A new report from the National Transportation Safety Board released Thursday describes gaps in the Federal Aviation Administration's oversight of Taquan Air Service operations discovered during the investigation into a July 2018 floatplane crash near Ketchikan.

On July 10, 2018, 10 passengers on board a de Havilland DHC-3T Turbine Otter floatplane were injured when it crashed into the side of Mount Jumbo. Six passengers were seriously injured; four had minor injuries.

'Serious fog' around the plane

According to the NTSB report, at least three people on the flight reported that heavy rain and clouds made it hard to see what was around the plane.

The pilot — 72-year-old Mike Hudgins of Ketchikan — said visibility decreased rapidly during the flight. At one point, he saw what he thought was a body of water, became "momentarily disoriented" and leveled the wings. He started an emergency climb when he realized he was heading for a mountainside, but wasn't able to avoid it.

The passenger seated in the front right seat "said the flight made numerous course deviations as the pilot maneuvered around weather, and, at times, all forward visibility was lost as they briefly flew in and out of the clouds." The passenger said he was uncomfortable and thought the pilot should land. He saw the mountain before the crash, but assumed there was an area they could pass through.

A second passenger, seated in the back, said there was "serious fog" around the plane during the flight. He texted his friend, who was the passenger in the front right seat, to ask the pilot to land and wait for better weather. According to the report, he didn't see the mountain until it was too late.

The NTSB report said Hudgins didn't remember any issues with the plane before the crash. He didn't report any mechanical malfunctions that would have prevented them from takeoff and an examination of the airframe and engine showed no evidence of mechanical issues.

Issues with Taquan operations

The NTSB report revealed issues with the way Taquan handled its air operations at the time of the crash, many of which can be attributed to gaps in management.

Taquan's director of operations was hired by the company in 2016. In 2017, he was also hired as the chief pilot for Grant Aviation. He moved to Anchorage for the job, but continued to work for Taquan despite that position being based in Ketchikan. In 2018, he was promoted to director of operations at Grant Aviation and also worked as a contract simulator instructor for Alaska Airlines.

Those working at Taquan said the director of operations would usually visit Ketchikan once a month, but was available by phone if he was needed. Because of the director's absence, Taquan's chief pilot had taken over some of his responsibilities. The president of the company told the NTSB they were mostly using the director to keep track of records.

The chief pilot said one person could handle both positions during the winter, but it was harder during summer months.

According to the report, Taquan's operations manual didn't explain flight movement procedures. No one — other than the director of operations, chief pilot and president — was specifically named as having operational control. However, operational control was often delegated to senior pilots.

The manual did state that the director of operations was able to delegate operational control to the flight coordinator, but the coordinator working at the time of the crash said she didn't have operational control. She did, however, have authority to cancel flights due to weather as well as arrange flights with whoever was in operational control.

Taquan's president described operational control as "having someone...that has the ability to check the weather." When asked by the NTSB who had the ultimate authority for operational control, he said the director of operations, adding "but he's not here."

The manual also didn't mention a company risk assessment process, though there was a separate document that explained a flight risk assessment form was to be filled out before flights took off.

Company pilots said the form required them to highlight potential risks based on a numbered scale. One pilot, the report said, viewed the form as "...just a piece of paper with some ink on it" and based decisions on his own experience instead.

FAA oversight failures

According to the report, the FAA was aware that Taquan's director of operations was also serving in a management role for Grant Aviation, despite it being against federal regulations.

However, the report said "there was a belief by the FAA's inspectors and management personnel responsible [...] that this was not contrary to the Federal Aviation Regulations or guidance."

There was also a lack of principal operations inspectors in the FAA's Juneau Flight Standards District Office at the time of the crash. According to the report, the office manager said only two out of five available positions were filled because they "were unable to attract applicants."

The report also said there was little to no coordination or communication between the principal operations inspectors responsible for Taquan and Grant Aviation.

The principal operations inspector for Taquan told the NTSB he had a heavy workload and wasn't able to complete all of his oversight tasks.

The NTSB database shows Taquan has been at the center of multiple aircraft accidents in Alaska since 1992, many of them fatal. Two deadly crashes involving the operator in May 2019 are still under investigation.

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