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  3. NTSB A-17-039
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NTSB · Safety Recommendation

Safety Recommendation A-17-039

Recommendation

TO THE FEDERAL AVIATION ADMINISTRATION: Establish minimum initial and recurrent training requirements for personnel authorized to exercise operational control, including, but not limited to, approved subject knowledge areas, training hours, subject hours, and qualification modules.

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

May 23, 2024 · NTSB Correspondence · FAA

We note that you continue to believe that existing FAA guidance and policy adequately address these recommendations and, therefore, you do not intend to establish the recommended initial and recurrent training requirements for personnel authorized to exercise operational control.

We remain concerned that, although Order 8900.1 says that operators must provide training on operational control, it does not include any information about what, specifically, needs to be included in that training. In addition, the order directs inspectors to encourage operators to establish a qualification module, but also says that one is not required. However, you have made it clear that you do not intend to act, and we do not believe keeping these recommendations open will result in any additional action. Consequently, Safety Recommendations A-17-39 and -41 are classified CLOSED-- UNACCEPTABLE ACTION.

September 18, 2023 · Recipient Response · FAA

-From Kathryn B. Thomson, Deputy Administrator: The Federal Aviation Administration (FAA) has reviewed our previously mentioned actions and continues to believe that we address these two safety recommendations. The existing FAA guidance and policy are adequate, and we are not planning to introduce rulemaking to establish new minimum or initial training for personnel authorized to exercise operational control.

The FAA updated Order 8900.1, Flight Standards Information Management System, to include requirements and policies related to operational control that apply to 14 CFR Parts 121 and 135 air carriers. Furthermore, the FAA directs its policy towards principal operations inspectors and aviation safety inspectors to clarify their Part 135 duty requirements and operator surveillance activities to verify regulatory compliance. Additionally, 14 CFR § 119.69, Management Personnel Required for Operations Conducted under Part 135 of this Chapter, outlines employee training, experience, and expertise to which air carriers must adhere.

Finally, Order 8900.1, Volume 3, Chapter 25, Section 5, Safety Assurance System: Part 135 Flight Locating Systems and Operating Rules, Paragraph 3-2021, General, also references Part 135

April 19, 2023 · NTSB Correspondence · FAA

We note that you do not intend to establish the recommended initial and recurrent training requirements for personnel authorized to exercise operational control because you determined that existing FAA guidance and policy are adequate. We also note that, on April 12, 2018, you updated Order 8900.1, volume 3, chapter 25, section 1, “Basic Requirements and Policy Applicable to All Air Carriers,” to include inspector guidance on Part 135 duty requirements and surveillance activities for verifying operator compliance.

You reported that operators are responsible for ensuring that people authorized to exercise operational control are trained to perform their assigned duties, such as by establishing a training and qualification program like that described in Order 8900.1, volume 3, chapter 22.

We do not believe Order 8900.1 is responsive to either of these recommendations. Although the order says that operators must provide training on operational control, it does not include any information about what, specifically, needs to be included in that training. In addition, the order directs inspectors to encourage operators to establish a qualification module, but also says that one is not required.

We point out that the intent of Safety Recommendation A-17-39 is to establish minimum training requirements, including subject knowledge areas, training hours, subject hours, and qualification modules, to ensure that those authorized to exercise operational control are adequately trained to make safe and appropriate decisions. The intent of Safety Recommendation A-17-41 is to establish guidance for your inspectors on how to assess the adequacy of an operator’s training program and the qualifications of its operational personnel.

Pending our review of a plan to address these concerns and completion of the recommended actions, Safety Recommendations A-17-39 and -41 remain classified OPEN-- UNACCEPTABLE RESPONSE.

March 8, 2022 · Recipient Response · FAA

-From Steve Dickson, Administrator: The FAA completed its review of existing FAA guidance and policy and determined that they are adequate. We are not planning to introduce rulemaking to establish new minimum or initial training for personnel authorized to exercise operational control, to include subject knowledge areas, training hours, subject hours, and qualification modules. Additionally, we have updated Order 8900.1 guidance, as mentioned above and in our response to Safety Recommendation A-17-41, for our POIs and ASIs to clarify part 135 duty requirements and operator surveillance activities to verify regulatory compliance.

July 22, 2020 · NTSB Correspondence · FAA

In your July 21, 2017, initial response to these recommendations, you indicated that the guidance for terrain avoidance could be expanded to include fixed-wing operations and to emphasize the importance of operational control; however, you said that you needed to first evaluate the existing guidance, regulations, and policy for Part 135 operators to determine if there are any alternative solutions that would satisfy these recommendations.

We normally expect actions to address our recommendations to be completed within 3 to 5 years; however, we have not received any additional information from you regarding your actions to address these recommendations, which were issued more than 3 years ago. We would appreciate receiving an update. Pending our review of your plan to establish the recommended training requirements and incorporate the recommended changes into Order 8900.1, Safety Recommendations A-17-38, -39, and -41 are classified OPEN--UNACCEPTABLE RESPONSE.

October 26, 2017 · NTSB Correspondence · FAA

You indicated that the guidance for terrain avoidance can be expanded to include fixed wing operations and to emphasize the importance of operational control. We note, however, that because this would be an operational change, you must first evaluate the existing guidance, regulations, and policy for Part 135 operators to determine if there are any alternative solutions that would satisfy these recommendations. Pending our review of the results of your evaluation, and a plan for establishing the recommended training requirements and incorporating the recommended changes into Order 8900.1, Safety Recommendations A-17-38, -39, and -41 are classified OPEN--ACCEPTABLE RESPONSE.

July 21, 2017 · Recipient Response · FAA

-From Michael P. Huerta, Administrator: The FAA agrees that guidance for terrain avoidance can be expanded to include fixed-wing operations and to emphasize the importance of operational control. However, because this operational control change would require rulemaking, we intend to evaluate our current guidance, regulations, and policy, for part 135 operators to determine potential options to satisfy these safety recommendations.

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.

Read Recommendation

Recommendation Facts

Status
Closed - Unacceptable Action
Issued
May 9, 2017
Priority
CLASS II
Recipient
FAA
Adopted
April 25, 2017
Closed
May 23, 2024
Related Investigation
ANC15MA041
Related Report
AAR-17-02
operational control. This paragraph contains direction and guidance for inspectors to use when reviewing an operator’s general operations manual and when conducting inspections of
Part 135
operators related to Safety Assurance System Elements 2.2.1, (OP) Airmen Duties/Flight Deck Procedures, 3.3.1, (OP) Operational Control, and 4.2.5, (AW) Maintenance Control Functions.

I believe the FAA has effectively addressed Safety Recommendations A-17-39 and -41 and consider our actions complete. The FAA will take no further action on these recommendations.