Contributor - Accidents and Regulations

Contributor - Accidents and Regulations

Gordon Gilbert

An air ambulance company’s “inadequate pilot training and performance tracking” that failed to identify the pilot’s “consistent lack of skill” resulted in his spatial disorientation and loss of control of the turboprop twin while using secondary instruments after the electronic attitude direction indicator failed, according to a recently released&nbsp;<a href="https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106468/pdf">NTSB final report</a>.
The Dec. 15, 2022 fatal crash of the Beechcraft King Air C90 offshore Kaupo, Hawaii, killed the pilot and two other crewmembers. Contributing to the accident, said the report, “was the lack of a visible horizon during dark night [VMC] overwater conditions and the pilot’s failure to declare an emergency with ATC.”
An NTSB review of the pilot’s certification history before he was employed by Guardian Flight (dba Hawaii Life Flight) revealed that, between 2009 and 2019, he had six notices of disapproval entries in his FAA records, each one the culmination of “multiple unsatisfactory training events” detailing “consistent deficiencies” in the use of navigation systems, instruments, and multi-engine aircraft maneuvering.
The pilot—who logged 950 of his nearly 7,000 hours in airplanes and had 650 hours in type—was employed by Hawaii Life Flight for three years and had six mandatory checks. He failed three check rides on the first attempt. Training records indicated that following each unsatisfactory training event, the accident pilot was given additional training and subsequently reevaluated as “satisfactory.”
During the accident flight, a cockpit imaging system recording showed the pilot using his cell phone to listen to music shortly after takeoff and talking to and passing money back to a medical flight crewmember as the airplane climbed through 1,400 feet above 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 (SOP).
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. However, it was unclear if a formal plan was developed. Both the assistant chief pilot and the chief pilot said the pilot was “retrained to proficiency.”
Despite the airplane having a CVR, ADS-B, cockpit imaging system, and a satellite communication transceiver, the NTSB said Guardian Flight did not download the data from these systems.
“Guardian Flight’s failure to monitor operations likely contributed to this pilot’s noncompliance with the [company’s] operating procedures,” stated the report. “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 [with the SOP].”
Found within his personal effects at the accident site was a handwritten note addressed to the pilot. It advised that he should not be “forced to fly through the clouds by any person in the back.” The author of the letter was the pilot’s next of kin and was written in March 2022.

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