport the patient according to their Operation Specifications. A review of the pilot’s certification history before he was employed by Hawaii Life Flight revealed that he had six Notice of Disapproval entries in his Federal Aviation Administration (FAA) records. Of those six notices, three were in rotorcraft and three were in fixed-wing aircraft, each one the culmination of multiple unsatisfactory training events. The records detailed consistent deficiencies in the use of navigational systems, instruments, and multiengine aircraft maneuvering. A review of the pilot’s training record at Hawaii Life Flight indicated that during initial Advanced Aviation Training Devices (AATD) training, which consisted of 6 training sessions during December 2019, he had five unsatisfactory ratings. Of those, two were on the last training event. The pilot was given two additional training sessions in January 2020 and all training areas indicated “satisfactory.” The pilot had been employed by Hawaii Life Flight for three years and had six mandatory checking events. He failed three checkrides on the first attempt. Training records indicated that following each unsatisfactory training event, the accident pilot was given additional training, and subsequently reevaluated. The second evaluations were marked as “satisfactory.” It is the responsibility of the operator to ensure their crews have the training, skills, competency, and proficiency to operate in their target environment. Guardian’s flight standards manual states that following multiple consecutive training or checking failures, the pilot should have been placed in remedial training and on an improvement plan. It was unclear if a formal plan was developed to address the issue. At no time did the pilot go to Guardian headquarters to facilitate retraining initiatives. Both the assistant chief pilot (ACP) and chief pilot (CP) stated the pilot was “retrained to proficiency.” Guardian Flight was not required to have a flight operations quality assurance (FOQA) program. However, with the airplane equipped with a cockpit voice recorder (CVR), ADS-B, the Appareo cockpit imaging system, and the SkyTrac ISAT-100A satellite communication transceiver, they had the tools installed and in place to have a FOQA program. But Guardian Flight did not acquire the mechanism or means to manage or download the data from these systems. Guardian Flight’s failure to monitor operations likely contributed to this pilot’s non-compliance with the operating procedures. With a lack of appropriate infrastructure to monitor the flights, Guardian Flight did not have any way to determine this pilot’s nor any other pilot’s, compliance. The pilot likely experienced spatial disorientation as result of the failed EADI and the autopilot disconnect. Spatial disorientation can affect even the most skilled pilots, but the phenomenon is more likely to occur with a pilot who has inexperience with or a history of deficiencies using navigational and instrument systems, such as exhibited by the accident pilot. Additionally, the pilot did not declare an emergency or communicate the loss of his attitude indicator or autopilot. Notifying ATC would have made them aware that they should limit communications to only what was necessary. Unaware of the issue, ATC continued to issue several instructions to which the pilot then tried to respond and adhere, diverting his attention away from manually flying the aircraft and maintaining spatial orientation. The loss of the EADI and autopilot disconnect in dark, overwater conditions, required the pilot to fly with a partial instrument panel and rely on the copilot’s attitude indicator, which likely resulted in the pilot’s spatial disorientation and loss of control. The pilot’s recurrent difficulties in aircraft maneuvering, systems management, and use of navigational instruments likely led to his inability to maintain positive control and spatial awareness once the EADI went inoperative and the autopilot ceased to function.
HISTORY OF FLIGHTOn December 15, 2022, about 2114 Hawaii-Aleutian standard time, a Raytheon Aircraft Company (formerly Beech) C90A, twin-engine, turbine-powered airplane, N13GZ, sustained substantial damage when it was involved in an accident near Kaupo, Hawaii. The airline transport pilot, flight paramedic, and flight nurse were fatally injured. The airplane was operated as a Title 14 CFR Part 91 air ambulance positioning flight. The flight, operated by Guardian Flight LLC, dba Hawaii Life Flight, departed the Kahului Airport (OGG) on the Island of Maui, Hawaii, about 2053, on an instrument flight rules (IFR) flight plan. The accident airplane was destined for the Waimea-Kohala Airport (MUE), a 21-minute flight, on the Island of Hawaii to pick up a patient to be transported to Honolulu, Hawaii. A review of the Appareo Vision 1000 recorded images and audio data, archived voice communication information, and ADS-B data revealed that the pilot engaged the autopilot shortly after takeoff at about 160 ft msl. He retracted the landing gear about 700 ft above ground level and reduced propeller pitch. After departure from OGG about 2055, the pilot contacted the departure ATC specialist on duty, indicating the flight was at 1,000 ft msl climbing to 11,000 ft msl. After the airplane departed OGG, it initially proceeded north, then it turned eastbound, which is consistent with the Onohi Two standard instrument departure procedure. As the airplane climbed through 1,400 ft msl, the pilot passed money to a medical flight crewmember seated in the cabin. About 2056, the pilot opened a music app on his cell phone and set it down in the right seat as the airplane climbed through 4,500 ft msl. The pilot looked at an approach plate on the iPad and entered approach frequencies. About 2100, as the airplane climbed through 8,000 ft msl, the pilot repeatedly manipulated the buttons on the Collins MFD, but the screen remained blank and unresponsive. Review of previous flights revealed the Collins MFD was not working in the last four flights of recorded video. According to the Daily Maintenance Records there were no entries for the MFD being inoperative in the two weeks prior to the accident. About 2102, the departure ATC specialist instructed the pilot to contact Honolulu Air Route Traffic Control Center (ARTCC). About 2103, the pilot contacted the ARTCC specialist on duty and reported level at 11,000 ft msl, and the pilot requested the RNAV 4 instrument approach at MUE. About 2104, the ARTCC specialist asked if the pilot could climb to 13,000 ft msl, and the pilot responded that he could. The flight proceeded on an east-southeasterly heading and along the northern shoreline of the Island of Maui, and then it turned southbound along the predetermined flight route. About 2106, the autopilot disconnect alert tone sounded, and the autopilot disconnect light illuminated. The pilot’s Electric Attitude Director Indicator (EADI) did not display artificial horizon information for the duration of the flight, red warnings flashed several times, and then remained lit (see Figure 1). The flight nurse asked the pilot if the autopilot had disconnected, and the pilot confirmed to the flight nurse that it had. Figure 1. Google Earth image of portion of the flight path. About 2107, the copilot side attitude indicator indicated a 30° bank angle to the right and then returned to level flight. The altimeter alert sounded, and the altimeter read 13,220 ft. The pilot adjusted the pitch trim, and the attitude indicator indicated a steepening right bank, and then a left turn. About 2108, as the flight continued on a southeasterly heading, the ARTCC specialist initially instructed the pilot to turn right to a heading of 180°, and then to an amended heading of 200°; the pilot acknowledged the 200° heading. The attitude indicator indicated a descending and deepening right bank turn. About 2109, as the flight continued on a 200° heading at 13,000 ft msl, the ARTCC specialist instructed the pilot to descend to 12,000 ft msl, and the pilot accepted. About 2110, the ARTCC specialist instructed the pilot to descend to 8,000 ft msl, and the pilot acknowledged. About 2111, ATC issued a traffic advisory and the airplane leveled off and began a left turn. Immediately following the pilot’s response to the traffic advisory, the airplane began an increasingly rapid descent through 12,000 ft msl and leveled off at 11,120 ft msl. About 2112, the ARTCC specialist instructed the pilot to fly a heading of 180°, and he cleared the flight to fly direct to TAMMI, the initial approach fix for the RNAV (GPS) 4 approach to MUE, and the pilot acknowledged the instructions. The airplane was in a slight left, descending turn. The pilot manipulated the GPS and selected direct TAMMI. The attitude indicator indicated an increasing right bank, and the airplane was descending at 1,000 ft per minute. The airplane continued to descend through 10,180 ft msl, and the rate of descent increased as the roll increased to 65° angle of bank to the right. At 2113:22, the ARTCC specialist contacted the pilot of N13GZ, asking him to verify that he was flying “direct to Tammi” as previously instructed. At 2113:40, the pilot replied: “Uhh, 13GZ is off navigation here… we’re gonna… we’re gonna give it a try.” The vertical speed indicator was pegged at -3,500 fpm (see Figure 2). Figure 2. Google Earth image of a portion of the flight track. At 2113:32, the ARTCC specialist acknowledged the pilot’s last statement and instructed him to turn right to a 170° heading and to maintain 8,000 ft msl. The copilot attitude indicator displayed 90° angle of bank. The airspeed indicator needle was at the maximum operating speed of 226 knots. At 21:13:41 the attitude indicator showed an inverted descending right turn. At 2113:43, as the airplane passed through 7,700 ft msl, a final radio transmission, believed to be from the accident pilot, is heard saying “Hang on.” The altimeter was showing a very rapid descent. The engine gauges were within normal range. At 21:13:51, the airplane passed through 4,000 ft msl and was rapidly decreasing. The yoke seemed to move quickly forward and then aft in a jolt like manner. As the movement towards the aft position of the yoke occurred, a sound similar to a loud metallic bang was audible. The camera recorded a rapid jolt, and the field of view of the recorded image noticeably changed. The control panel illumination appeared to be extinguished, consistent with the airplane main power bus failing, and switching over to battery power. The last recorded frame of the video and end of audio recording at 21:14:06 showed the altimeter indicating about 400 ft msl. There were no further communications with the accident flight. The pilot did not declare an emergency, report the instrumentation failure, or report that the autopilot was disengaged. The ADS-B data stopped about 10 miles south of Kaupo, near where a witness observed the accident airplane impact the water. (Figure 3) Figure 3. Google Earth image of the flight path from the departure airport, and depecting the destination airport. A witness, who was flying a low-wing Piper PA-44 airplane from Hilo, Hawaii, to Honolulu, reported seeing the accident airplane well above and to the north of his flight path. The ARTCC specialist reported that N13GZ was at the PA-44 pilot’s 3 o’clock position at 12,000 ft msl, descending to 8,000 ft msl. The witness continued watching the lights of the airplane and said that as the airplane continued southbound it began a right turn. Then it entered a spiraling right descending turn, which steepened as the descent increased. The airplane continued to descend until it impacted the surface of the water. He lost sight of the airplane’s lights shortly after the airplane impacted the water. The red flight track represents the accident airplane, and the yellow flight track represents the eyewitness airplane (see Figure 4). Figure 4. Google Earth image of the accident flight path and the witness’s airplane flight path. PERSONNEL INFORMATIONThe pilot held an Airline Transport Pilot (ATP) certificate with a rating for multiengine land and Rotorcraft-helicopter, with commercial pilot privileges for airplane single-engine land and airplane single-engine sea, and type ratings on the B-737, EMB-145, and LR-60. The pilot’s ratings included limitation of B-737, EMB145 Circling approach – VMC only, EMB-145 is subject to pilot-in-command limitation(s), LR-60 SIC privileges only, and English proficient. He held a flight instructor certificate with ratings for rotorcraft-helicopter and instrument helicopter, and a remote pilot certificate with a rating for small, unmanned aircraft system. He held an FAA second-class medical certificate dated April 21, 2022, with limitation of must have available glasses for near vision. At the time of the accident, he was based at OGG. When he was hired by Hawaii Life Flight on December 2, 2019, he had 7,668 total hours of flight time, about 950 of which were in fixed-wing airplanes. Before being hired at Guardian Flight, from 2009 to 2019, pilot had six Notice of Disapproval entries on his certification records: three for rotorcraft and three for fixed-wing — each one the culmination of multiple unsatisfactory training events. Of the three fixed-wing notices, two were issued when the applicant was applying for an ATP multiengine land airplane certificate. The third and most recent notice of disapproval was when the applicant was applying for an additional type rating to his ATP certificate. A review of the unsatisfactory items in the three most recent notices of disapproval indicated, in part: “poor automation management especially as to the FMS and lateral nav[igation] situational awareness;” “applicant did not demonstrate proper recovery for clean stall;” and various other reasons including, but not limited to, airplane performance procedures. The records detailed consistent deficiencies in use of navigational systems, instruments, and multiengine aircraft maneuvering. The pilot’s schedule consisted of a two-weeks-on, two-weeks-off rotational cycle where the pilot was on call at his personal residence for a 12-hour period. The shifts would alternate between day shift (0500 – 1700) for the first week and night shift (1700 - 0500) for the second. The pilot was working his second week at the time of the accident. On December 14, the pilot moved to the night shift and received a call out in the morning of December 15. He was actively flying from approximately 0400 to 0630. The pilot then went off shift and returned to his personal residence. According to his next of kin, the pilot was active in the morning, had lunch and was active again in the afternoon. They had dinner together and were ready to retire for the evening about 1930 when he later received the call out for what resulted in the accident flight. Training A review of the pilot’s training record indicated that during initial Advanced Aviation Training Devices (AATD) training, which consisted of 6 training sessions during December 2019, the pilot had five unsatisfactory ratings. Of those, two were on the last training event. The pilot was given two additional training sessions in January 2020 and all training areas indicated satisfactory. The pilot had been employed by Hawaii Life Flight for three years and had conducted three 6-month pilot proficiency checks and three annual recurrent 135.293, 135.297, and 135.299 proficiency checks. He failed three checkrides, or half of those events, on the first attempt. Records indicated that the pilot’s recurrent 135.293, 135.297, and 135.299 proficiency check on February 2021 was unsatisfactory. The flight maneuvers that were graded unsatisfactory were “Landing with simulated powerplant failure.” According to the assistant chief pilot (ACP) of Hawaii Life Flight, he had conducted some of the accident pilot’s checkrides. The ACP recalled that in July of 2020 the accident pilot unsatisfactorily completed two maneuvers. “The first one was an unsatisfactory non-precision RNAV three approach. Failure to follow correct approach procedure. Descent below authorized altitude before the final approach fix. And then I put satisfactory on the next non-precision approach, correct altitude procedure on the next approach. His second …maneuver that was unsatisfactory. Landing from a circle approach, bank angle exceeded 30 degrees from base to final. Satisfactory on the next landing from circle approach. And then that was a satisfactory check.” The ACP conducted a second checkride with him about a year later; that checkride was marked as “unsatisfactory.” According to the ACP, “it was a missed approach. Unsatisfactory missed approach. Failure to stop climb at authorized given altitude. The second unsatisfactory I put in there was ILS power plant failure. Improper airplane configuration before DA or DH. Yeah, I remember he went full flaps before that that. He put full flaps after the final approach fix…and a third one was again on the second missed approach failure to ensure proper airplane configuration during missed approach. So, we were at miss on that one and he didn’t clean the airplane up. We were, we were already headed out with the hold and the gear was still down and everything was still configured for landing.” The ACP provided the accident pilot with his recheck event, which was “satisfactory.” After the accident, the Director of Operations (DO) at Guardian Flight, LLC reviewed the pilot’s training records and said there were some concerns, and it wasn’t “what [he] would consider a normal training record.” The DO said he believed there was “missed communication” between Hawaii Life Flight’s ACP and the Chief Pilot (CP) on how the accident pilot was performing. The DO said he believed there was a drive for Hawaii Life Flight leadership to take care of performance or intrapersonal issues autonomously rather than involve others at the Guardian Flight level. When asked about the accident pilot, the CP stated he had reviewed the accident pilot’s records and noted there were some deficiencies in training listed on the PRIA and that the pilot had “a lot of helicopter hours and the fixed wing hours were low.” The CP said the accident pilot’s two previous jobs were flying fixed-wing aircraft professionally; that information combined with his interview and AATD performance made the pilot a candidate to consider. The ACP was responsible for reviewing pilots’ applications for Hawaii Life Flight and did so for the accident pilot’s application, although he said the final approval had to come from the chief pilot. Human resources at Guardian Flight was responsible for clearing the applicant’s work history and for drafting the offer letter. The ACP could not remember any specifics about the accident pilot’s hiring process but did remember he was referred to the company by another line pilot. When asked what he looked for in an applicant, the ACP said he would make inquires with the applicant’s previous employer and consider their overall experience and performance in the AATD. The Director of Training (DT) stated that he conducted a records review postaccident and noted there were “multiple unsatisfactory remarks, repeat unsatisfactory remarks on similar or same tasks, [and] failed check rides” and that he was not made aware of the pilot’s performance. The exception was when the pilot was hired initially as the DT was part of an additional panel convened to assess the pilot’s past training deficiencies denoted in his Pilot’s Record Database (PRD) record. A performance and training plan was created, which the accident pilot successfully completed. The DT stated, “…if there is an individual that is demonstrating weakness throughout simulator AATD training, they should be given training to bring that individual to satisfactory standards.” He also said that any pilot not meeting the standard should be brought to the attention of the CP, the DO, and the DT. Guardian’s flight standards manual states that, following multiple consecutive training or checking failures,
Guardian Flight’s inadequate pilot training and performance tracking, which failed to identify and correct the pilot’s consistent lack of skill, and which resulted in the pilot’s inability to maintain his position inflight using secondary instruments to navigate when the airplane’s electronic attitude direction indicator failed, leading to his spatial disorientation and subsequent loss of control. Contributing to the accident was the lack of a visible horizon during dark night overwater conditions and the pilot’s failure to declare an emergency with air traffic control.
Source: NTSB Aviation Accident Database
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