Alaska Accidents Show Pattern of Lenient FAA Oversight

 - August 4, 2021, 9:00 AM
NTSB investigator Clint Crookshanks and board member Jennifer Homendy near the site of some of the wreckage of the DHC-2 Beaver that was involved in the midair collision near Ketchikan, Alaska, on May 13, 2019. (NTSB Photo by Peter Knudson)

In 2018 and 2019, Alaskan small commuter and air-taxi operator Taquan Air Services was involved in three accidents that caused serious injuries and fatalities. While they appear unrelated at first glance, a closer examination reveals a company struggling with deficits in training and operational control coupled with a lack of FAA oversight.

The federal issues in particular raise many questions. Taquan Air cycled through five FAA principal operations inspectors (POIs) in the 15 months before the most recent crash. The inspectors suffered from excessive caseloads, heavy travel schedules, lack of relevant aircraft knowledge, and dearth of experience in Alaskan Part 135 operations. Two of them were based in South Carolina, on the other side of the country.

Taquan’s third accident during this period occurred on landing in Metlakatla harbor on May 20, 2019. Flight 20 was a scheduled trip for the Ketchikan, Alaska-based FAR Part 135 operator. Both the pilot of the de Havilland Beaver and the single passenger, an epidemiologist for the Alaska Native Tribal Health Consortium, were killed in the accident.

In its probable cause report, the NTSB determined weather was not a factor and the pilot failed to compensate for a quartering tailwind while landing. The pilot had an estimated 1,623 hours total time and only about 27 hours on floats.

Its second accident was a midair collision on May 13, 2019, near Ketchikan. Both Taquan Air and Mountain Air Service, the operator of the second aircraft, were flying tourists from a Royal Princess cruise ship. Taquan Air was operating a de Havilland Turbine Otter, Mountain Air a Beaver. All four passengers and the pilot on the Beaver were killed; one passenger was killed in the Otter and nine seriously injured.

The Mountain Air pilot was a local owner and operator of his single aircraft air taxi and although his personal flight records were not found, investigators determined he had about 11,000 hours total time with an initial competency check in the Beaver seven years earlier. He had flown with four local operators in the past, including Taquan Air. The Taquan Air pilot was a seasonal employee and former airline pilot with about 25,000 hours total time. 

Flight path
The flight paths of the de Havilland DHC-2 and DHC-3 involved in the midair collision eight miles northeast of Ketchikan, Alaska, May 13, 2019. The flight paths depicted are from the Misty Fjords National Monument area to the location of the collision. (NTSB overlay on a Google Earth image.)

In its probable cause report, the NTSB determined “the inherent limitations of the see-and-avoid concept” prevented the pilots from avoiding each other before the collision.
Taquan’s first accident during this span was controlled flight into terrain on July 10, 2018, in the area known as Jumbo Mountain, about nine miles from Hydaburg. Taquan Air was operating a Turbine Otter on a contract charter for Steamboat Bay Fishing Club to Ketchikan, 80 miles away. Six of the 10 passengers received serious injuries.

The NTSB determined this accident was caused by the pilot’s decision to fly under visual flight rules into instrument meteorological conditions. The pilot, a longtime seasonal hire and retired airline captain, had 27,400 hours total time.

Jumbo Investigation

In the Jumbo Mountain accident, investigators found that the pilot, flying the second of three company aircraft that departed the lodge, crashed about 8:35 a.m. while flying in heavy rain and clouds. He told the NTSB that after realizing early on that conditions precluded his ability to stay on his planned route, he diverted only to find himself in “rapidly deteriorating circumstances.”

He attempted to execute a climbing, 180-degree right turn but lost situational awareness, thought he glimpsed water, and briefly leveled off. When he realized he was wrong, he initiated a steep climb; the aircraft stalled as it hit rising terrain.

As the investigation unfolded, the NTSB discovered that Taquan’s director of operations (DO), George Curtis, held a second position as DO for Grant Aviation, a larger, scheduled Part 135 based in Anchorage. He was also a contract instructor with Alaska Airlines in Seattle, traveling there about once a month.

Curtis recalled visiting Taquan four or five times in 2018. In his absence, many of the responsibilities of his position fell to the chief pilot, significantly increasing his workload. That job was further exacerbated by conflicts with staff, some of whom, the chief pilot told the NTSB, did not accept him in a supervisory capacity.

The DO managed several departments, the chief pilot explained, and “not being here to do that is—it gets frustrating. There’s a lack of oversight.”

Brian Frederick was Taquan’s POI for about two years before leaving the FAA four months before the Jumbo Mountain accident. He told investigators he knew that Curtis was chief pilot for Grant Aviation (he took that position on Oct. 1, 2017), but was unaware of his promotion there to DO.

Frederick was worried about Taquan finding the right replacement for Curtis. “The one thing I was concerned about,” he said, “was them finding somebody who just met the letter of the FARs and putting them in that position. Taquan was a big enough company I wanted there to be somebody like George who was really a professional director of operations. He’s not a guy that was flying the line. He was somebody that was actually running the company.” Frederick did not know that Curtis moved to Anchorage soon after taking the chief pilot job at Grant.

Frederick, as POI, was responsible for anywhere from 25 to more than 30 other operators while overseeing Taquan. When asked specifically how many certificates he oversaw, Frederick told investigators, “…sometimes I didn’t know…all the operators I had, it was changing so rapidly.” When prompted that the latest revision to Taquan Air’s training program—Revision #13—was given initial approval in 2016 and expired in February 2018, he did not recall giving final approval for the program. He did not recall if he visited Taquan at all in 2018.

Frederick’s replacement, Jon Percy, took over as POI in April 2018. He told investigators Taquan was one of about 40 operators he was responsible for. His workload meant oversight of Taquan was limited; he visited the company only for three check airman observations before the July 2018 crash and did not observe any training.

He spoke with DO Curtis only once, was unaware that he did not live in Ketchikan, and did not recall learning of his position with Grant Aviation until after the accident. He was unaware that Taquan was still operating under an initial approval for its training manual.

In Anchorage, Grant Aviation POI Hugh Youngers told investigators he was part of the approval process when Curtis became chief pilot. Youngers also later approved Curtis to be DO of Grant in March 2018. He insisted, however, that he was unaware until a month after that, when a colleague informed him, of the concurrent employment with Taquan. Youngers said he spoke with Curtis about his multiple jobs at that time, but “…didn’t have a lot of concerns…because he’s here every day, you know, working at Grant.” Later in the interview, he reiterated that point stating, “…he’s overseeing the operation that I oversee, so it wasn’t an issue for me.”

Curtis told investigators he was interviewed directly by the FAA when he was applying for the chief pilot position at Grant and, further, that they “absolutely, yes” knew at that time he was still with Taquan. The disparity between his recollection of events versus that of Youngers’ was never resolved by the NTSB.

All of the POIs made clear, though, that none of them discussed Curtis’s multiple positions, or their potential negative impact, with each other before the aircraft was flown into Jumbo Mountain.

Distance Oversight

In September 2018, both Taquan’s DO and chief pilot were replaced. A month earlier, a new POI, Todd Clamp, from Columbia, South Carolina, had been assigned to oversee Taquan Air.

In his interview with investigators in October 2019, the Juneau FSDO office manager, Joseph Pocher, explained the office was responsible for about 160 certificates but had only two POIs despite approval for eight. This explained the need for assistance from outside the region.

At the same time, FAA front line manager Richard Peabody described the shift of some responsibilities to South Carolina as “uncharted territory.” He said, “Right now what we’re doing is every Monday morning meeting that we have, we stress CMT [certificate management team] communication.” When asked who participated in those meetings, he replied, “Everybody.” But investigators knew Clamp—based 2,800 miles away—did not. “Is that something he should be doing?” Peabody was asked. “Speculation,” he responded, “but yes.”

Clamp was not interviewed as part of the Jumbo Mountain accident investigation. The NTSB spoke to him the following year, in November 2020, as part of the midair collision investigation. At that time, he stated the Juneau FSDO reached out to South Carolina “for our assistance to come up and do some inspections because they [were] behind.” This was also why he was assigned as POI to Taquan.

Clamp traveled with a colleague to Ketchikan once, where they conducted inspections or visits of 12 Part 135 operators. He thought he saw Taquan twice on that trip. However, Clamp did not observe any training or conduct any check rides, nor was he seaplane-rated. He did extend Taquan’s long-expired training program, explaining in a letter to the chief pilot that “the reason for the extension is due to understaffing circumstances of the certificate holding district office.”

Lana Boler, Taquan’s principal maintenance inspector, was based in Ketchikan. She exhibited a degree of frustration to investigators when discussing communication with the revolving number of POIs assigned to the company and recalled voicing concerns with Curtis’s job in Anchorage to her superiors as early as December 2017 or early 2018. When asked if she met with Clamp on his visit from South Carolina, she responded that she gave him a ride, “which was about five minutes.” They did not discuss Taquan Air.
Clamp was replaced as POI after about six months by another South Carolina-­based inspector, Billy Marlowe. He never traveled to Alaska.

A Freedom of Information Act (FOIA) request was submitted to the FAA’s Alaska Region seeking correspondence between Taquan’s assigned POIs and the company to determine if particular concerns about oversight were passed from one inspector to the next. In denying AIN’s request due to “vagueness,” the Juneau FSDO specifically noted that, “as he was no longer employed with the FAA”, no records at all existed for Frederick.

A separate FOIA request for records associated with the formal assignments of Taquan’s out-of-state POIs—Clamp and Marlowe—was denied as “no records found.” A third request, to the FAA’s Southern Region, on Clamp’s and Marlowe’s Taquan assignments and associated correspondence, has yet to be acknowledged. 

DHC-3 instrument panel
View of the DHC-3 instrument panel. (Photo: John Leach)

Midair Confusion

When the midair collision occurred on May 13, 2019, the NTSB sent a “go team” that soon focused on the ADS-B units used by both pilots in the high-­density tourist season traffic environment. Investigators found that the Otter’s Garmin GSL 71 control panel—which controlled the airplane’s transponder—was recovered from the wreckage with its switch in the “OFF” position.

The NTSB team speculated the unit was turned off a couple of weeks prior, while the aircraft was in for maintenance, although there was no hard proof of this. Without the GSL 71 switched on, the NTSB said the aircraft’s pressure altitude was not broadcast—a conclusion that was affirmed when recovered data from an FAA ground station showed both aircraft ADS-B units were transmitting at the time of the accident, but the Otter’s pressure altitude was missing and it “indicated an invalid squawk code.”

The Garmin unit was installed in September 2015 as part of an upgrade to the aircraft’s Capstone systems. (Capstone was a long-running FAA program in Alaska to test and promote ADS-B, providing cockpit display of the pilot’s location relative to other equipped aircraft, terrain, and weather.) At the time of the upgrade, the aircraft was owned by Promech Air. Taquan purchased it a year later, along with all of the company’s Alaskan assets, after Promech was involved in a multiple-fatality crash.

The Otter pilot had received training in the aircraft just before the accident with the Taquan chief pilot and another senior pilot—both of whom worked for Promech—but none of them noted the GSL 71 or seemed aware of its significance to the broadcast of pressure altitude. Verifying the GSL’s operational status was not part of the aircraft checklist, which still bore the Promech name.

At the time of the midair, Taquan had yet another POI, Matt Dahl, who was assigned to the Juneau FSDO but based on the Kenai Peninsula. Dahl had 31 other certificates assigned to him but noted to investigators that “movement within the FAA for inspectors” caused the number to fluctuate.

He still managed to make two separate week-long visits to Taquan and observe training in the two months he oversaw the company before the accident. The NTSB spoke with Dahl, Clamp, Percy, and Frederick during the course of the midair investigation. None of them were familiar with the GSL 71, nor had they been in contact with anyone about the equipment changes that occurred back in 2015.

One week after the midair, Taquan experienced another crash, in Metlakatla. In that investigation, attention turned to the company’s risk-assessment procedures.
In his NTSB interview, the chief pilot acknowledged that Metlakatla could be “challenging” and did not know why a pilot who had completed training only nine days earlier was scheduled for the flight. Pressed on specific hazards, he stated, “It’s rising terrain, open water. There can be ocean swells in there…There can be different wind directions in there.” New hires, he explained, were assigned to “easy” flights, such as tours. After about six weeks, new pilots might incur lodge work before moving on to certain commuter flights.

A flight follower had filled out the risk-assessment form for Flight 20 as part of regular dispatch procedures; she expressed no knowledge of the chief pilot’s concerns about the new pilot’s inexperience. This breakdown in operations management prompted the NTSB to include “the company’s inadequate operational control of flight release procedures” as a contributing factor in the accident. There are no interviews with the FAA on the docket for the Metlakatla accident.

Disfunction and Neglect

In each of the three accident investigations, NTSB investigators found themselves repeatedly analyzing existing safety programs. The disfunction in risk-assessment procedures, training programs, checklists, and the entire operations department made it impossible to ignore the fallout from the FAA’s diminished oversight capacity.

While the probable causes focused on the actions of the individual pilots and Taquan Air’s deficiencies, the more than 1,300 pages of company and FAA interviews in the accident dockets reveal a pattern of consistent neglect on the part of the agency tasked with enforcing safety standards.

This is perhaps best summed up in a paragraph from the Jumbo Mountain NTSB final report: “Based on [sic] the FAA’s inappropriate approval of the DO, the insufficient company onsite management, the inadequate operational control procedures, and the exercise of operational control by unapproved persons likely resulted in a lack of oversight of flight operations, inattentive and distracted management personnel, and a loss of operational control within the air carrier.”

In an attempt to gain perspective on the history of Taquan’s POI assignments, AIN filed a series of FOIA requests to the FAA. In response to an initial request for the certificate management team members between 2017 and 2020, the FAA responded with a list that did not include Marlowe, the second South Carolina-­based POI tasked to oversee an Alaska operator. A subsequent request for all the inspectors assigned between the years 2000 and 2020 did not include Clamp, Marlowe, or Percy.

This inconsistent and incomplete information is not unusual. When responding to FOIA requests for POI assignments to other small commuter and charter operators in Alaska, the FAA has responded with limited information ranging from no more than five years to less than three years. For the state’s largest Part 135 operator, the former Hageland Aviation, part of now-bankrupt Ravn Air Group, which was involved in 15 accidents between 2008 and 2020, the FAA provided no records for POI assignments before 2015, except for the name of one inspector who served from May to August 2013.

Assessing the workload for Taquan Air’s POIs as compared to other Alaskan Part 135 operators is also difficult. Reading through accident dockets over the past several years gleans mentions of workload assignments that varied from 20 to 70 operators. Some inspectors said they were also responsible for multiple large and/or “high risk” operators, or further tasked with providing check rides for other companies, supervising designated examiners, or often required to travel outside their region and provide assistance elsewhere, all while managing their own responsibilities.

While investigating a 2018 accident that resulted in a pilot fatality, the FAA POI overseeing that company told the NTSB he had oversight for 50 certificates. One year later, the same company was involved in two more accidents, resulting in two additional deaths and three serious injuries.

The NTSB did not even interview the POI during either of those investigations and it remains unclear how often that company’s POI changed during this period.

In its final report on the midair released earlier this year, the NTSB noted that Taquan did not have a safety management system (SMS). (It has, however, voluntarily established one since that crash.)

The agency considered lack of an SMS a “safety issue” for Taquan at the time of the accident and asserted that if it had been required for Part 135 operators to have an SMS, there would have been better opportunity to “discover and mitigate the increased risk” caused by issues with the Capstone equipment.

Like the Jumbo Mountain and Metlakatla accidents, there were no recommendations in the midair final report concerning FAA oversight, nor was the agency cited in the probable cause findings for any of the Taquan accidents.

Taquan Air did not respond to a request for comment concerning the multiple POI assignments made to the company during 2018 and 2019. The FAA, in its response to a question regarding staffing and oversight of Alaskan Part 135 operators, said it “has increased inspector staffing in all of the Alaska safety offices as we have elsewhere in the country. The number of operators per inspector is in line with agency standards.”

At the end of 2019, FAA inspector Dahl was responsible for 67 certificates. He was replaced as Taquan Air’s POI late last year. There are currently three POIs listed as assigned to the Juneau FSDO.