QUEST AIRCRAFT COMPANY LLC KODIAK 100

Full Narrative

HISTORY OF FLIGHTOn September 30, 2012, about 1545 Alaska daylight time, an amphibious float-equipped Quest Aircraft Company, LLC, Kodiak 100 airplane, N745, sustained substantial damage while landing at the Lake Hood Seaplane Base, Anchorage, Alaska. The airplane was being operated as a visual flight rules (VFR) cross-country public-use flight under 14 Code of Federal Regulations (CFR) Part 91 when the accident occurred. The airplane was operated by the U.S. Department of Interior (DOI), U.S. Fish and Wildlife Service. The certificated commercial pilot, the sole occupant, was not injured. Visual meteorological conditions prevailed, and a VFR flight plan had been filed. The flight originated at the King Salmon Airport, King Salmon, Alaska, about 1300.

The flight was the final leg of a 4-day Emperor Goose survey that began on September 27, when the pilot and another pilot/biologist departed from Ted Stevens Anchorage International Airport, Anchorage, Alaska to King Salmon Airport. On September 28, they flew a 5-hour mission to Cold Bay Airport, Cold Bay, Alaska. On September 29, they flew a 4-hour survey mission and then departed the Cold Bay Airport for the King Salmon Airport. All landings during this 4-day mission prior to the accident flight were made on a prepared runway surface using wheels.

The accident flight originated at the King Salmon Airport, stopped briefly at the Kenai Municipal Airport, Kenai, Alaska, to drop off the accompanying pilot/biologist, and continued to the Lake Hood Seaplane Base. The pilot stated she had not conducted a water landing since September 1, and had predetermined that, if the conditions were favorable, she would land at Lake Hood Seaplane Base to maintain water-landing proficiency, rather than land at the Ted Stevens Anchorage International Airport on wheels. The pilot reported that, before landing, she completed the before-landing checklist, set approximately 50 percent right rudder trim, and confirmed the wheels were in the up position. She noted that her airspeed on approach was slightly faster than normal. During touchdown the airplane veered to the left, then to the right. The airplane then veered violently to the right, as though it "caught a float," and the right wing struck the water. The airplane pivoted abruptly, cartwheeled, and the wreckage began to sink. After unfastening her seatbelt, the pilot attempted to open the pilot side door but was unable. Looking rearward, she noticed a broken passenger window at water level and exited through the window onto the inverted fuselage.

A pilot-rated witness who was standing on the north shore of Lake Spenard at the Lake Hood Seaplane Base stated that the airplane appeared to touch down in a slight nose-low attitude. After touchdown, the airplane veered left and right, and rolled from side-to-side. The amplitude increased rapidly, and the airplane pivoted to the right, cartwheeled, and came to rest inverted. During the accident, sequence the airplane appeared to shed parts, and the floats became detached from the fuselage. PERSONNEL INFORMATIONThe pilot, age 36, was a dual-function pilot (pilot/biologist) for the DOI, U.S. Fish and Wildlife Service.

She held a commercial pilot certificate with ratings for airplane single-engine land and single-engine sea. She reported 1,650 total hours of flight experience, 550 hours which were in seaplanes. She had accumulated 232 hours and 68 water landings, 66 of which were associated with training or ongoing proficiency accompanied by an instructor in the Kodiak 100 equipped with amphibious floats. Her most recent FAA second-class medical certificate was issued in September 2011.

The pilot had received approximately 8 hours of flight training in the Kodiak 100 equipped with amphibious floats from Lake and Air Inc., and approximately 68 hours of flight training from a combination of the U.S. Fish and Wildlife Service and Office of Aviation Services. The training included both water and land operations and was completed in March 2012. Her interagency pilot evaluation/qualification check was completed on April 1, 2012.

The Airplane Pilot Qualification card, issued by the DOI, authorized her to fly the Kodiak 100 with the following limitations: "MISSION FLIGHTS = LOW LEVEL. Mission flights limited to 2 (two) carded pilots on board. OK for solo non mission flights."

The pilot's most recent flight review was completed on October 15, 2011. According to training records provided by the DOI, the flight review consisted of 2 hours of ground training and 0.7 hours of flight time in an amphibious float-equipped Kodiak 100. Title 14 CFR 61.56 states, in part: "A flight review consists of a minimum of 1 hour flight training and 1 hour of ground training."

During an interview with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) on October 2, the pilot stated that she was not comfortable landing in the water lane at Lake Hood Seaplane Base due to the left-turning tendency of the airplane during water landings. She had set 50 percent right rudder trim in anticipation of the left-turning tendency. She also stated that, at the first sign of a loss of directional control, her initial instinct was to lower the water rudders or add power.

During a separate telephone conversation with the NTSB IIC on October 16, the pilot stated that she had completed one 180-degree step turn during her initial training. In addition, she stated that, during her interagency pilot evaluation/qualification check, step turns were not completed. According to the accident pilot, the check pilot was not comfortable performing step turns, so they agreed to sign off the maneuver on the check ride form but did not accomplish the task. AIRCRAFT INFORMATIONThe airplane was manufactured in 2009 and registered to the owner in September 2010. It was equipped with a Pratt & Whitney PT6A-34, 750-shaft horsepower turbo-propeller engine and a Hartzell HC-E4N-3PY/D9511FS four-blade propeller. The airplane had accumulated 284 hours at the time of the accident. Its most recent annual inspection was completed on May 31, 2012. The airplane was manufactured with fixed tricycle landing gear and received Supplemental Type Certificate (STC) approval for the installation of Wipaire, Inc., Wipline 7000 amphibious floats in June 2010. The float installation was completed on July 8, 2010, and the airplane had accumulated approximately 245 hours of flight time since the installation. METEOROLOGICAL INFORMATIONThe closest weather reporting facility is Ted Stevens Anchorage International Airport, approximately 1 mile west of the accident site. About 8 minutes after the accident, at 2353, an aviation routine weather report reported in part, wind calm, visibility 10 statute miles, few clouds at 6000 feet, scattered clouds at 13,000 feet, scattered clouds at 20,000 feet, temperature 45 degrees F, dew point 29 degrees F, and altimeter 30.02 inHG. AIRPORT INFORMATIONThe airplane was manufactured in 2009 and registered to the owner in September 2010. It was equipped with a Pratt & Whitney PT6A-34, 750-shaft horsepower turbo-propeller engine and a Hartzell HC-E4N-3PY/D9511FS four-blade propeller. The airplane had accumulated 284 hours at the time of the accident. Its most recent annual inspection was completed on May 31, 2012. The airplane was manufactured with fixed tricycle landing gear and received Supplemental Type Certificate (STC) approval for the installation of Wipaire, Inc., Wipline 7000 amphibious floats in June 2010. The float installation was completed on July 8, 2010, and the airplane had accumulated approximately 245 hours of flight time since the installation. WRECKAGE AND IMPACT INFORMATIONOn October 2, 2012, recovery crews and a diver recovered the wreckage from Spenard Lake. All of the airplane's major components were recovered from the accident site, and control continuity was established to all flight controls.

On October 2 and 3, a wreckage examination and layout was conducted under the direction of the NTSB IIC. A Federal Aviation Administration (FAA) Operations aviation safety inspector from the Anchorage Flight Standards District Office, two air safety investigators from Quest Aircraft Company, and two engineers from Wipaire, Inc., assisted the NTSB IIC.

The left wing was separated at the fuselage with extensive leading edge crushing and upward bending from approximately wing station (WS) 176 outboard. The left wing flap remained connected to its respective attach point, the right aileron was fragmented at WS 176, and the hinge bracket was pulled out of the aileron spar. The right wing remained attached to the airplane fuselage, but it was displaced aft of its normal position. The right wing's flight control surfaces remained connected to their respective attach points.

The engine remained attached to the firewall and sustained impact damage to the front and left side. The propeller remained attached to the reduction gearbox. All four of the propeller blades remained attached to the hub assembly, were bent aft, and had torsional "S" twisting.

The fuselage was intact and relatively free of impact damage.

The left and right horizontal stabilizers and elevators remained attached to the fuselage mounting attach points, but the right horizontal stabilizer and elevator sustained impact damage.

The vertical stabilizer and rudder remained attached to the empennage and were relatively free of impact damage.

The rudder trim was measured at approximately 50 percent to the right.

Both left and right forward and aft float struts were separated at their attachment fittings. The rear float spreader bar separated at both float attachment points, and the spreader bar was not recovered. The wheels were confirmed in the up and locked position, consistent with a water landing. ADDITIONAL INFORMATIONDuring an interview with the NTSB IIC on October 3, the Chief Pilot/Training and Standardization Manager for the Alaska Region, Office of Aviation Services (OAS), who conducts training and checking for the DOI, stated that the Kodiak 100 on Wipline 7000 amphibious floats had a left-turning tendency when the propeller was in beta and that the water rudders could be deployed if directional control was needed once coming off the step. He also stated the Kodiak 100 on Wipaire, Inc., Wipline amphibious floats was not a "beginner's airplane" and tended to be unforgiving.

During a telephone conversation with the NTSB IIC on October 3, the Senior Flight Instructor for Lake and Air, who conducted training for Wipaire, Inc., stated that, as the Kodiak 100 on Wipline 7000 amphibious floats came off the step, there was a left-turning tendency when power was applied to the propeller. He also stated that he did not condone nor recommend deploying the water rudders with the airplane still on the step.

FAA Order 8900.1, Volume 3, Chapter 19, Section 1, Scope, Concept, and Definitions states in part:

Training program - "A system of instruction which includes curriculums, facilities, instructors, check airmen, courseware, instructional delivery methods, and testing and checking procedures."

Curriculum - "A complete training agenda specific to an aircraft type, a crewmember or dispatcher duty position, and a category of training".

Event - "An integral, task- oriented part of training, checking, or qualification module that requires the use of a specific procedure or procedures. A training event provides a student an opportunity for instruction, demonstration, and/or practice using specific procedures. A checking or qualification event provides an evaluator the opportunity to evaluate a student's ability to correctly accomplish a specific task without instruction or supervision. ORGANIZATIONAL AND MANAGEMENT INFORMATIONPilot Requirements

The DOI Departmental Manual, Aviation Management, Part 351 Aviation Operations, Chapter 3 Flight Crewmember Policy, 3.2 Pilot Qualifications states in part: Pilots shall meet the following minimum rating, and experience requirement prior to flying operational missions.

Incidental/Dual Function: Commercial Pilot Certificate with appropriate category and class ratings, Instrument Rating, Recent Flight Experience as appropriate (14 CFR Part 61), VFR 500 hours Pilot in Command (PIC), 25 hours PIC night, 24 hours PIC last fiscal year in category, 10 hours PIC in make and model, and 25 hours PIC in seaplanes.

Vendor Pilot Qualifications: Shall meet the PIC requirements of 14 CFR Part 135; 1500 hours total pilot time, 1200 hours PIC time, 25 hours PIC in seaplanes, and 100 hours in the last 12 months.

Training Program

Prior to operating aircraft for the DOI, a pilot must complete certain flight training requirements. An aircraft make and model checkout requires 10 hours of flight time in the specific make and model to be operated. The turbine aircraft training module requires 50 hours in make and model. The floatplane operations training module requires 10 hours lake and general float operations, 10 hours river and stream operations, 5 hours for ocean and saltwater operations, and 10 hours for amphibious float operations. If a pilot has accumulated 25 hours or more of seaplane operations, the hour requirement is waived, and the pilot must only meet the standards of the module with no hourly requirement.

In order to operate the Kodiak 100 on amphibious floats for the DOI, the pilot must have completed a minimum of 50 hours flight training.

An in depth review of the DOI flight training program revealed a general outline with hour requirements. The flight training program did not include curriculums, events, or testing and checking procedures. No maneuvers and procedures, or acceptable performance guidelines were developed for the amphibious float-equipped Kodiak 100.

The flight training for the Kodiak 100 was recorded on the "Seaplane Instruction Form" grading is accomplished by placing a number next to the maneuver that was performed: 1 = Below Acceptable Standards, 2 = Improving/Below Standards, 3 = Satisfactory, 4 = Above Average, 5 = Excellent. No grading was used on the accident pilot's Kodiak 100 flight training record, a check mark was placed next to the maneuver that was performed.

The DOI had not developed or written any specific procedures for the Kodiak 100. According to the Chief Pilot/Training and Standardization Manager for the Alaska Region, Office of Aviation Services (OAS) who is responsible for conducting training and checking for DOI, multiple checklists existed for the Kodiak 100, and pilots were allowed to use whichever checklist they preferred.

Government Aircraft Operations

FAA Advisory Circular (AC) 00.1-1, "Government Aircraft Operations," dated April 19, 1995, provides "guidance on whether particular government aircraft operations are public aircraft operations or civil aircraft operations under the statutory definition of public aircraft." As explained in the AC, an operation is considered public or civil depending on the circumstances of the particular operation rather than the ownership or overall use of an aircraft. Generally, public aircraft operations include law enforcement, low-level observation, aerial application, firefighting, search and rescue, biological or geological resource management, aeronautical research, national defense, and intelligence missions.

During the NTSB's February 2009 public hearing on the safety of helicopter emergency medical services operations, FAA representatives testified that, with the exception of operations within the National Airspace System, the FAA has no statutory authority to regulate public aircraft operations. Title 49 United States Code Section 44701 is the primary authority for federal aviation regulations. This section instructs the FAA administrator to promote the safe flight of civil aircraft in air commerce through regulations and standards prescribed in the interest of safety. Unless a government-owned aircraft is engaging in a civil operation, it is not subject to civil aircraft and pilot requirements pertaining to certification, maintenance, and training.