ANC14FA068

The pilot’s improper inflight planning and improper decision to deliberately operate the airplane at low altitude in close proximity to obstructions and rising terrain. Contributing to the accident were the pilot’s improper preflight planning and the Federal Aviation Administration’s inappropriate decision to issue a 14 Code of Federal Regulations Part 135 certificate to the operator despite the pilot’s history of accidents, incidents, reexaminations, and checkride failures.

The commercial pilot was conducting a 14 Code of Federal Regulations (CFR) Part 135 commercial air tour flight with three passengers onboard when the airplane impacted rising terrain below the entrance of a high mountain pass. The airplane was substantially damaged, and the pilot and his three passengers were seriously injured. Thirty-five days later, one of the passengers died as a result of his injuries. The pilot initially reported to first responders that he had encountered a severe downdraft while approaching the high mountain pass, which caused the airplane to lose altitude. Review of reported weather conditions at the time of the accident in the area of the pass indicated that the wind speed was 4 to 7 knots, and no indications of sudden downdrafts were discovered. When interviewed by investigators about 2 weeks after the accident, the pilot stated that the right front seat passenger was not wearing his shoulder harness and had slumped onto the flight controls and become unresponsive after taking a motion sickness drug. The pilot further stated that the two rear seat passengers (who had also taken the drug) were also unresponsive when this occurred. However, none of the three passengers recalled this, and the front seat passenger was found with his seatbelt and shoulder harness on when first responders arrived on scene. In a written statement dated about 2 months after his interview, the pilot stated that a propeller blade had separated in flight, as one propeller blade was missing and not recovered from the accident site. The passengers did not recall that this had occurred, and postaccident examination of the propeller hub, propeller blade pilot tubes, propeller blade clamps, and the remaining propeller blade indicated that the missing propeller blade had separated during the impact sequence. Evidence that the missing propeller blade separated on impact included the existence of power signatures on the remaining propeller blade and the presence of a large amount of grease in the hub, which was not thrown out in a centrifugal pattern from the missing propeller blade side of the hub as it would have been if the blade had separated in flight. Further findings indicating that the missing propeller blade separated on impact were a broken clamp bolt head found lying inside the clamp bolt cup of the clamp from the missing propeller blade, impact damage on that same clamp, and a shiny-crescent shaped contact mark on the hub butt in the aft quadrant where the trailing edge of the missing propeller blade would have been located; the crescent-shaped contact mark, which was indicative of aluminum transfer from the missing blade to the hub butt, is typically seen when propeller blades separate during impact. Additionally, metallurgical testing showed that the impact-damaged clamp from the missing propeller blade as well as both of the propeller blade tubes had failed due to overload, and no evidence of fatigue cracking was found. Postaccident examination of the airframe and engine found no evidence of preimpact mechanical malfunctions or anomalies that would have precluded normal operation of the airplane. Several discrepancies were noted with the engine, including the presence of metallic particulates within the oil filter, contamination of the fuel inlet screen with a rubber-like material, and damage to the oil pump consistent with hard particle passage; however, none of these discrepancies would have prevented the engine from producing power. Witness statements, passenger statements, photographs taken during the flight by one of the passengers, and GPS data recovered from a GPS receiver onboard the airplane indicated that, after takeoff, the pilot did not climb to a safe cruising altitude to cross through the mountain pass but instead remained at low altitude. After circling a town, he proceeded up a valley that led to the high mountain pass, flying below the tops of the surrounding mountains in close proximity to terrain and obstructions about 500 feet above ground level. This low altitude flying resulted in the airplane reaching the area of the pass, being boxed in by the surrounding terrain, and not having enough energy or performance to climb up and cross over the pass as the terrain at that point was rising faster than the airplane could climb. Examination of weight and balance information indicated that the pilot had taken off with the airplane loaded over maximum gross weight and that the airplane was near its maximum gross weight when the accident occurred. The pilot's decision to operate the airplane near its maximum gross weight likely contributed to the accident because it reduced the margin of power available for climb. Review of Federal Aviation Administration (FAA) records revealed that, from 2007 to 2012, the pilot had a history of accidents, incidents, reexaminations, and checkride failures. Despite the pilot's history and concerns voiced by numerous FAA personnel during the certification process, the FAA issued a certificate to the pilot in 2012 to conduct commercial air transportation pursuant to 14 CFR Part 135.

Kirst Aviation, FAA designator code K70A, was owned by the pilot and based at PAFA. The pilot provided flight instruction, aircraft rental, on-demand charters, and other specialized services. On December 27, 2009, the pilot submitted an application for a single-pilot 14 CFR Part 135 Air Taxi certificate to the FAA. On August 29, 2012, the FAA issued an Air Carrier Certificate to the pilot. FAA records on the pilot, including Program Tracking and Reporting Subsystem (PTRS) records that were released by the FAA in response to a Freedom of Information Act (FOIA) request by an attorney representing the pilot and documents provided by the FAA to the NTSB regarding the certification of Kirst Aviation, were reviewed; these records included the following information: • On February 7, 2008, as a result of the pilot's December 26, 2007, accident, the FAA sent a letter of reexamination to the pilot to evaluate if he was qualified to hold a flight instructor certificate. The reexamination consisted of the pilot's knowledge of the Piper PA-22's systems and his judgement in selecting safe landing areas before attempting to land. On February 27, 2008, an oral reexamination of the pilot was conducted, and the results were satisfactory. • On November 16, 2009, as a result of the pilot's November 14, 2008, accident, the FAA proposed a 120-day suspension of the pilot's certificates. The final duration of the suspension was 60 days. • On April 24, 2011, the pilot was acting as pilot-in-command on an instructional flight when the landing gear on the accident airplane failed to fully extend. During landing roll, the propeller contacted the runway, and the airplane then veered off the runway and struck a snow bank. As a result of this incident, on June 23, 2011, the pilot was reexamined by an FAA inspector for his commercial pilot single engine privileges. During the reexamination, the pilot received both an oral and flight evaluation, and special emphasis was given in the areas of emergency landing procedures, hydraulic failure emergencies, engine out procedures, approach to stall, and aeronautical decision-making. The results of the reexamination were satisfactory. • A memorandum dated December 6, 2011, sent from the Certification Manager of the Fairbanks FSDO to the Alaska Region Division Manager (AAL-200), recommended termination of the certification process for Kirst Aviation. The memorandum stated, "[the pilot] has demonstrated poor judgment, a lack of knowledge, and failure to comply with the Federal Aviation regulations on multiple occasions and his record demonstrates an inability to conduct safe operations under Part 135." • A second memorandum dated December 20, 2011, sent from a Technical Operations Specialist (AAL-232) to the Alaska Region Division Manager (AAL-200), supported the recommendation made in the December 6, 2011, memorandum "to deny the certification request submitted by [the pilot] for Kirst Aviation." The memorandum cited 14 CFR Part 119.39(b)(1), which states that "an application for a certificate may be denied if the administrator finds the applicant is not properly or adequately equipped or is not able to conduct safe operations." The memorandum stated, "it is clear, based on [the pilot's] history of accidents and lack of ability to comply with Air Traffic Control (ATC) instructions, that he has not exemplified the characteristics of someone who could adequately conduct safe operations as is required by the above listed regulation." • On July 17, 2012, during a 14 CFR Part 135.293(a) checkride in the accident airplane, the pilot failed to perform steep turns within commercial pilot test standards. After the failure, the pilot elected to continue the checkride. During the next maneuver, which was an approach to landing stall, the "GEAR UNSAFE" light remained on when the landing gear was selected to the down position. The checkride was then discontinued, and the pilot landed the airplane without incident. • PTRS entries indicated that, during a 14 CFR 135.293 checkride, the accident airplane began to leak engine oil. There were PTRS entries regarding this checkride dated August 10, 2012, and August 24, 2012, and the exact date of the checkride could not be determined from the available records. When the oil leak occurred, the pilot turned towards PAFA and started a descent. The FAA inspector administering the checkride advised the pilot to maintain altitude until within gliding distance of the airport in case the engine seized, and the pilot complied. The landing at PAFA was uneventful. During post flight inspection, the oil filler cap was found hanging from its chain. The pilot stated that he was not sure how the cap came off. The FAA inspector put the cap back on, checked it for tightness, and determined that the cap could not have come loose if it was securely put on. • A PTRS entry dated August 10, 2012, stated that a recheck was done, and the pilot completed all of the required elements from the checking module within minimum standards. The entry also stated that the pilot was "reevaluated on emergency engine out procedures (not descending too soon during an engine issue)" with satisfactory completion. The PTRS entry did not specify the date of the recheck. • A PTRS entry dated August 29, 2012, stated that an FAA inspector "administered a continuation of a 14 CFR 135.293(a) checkride after the first attempt was unsatisfactory followed by an illuminated gear unsafe light." The PTRS entry did not specify the date of the checkride. During this checkride, the pilot was asked to demonstrate a normal landing and had to "add a significant power increase on final to make the runway." When asked to demonstrate a short field landing, the pilot again had to "add significant power to make the runway." When asked to demonstrate a simulated engine failure to a landing, it became evident to the FAA inspector that the airplane would not make the runway, and he instructed the pilot to go around. The checkride was discontinued with the emergency landing being unsatisfactory. During the postflight debriefing, the pilot stated that he could have made the runway area. At the request of the NTSB investigator-in-charge, the FAA's Office of Accident Investigation (AVP-100) reviewed certain documents deemed privileged by the FAA and made inquiries within the FAA in an effort to provide NTSB with additional information regarding the issuance of the commercial air carrier certificate for the operator. A letter dated June 17, 2016, from the Manager of AVP-100 to the NTSB investigator-in-charge stated, in part: "As you are aware from the documents that were provided to you as part of your request submitted to my office, several FAA employees raised concerns about the approval of the operator's application for an air carrier certificate that was granted two years prior to the accident. My review and inquiries have revealed that FAA personnel debated internally regarding these concerns. Some of the deliberations were mentioned in the draft documents and emails that were provided to you. Those records – which should not be construed as final agency decisions – mostly indicate that FAA inspectors were seeking legal and managerial advice regarding the disposition of the operator's Part 119 application for a Part 135 commercial air carrier certificate. Aside from the contents of these documents, my review indicates that the majority of the deliberations regarding these concerns occurred verbally – either in person or over the telephone – and I found no additional records that documented these discussions. Also, I found that these deliberations occurred sporadically over an 8-month period – from December 2011 through August 2012 – and involved several FAA inspectors, managers, attorneys and other staff who held positions in the Office of Flight Standards (AFS) and the Office of Chief Counsel (AGC) lo