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NTSB · Safety Recommendation

Safety Recommendation A-17-035

Recommendation

TO THE FEDERAL AVIATION ADMINISTRATION: Implement ways to provide effective terrain awareness and warning system (TAWS) protections while mitigating nuisance alerts for single-engine airplanes operated under 14 Code of Federal Regulations Part 135 that frequently operate at altitudes below their respective TAWS class design alerting threshold.

Safety Issue and Context

On June 25, 2015, about 1215 Alaska daylight time, a single-engine, turbine-powered, float-equipped de Havilland DHC-3 (Otter) airplane, N270PA, collided with mountainous, tree-covered terrain about 24 miles east-northeast of Ketchikan, Alaska. The commercial pilot and eight passengers sustained fatal injuries, and the airplane was destroyed. The airplane was owned by Pantechnicon Aviation, of Minden, Nevada, and operated by Promech Air, Inc., of Ketchikan.

The flight was conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 135 as an on-demand sightseeing flight; a company visual flight rules flight plan (by which the company performed its own flight-following) was in effect. Marginal visual flight rules conditions were reported in the area at the time of the accident. The flight departed about 1207 from Rudyerd Bay about 44 miles east-northeast of Ketchikan and was en route to the operator’s base at the Ketchikan Harbor Seaplane Base, Ketchikan.

Response History

August 10, 2026 · Recipient Response · FAA

-Bryan Bedford, Administrator: In June 2025, the Federal Aviation Administration’s (FAA) Radio Technical Commission for Aeronautics (RTCA) Special Committee 231 (SC-231), Terrain Awareness Warning System (TAWS), delivered its internal report to the RTCA Program Management Committee (PMC). SC-231 concluded the PMC should update the requirements for Class B and C TAWS in DO-367, Minimum Operational Performance Standards (MOPS) for Terrain Awareness and Warning Systems, to address the issue of permanent inhibition of the Forward Looking Terrain Avoidance (FLTA) function in conjunction with the addition of the Ground Collision Avoidance System (GCAS) requirements.

The PMC pointed out that any changes to DO-367 that preclude permanent inhibition of FLTA should allow the function to be implemented in either the TSO-approved TAWS unit or at the installation level. SC-231 converted the internal report into an external report for the public, published September 9, 2025, and can be found at:

https://my.rtca.org/productdetails?id=a1BPP00000JNp5K2AT

The PMC will set the schedule for updating DO-367 when the revised GCAS requirements are complete. Once RTCA updates DO-367, the FAA will provide an anticipated publication date for the revised TSO-C151d, Terrain Awareness and Warning Systems, which will invoke the updated DO-367. Resource constraints among industry and government participants during this process have delayed the development of the PMC’s deliverables. As a result, RTCA has advised the FAA that the anticipated completion of the GCAS requirements is now expected in December 2028. SC 231 will use these requirements in developing the next version of DO-367.

Lastly, the FAA extended Exemption No. 18544B to April 30, 2031, granting relief from § 135.154(b)(2), Terrain Awareness and Warning System, while we continue to develop and implement the GCAS requirements. Exemption No. 18544C allows operators to apply the exemption as an interim Controlled Flight into Terrain risk mitigation until GCAS can be implemented for aircraft operating at low altitude near proximate terrain.

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Recommendation Facts

Status
Open - Acceptable Response
Issued
May 9, 2017
Priority
CLASS II
Recipient
FAA
Adopted
April 25, 2017
Related Investigation
ANC15MA041
Related Report
AAR-17-02

I will keep the Board informed of the FAA’s progress on our actions to address these safety recommendations and anticipate providing an update by July 31, 2027.

March 11, 2025 · NTSB Correspondence · FAA

We understand that the Radio Technical Commission for Aeronautics (RTCA) Program Management Committee and SC-231 are working to establish a schedule for publishing the revised TAWS standards, which will include Ground Collision Avoidance System (GCAS) algorithms to provide a more effective means to reduce navigational nuisance alerts and auto uninhibit functionality. We also see that the FAA intends to update TSO-C151, TAWS, to include the revised standards, and that you are continuing work to implement GCAS for aircraft operating at low altitude near proximate terrain.

We believe the actions you described are responsive to both recommendations. Pending completion of this work and appropriate revisions to RTCA DO-367 and TSO C151, the Board has classified Safety Recommendations A 17-35 and A-18-15 OPEN-- ACCEPTABLE RESPONSE.

May 8, 2024 · Recipient Response · FAA

-From Michael G. Whitaker, Administrator: The Federal Aviation Administration (FAA) met with RTCA Special Committee (SC) 231, Terrain Awareness Warning System (TAWS), to initiate actions to reactivate the committee and begin work on revising current TAWS standards. As a result of the RTCA Program Management Committee (PMC) on December 14, 2023, the SC-231 PMC co-chairs were given the action to coordinate industry interest and propose the appropriate Terms of Reference to guide the committee’s work. The RTCA PMC and SC-231 will establish the schedule for publishing the revised TAWS standards.

The new standards will include Ground Collision Avoidance System (GCAS) algorithms to provide a more effective means to reduce navigational nuisance alerts and auto un-inhibit functionality. Subsequently, the FAA will update Technical Standard Order (TSO)-C151, Terrain Awareness and Warning Systems, to include all revised standards. We will provide an anticipated publishing date for the revised TSO once a schedule for revising the SC-231 TAWS standards has been determined. These revisions will provide increased safety for single-engine airplanes operated under 14 CFR part 135.

We also continue to advance and participate in GCAS research and development programs to implement GCAS for aircraft operating at low altitude near proximate terrain, and we expect to complete this research in Fiscal Year 2024 and inform the SC-231 of these results.

I will keep the Board informed of the FAA’s progress on Safety Recommendations A-17-35 and A-18-15 and anticipate providing an update by March 31, 2025.

September 6, 2023 · NTSB Correspondence · FAA

We note that, on June 11, 2021, the General Aviation Joint Steering Committee’s (GAJSC’s) Controlled Flight into Terrain (CFIT) Working Group published its final report, which included previously approved Safety Enhancement 54, “TAWS for General Aviation, Addressing Time-Limited Inhibit, and Future Auto Ground Collision Avoidance.” In response to Safety Enhancement 54, you are working with TAWS equipment manufacturers to establish a software-based means to override and uninhibit TAWS.

We also note that you are working with the National Aeronautics and Space Administration’s Armstrong Flight Research Center on a program to develop and implement a ground collision avoidance system (GCAS) for aircraft operating at low altitude near proximate terrain. You believe this work will establish the basis for revising the current TAWS standards. In addition, we note that you plan to invoke RTCA DO-367, “Minimum Operational Performance Standards for TAWS Airborne Equipment,” and update TSO C151, to include auto uninhibit functionality to reduce nuisance alerts and enhanced risk mitigation algorithms of GCAS.

We are encouraged by your actions thus far to address these recommendations. Pending completion of this work and appropriate revisions to RTCA DO-367 and TSO C151, Safety Recommendations A-17-35 and A-18-15 remain classified OPEN-- ACCEPTABLE RESPONSE.

January 10, 2023 · Recipient Response · FAA

-From Billy Nolen, Acting Administrator: The Federal Aviation Administration (FAA) continues to advance a number of safety initiatives that support TAWS alerts. These initiatives include:

• The General Aviation Joint Steering Committee’s Controlled Flight into Terrain (CFIT) Working Group included previously approved Safety Enhancement 54, TAWS for General Aviation, Addressing Time-Limited Inhibit, and Future Auto Ground Collision Avoidance, in its final report, CFIT, published June 11, 2021. The report is available at the following website: https://www.gajsc.org/document-center/gajsc-cfit-wg-report-june11-2021-reportlesses-3/

• The FAA continues to focus on restoring TAWS functionality subsequent to a pilot-initiated inhibit due to a nuisance alert (inhibit logic change). We are in discussions with the General Aviation Manufacturers Association to involve TAWS equipment manufacturers in establishing software-based means to override and un-inhibit TAWS based on revisions to internal un-inhibit logic in current and future systems. This includes a means that provides release of external TAWS inhibit for currently fielded systems.

• We continue to advance a research and development program to develop and implement a Ground Collision Avoidance System (GCAS) for aircraft operating at low altitude near proximate terrain. Addressing TAWS lateral escape maneuvers, this program is supported by the National Aeronautics and Space Administration’s Armstrong Flight Research Center, with flight test demonstrations conducted by an FAA contractor. This project will guide requirements, testing, and certification standards for future systems integrated into general aviation aircraft.

• To further mitigate the CFIT risk, we continue to work with the Alaska Air Carriers Association to extend Exemption No.18544, Regulatory Docket No. FAA-2019-0049, issued April 27, 2020, that established operational requirements for TAWS and granted relief from §135.154(b)(2), TAWS. This extension will allow more operators to apply the exemption to their operations as an interim measure pending the availability of GCAS algorithms.

The FAA expects these efforts to provide a basis for RTCA, Inc. Special Committee 231, TAWS, to reactivate the work previously completed in May 2020, and provide revisions to current TAWS standards. We intend to invoke RTCA DO-367, “Minimum Operational Performance Standards for TAWS Airborne Equipment,” and update Technical Standard Order C151, “TAWS,” to include auto un-inhibit functionality to reduce nuisance alerts and enhanced risk mitigation algorithms of GCAS. This revision is to provide increased safety for single-engine airplanes operated under part 135.

I will keep the Board informed of the FAA’s progress on Safety Recommendations A-17-35 and A-18-15 and anticipate providing an update by February 29, 2024.

March 11, 2022 · NTSB Correspondence · FAA

We note that, although the GAJSC’s workgroup’s final CFIT report has been delayed due to COVID, you have started work on an SE recommended by the workgroup that seeks to improve TAWS capabilities and algorithms to better protect pilots operating in areas with challenging terrain, and to develop additional safety protections to prevent the permanent inhibition of nuisance TAWS alerts during a terrain-critical flight. We also note that RTCA SC-231, “TAWS,” published a white paper with recommended solutions to address this safety issue.

In addition, you are considering changes that would prevent pilots from tampering with proper TAWS functioning (inhibit logic change) and allow for TAWS lateral escape maneuvers to resolve CFIT issues in Alaska. You also reported that, to reduce nuisance alerts encountered with Class B TAWS that resulted in flight crews inhibiting the TAWS during VFR operations, an exemption was issued to allow single engine turbine-powered aircraft equipped with six to nine passenger seats to operate in Alaska under VFR with Class C TAWS, with a display, installed instead of Class B TAWS.

We are encouraged by your actions thus far to address these recommendations. Pending our review of the GAJSC’s report, the RTCA SC-231 recommendations, and a detailed plan for addressing the actions described in these recommendations, Safety Recommendations A-17-35 and A-18-15 remain classified OPEN-- ACCEPTABLE RESPONSE.

September 1, 2021 · Recipient Response · FAA

-From Steve Dickson, Administrator: The Federal Aviation Administration (FAA) previously informed the Board that the General Aviation Joint Steering Committee’s (GAJSC) Controlled Flight into Terrain (CFIT) Working Group (WG) completed its work and would publish its final report concerning reducing the number of CFIT general aviation accidents by December 2020. The report, summarizing the developed safety enhancements (SE), was delayed due to COVID-19, although the work surrounding the GAJSC-approved SEs started immediately. We now anticipate a final report to be published by the end of calendar year 2021.

The GAJSC approved SE-54, Terrain Awareness and Warning System [TAWS] for General Aviation, Addressing Time-Limited Inhibit, and Future Auto Ground Collision Avoidance, on February 19, 2020, and the activity began immediately. SE-54 was developed to improve TAWS capabilities and algorithms to better protect pilots operating in areas with challenging terrain. It also seeks to develop additional safety protections to prevent the permanent inhibition of nuisance TAWS alerts during a terrain-critical flight.

The RTCA Program Management Committee also completed its reconvening of Special Committee (SC)-231, TAWS, in May 2020. The committee published a white paper titled, Recommended Solutions to Address TAWS Manual Inhibition CFIT Cases Raised by NTSB Safety Recommendations A-17-035 and A-18-015 and GAJSC CFIT WG Safety SE-54 in June 2020. The paper is available here: https://www.rtca.org/sc-231/

Based on SC-231 recommendations, the FAA is focusing on implementing the following changes: 1. Prevent the pilot from tampering with proper TAWS functioning (inhibit logic change); and 2. Allow for TAWS lateral escape maneuvers in order to resolve CFIT issues in Alaska.

Additionally, the FAA adopted one of the SC-231’s recommendations (discussed in the white paper) to issue an exemption to allow the use of Class C TAWS in lieu of Class B TAWS for certain Alaskan operators. On April 27, 2020, the FAA issued Exemption No. 18544, Regulatory Docket No. FAA-2019- 0049, to members of the Alaskan Air Carriers Association. The exemption granted relief from § 135.154(b)(2), TAWS, allowing for the operation of single engine turbine-powered aircraft equipped with six to nine passenger seats in Alaska under VFR with Class C TAWS, with a display, installed instead of Class B TAWS.

The Class C TAWS with a display maintains the necessary level of safety while reducing nuisance alerts encountered with Class B TAWS that caused the flight crew to inhibit the TAWS during VFR operations.

Finally, the TAWS alerting thresholds for reduced terrain for Class A and B systems were previously 700 feet under Technical Standard Order (TSO) C151c, TAWS, and earlier TSO versions. The committee updated RTCA/Document (DO)-367, Minimum Operational Performance Standards (MOPS) for TAWS Airborne Equipment, reducing the previous 700 feet to 500 feet in order to resolve the inconsistency in level flight and descending flight requirements. Performance requirements in RTCA/DO-367 are invoked in TSO C151d.

I will keep the Board informed of the FAA’s progress on Safety Recommendations A-17-35 and A-18-15 and anticipate providing an update by August 31, 2022.

May 7, 2020 · NTSB Correspondence · FAA

We note that your General Aviation Joint Steering Committee (GAJSC), which has assembled a working group to examine controlled flight into terrain (CFIT) accidents—including those involving aircraft operating under Part 135—intends to issue a final report with recommendations to reduce the number of CFIT accidents. We also note that the RTCA reconvened Special Committee (SC)-231, “TAWS,” which has been tasked with developing potential TAWS-based solutions and determining if standards are needed for RTCA/00-367, Minimum Operational Performance Standards for TAWS Airborne Equipment.

Pending our review of the RTCA SC-231 recommendations and a detailed plan for addressing the actions described in these recommendations, Safety Recommendations A-17-35 and A-18-15 remain classified OPEN--ACCEPTABLE RESPONSE.

February 18, 2020 · Recipient Response · FAA

-From Steve Dickson, Administrator: The Federal Aviation Administration (FAA) continues to participate in the General Aviation Joint Steering Committee (GAJSC) Controlled Flight into Terrain (CFiT) Working Group. This group looks at accidents, including part 135 operations, and holds discussions with manufacturers and operators. The outcome of this collaboration is that the GAJSC's plans to release its final report by December 2020, targeted at reducing the number of CFiT general aviation accidents. At the FAA 's request, RTCA reconvened Special Committee SC-231, TAWS, and the initial meeting took place May 14-15, 2019. The committee's tasks include:

• Consider NTSB Safety Recommendations A-17-35 and A-18-15; • Consider forthcoming GAJSC CFiT Working Group recommendations; and • Recommend potential TA WS based solutions by June 2020.

The FAA is actively participating in SC-231 quarterly meetings. This committee will produce solutions to enhance TA WS protections and determine if standards are necessary for RTCA/00-367, Minimum Operational Performance Standards for TA WS Airborne Equipment. We will review the RTCA SC-231 recommendations and determine the next appropriate actions. I will keep the Board informed of the FAA's progress on these safety recommendations and anticipate a follow-on response by February 2021.

April 26, 2018 · NTSB Correspondence · FAA

The following is from the NTSB Aviation Accident Report “Collision with Terrain Hageland Aviation Services, Inc. dba Ravn Connect Flight 3153 Cessna 208B, N208SD, Togiak, Alaska October 2, 2016.” Report number AAR-18-02. Adopted on April 17, 2018 and published on April 26, 2018. 2.4.3 Routine Use of TAWS Terrain Inhibit Switch The Honeywell KGP 560/860 Pilot’s Guide for GA-EGPWS recommended that the TAWS alerts should not be inhibited during normal operations. The guide stated that the purpose of the terrain inhibit switch was to allow for operations without nuisance warnings at certain airports that were not in the system database.

Although Hageland had no official published policy, Hageland allowed pilots to inhibit the alerts outside of the manufacturer’s recommendations because the alerts could be distracting to the crew during flights below the TAWS RTC. The chief pilot, DO, and a check airman each described scenarios in which pilots were allowed to inhibit the system when flying in VMC, including en route flight below 700 ft agl. The lack of specific guidance on TAWS use led to pilots routinely inhibiting a safety system important in CFIT prevention.

The NTSB has investigated several other accidents in which pilots were involved in fatal terrain collisions in Alaska while conducting normal operations with their TAWS alerts inhibited.42 Research has shown that frequent nuisance alerts decrease user confidence in the alerts due to the “cry wolf” effect, motivating users to disable or otherwise disregard them (Sorkin 1988).

As a result of these investigations, on May 9, 2017, the NTSB issued Safety Recommendation A-17-35, which asked the FAA to implement ways to provide effective TAWS protections while mitigating nuisance alerts for single-engine airplanes operated under Part 135 that frequently operate at altitudes below their respective TAWS class design alerting threshold (NTSB 2017a). On July 21, 2017, the FAA responded that it would review the issue and determine its next steps. Pending action from the FAA to address the recommendation, the NTSB classified Safety Recommendation A-17-35 “Open—Acceptable Response.”

Due to the recommendation’s relevance to the circumstances of this accident, which also involved an operator allowed to conduct VFR flights at altitudes that could result in continuous TAWS alerts, the NTSB reiterates Safety Recommendation A-17-35. The NTSB notes that, since the FAA’s initial response, the FAA issued TSO-C151d, which required a FLTA en route alerting altitude of 500 ft agl (per DO-367) for new models of Class B TAWS equipment (for fixed-wing aircraft) identified and manufactured on or after August 31, 2017. (TSO-C151c, which applied to the TAWS installed in the accident airplane and specified a Class B minimum RTC of 700 ft, remains effective until February 28, 2019.)

The NTSB looks forward to further updates from the FAA regarding any completed or planned action related to this safety recommendation.

October 26, 2017 · NTSB Correspondence · FAA

We note that the General Aviation Joint Steering Committee (GAJSC) has assembled a working group to examine controlled flight into terrain (CFIT) accidents, including those involving aircraft operating under Part 135. Pending updates on the GAJSC’s efforts, and a plan that addresses the specific concerns outlined in Safety Recommendation A-17-35, the recommendation is classified OPEN--ACCEPTABLE RESPONSE.

July 21, 2017 · Recipient Response · FAA

-From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) will review this issue and determine its next steps. However, we note that the accident that resulted in this recommendation involved Controlled Flight into Terrain (CFiT), which is of interest to the General Aviation Joint Steering Committee (GAJSC). The GAJSC has approved and assembled membership for a working group aimed at examining CFiT accidents, to include pa11 135 operations. The FAA 's goal is to begin the work of this group by late summer of 2017.

May 9, 2017 · NTSB Correspondence · FAA

On April 25, 2017, the National Transportation Safety Board (NTSB) adopted its report concerning the June 25, 2015, accident in which a single-engine, turbine-powered, float-equipped de Havilland DHC-3 (Otter) airplane, N270PA, collided with mountainous, tree-covered terrain about 24 miles east-northeast of Ketchikan, Alaska.1 Additional information about this accident and the resulting recommendations may be found in the report of the investigation, which can be accessed at our website, http://www.ntsb.gov, under report number NTSB/AAR-17/02.

As a result of this investigation, we issued 10 new recommendations, including 1 to the Cruise Lines International Association and the following 9 recommendations to the Federal Aviation Administration.