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NTSB · Safety Recommendation

Safety Recommendation A-17-040

Recommendation

TO THE FEDERAL AVIATION ADMINISTRATION: Publish an advisory circular that provides guidance on operational control best practices, including, but not limited to, such areas as risk mitigation strategies, joint flight safety responsibilities, prior experience of operational control personnel, and operational control personnel duty time limitations.

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

February 2, 2026 · Recipient Response · FAA

-From Jimmy Bruno, Analyst, Aviation Safety: Please see the attached Advisory Circular, that was recently published ahead of schedule, to address the safety issues identified with Safety Recommendation A-17- 40. We wanted to share this with you upon publication, rather than wait for the 1- year response date. The attached file can be publicly accessed at: https://drs.faa.gov/browse/excelExternalWindow/DRSDOCID14396755292026020214 3307.0001

Should you have any questions or need further information, please contact Mr. James Bruno, AVP-120.

June 24, 2025 · Recipient Response · FAA

-From Christopher J. Rocheleau, Acting Administrator: The FAA plans to publish an advisory circular (AC) for Enhanced Flight Following Center (EFFC) for Commercial Air Tour Operators. This AC will provide information and recommendations that may assist commercial air tour operators of all sizes and scope to develop, implement, and integrate enhanced flight-following procedures for improved operational control and create an EFFC. The publication will include processes to train personnel in preflight risk analysis, providing pilots with weather briefings, monitoring the progress of the flights, and participating in two-way communications with pilots to alert them of any weather hazards.

The anticipated publication date of this AC is September 30, 2026.

The FAA continues to review Hawaii air tour operators’ proprietary training materials to ensure they include cue-based, island-specific weather training. The improved quality of available training materials reviewed so far has satisfied the need for training examples, which the FAA would have provided otherwise.

Advisory Circular 136-B048 (now AC 136-4), Supplemental Information for the Creation of Operating Procedures and Pilot Training Subjects Related to Operations Specifications (OpSpec)/Letter of Authorization (LOA) B048, was published on 11/12/2024. The AC will provide guidance to air tour operators on training flight support personnel in the process of preflight risk analysis, providing pilots with weather briefings, monitoring the progress of active tour flights, and participating in two-way communications with pilots to alert them of any unanticipated weather hazards.

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Recommendation Facts

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

Additionally, the AC also has a specific inclusion for cue-based, island-specific weather training to enable pilots to evaluate weather patterns based on visual cues, and to determine from those cues if it is appropriate to continue the flight as planned or if an alternate route of flight is necessary. The AC is available at the following website: https://drs.faa.gov/browse/excelExternalWindow/DRSDOCID18726233262024111420241.0001

FAA Notice 8900.718, Revised and Reinstated OpSpec/LOA B048, Commercial Air Tour Operations Below 1,500 Feet Above the Surface in the State of Hawaii: Decommissioning of LOA B548 (HQ Revision: 000); and the Cancellation of the Hawaii Air Tour Common Procedures Manual (HATCPM), was published on 11/12/2024. This notice announces the change to B048 and includes draft copies of the Opspec/LOAs. B548 is rescinded, and only B048 will be issued for all applicable FAR parts. Operators will be required to archive previous versions of OpSpec B048 and LOA B548, and request approval of the new versions. The notice is found at the following website:

https://drs.faa.gov/browse/excelExternalWindow/DRSDOCID19235245282024111420285.0001

I will keep the Board informed of the FAA’s progress on Safety Recommendations A-17-40, A-22-13, and A-22-14, and I anticipate providing an update by September 30, 2026.

October 9, 2024 · NTSB Correspondence · FAA

We note that you anticipate publishing an AC in September that will include guidance for commercial air tour operators on implementing a flight monitoring system and training flight support personnel. Although we look forward to reviewing the published AC, we continue to believe the delays associated with developing this AC are unacceptable. Pending the timely issuance of the recommended AC, Safety Recommendation A-17-40 remains classified OPEN-- UNACCEPTABLE RESPONSE.

October 2, 2023 · Recipient Response · FAA

-From Kathryn B. Thomson, Deputy Administrator: The Federal Aviation Administration (FAA) continues to expand weather camera services in Hawaii to enhance aviation safety and pilot decision-making with the installation of 15 of the 26 planned sites to date. The following 10 new sites, in addition to the 5 sites listed in our previous letter, include (available at https://weathercams.faa.gov/):

1. Holei Pali (POAA) 2. Kalaupapa (PHLU) 3. Kapalua (JHM) 4. Laie (HI58) 5. Laupahoehoe (QHC) 6. Lihue (PHLI) 7. Makaha Ridge (PHBK) 8. Upolo (PHUP) 9. Wahiawa (PHHI) 10. Waimanalo (CKH) The FAA also continues to develop an advisory circular (AC) providing guidance for all commercial air tour operators to implement an operator-specific flight monitoring system. This AC will include processes to train flight support personnel in the process of preflight risk analysis, provide pilots with weather briefings, monitor the progress of the flights, and participate in two-way communications with pilots to alert them of any weather hazards.

The FAA has initiated this draft AC with its anticipated publication by September 30, 2024.

Additionally, the FAA released draft AC 136-B048, Supplemental Information for the Creation of Operating Procedures and Pilot Training Subjects Related to OpSpec/LOA B048, for public comment, which can be found at the following website: https://www.faa.gov/aircraft/draft_docs/afs_ac/AC_136-B048_Coord_Copy.pdf

Finally, revisions to Operations Specifications (OPSPEC) Paragraph B048, Operations in the Vicinity of the Hawaiian Islands, and Letter of Authorization (LOA) B548 continue to be delayed due to the need for additional internal coordination. We are continuing to evaluate requirements for the use of ADS-B Out equipment in air tour operator aircraft as a requirement to obtain the revised OPSPEC B048/LOA B548. While the OPSPEC and LOA are being revised, the FAA continues to review Hawaii air tour operators’ proprietary training materials for the required cue-based, island-specific weather training.

The improved quality of available proprietary training materials has satisfied the need for training examples, which would have otherwise been provided by the FAA.

I will keep the Board informed of the FAA’s progress on Safety Recommendations A-07-18, A-07-19, A-17-40, A-22-13, and A-22-14 and anticipate providing an update by August 31, 2024.

April 19, 2023 · NTSB Correspondence · FAA

We note that, although you are developing the recommended AC, it will not be published until 2024. We believe that since we issued this recommendation in 2017, sufficient time has passed to develop best practices guidance on operational control. Acceptable guidance on this topic already exists in AC 120-96A, “Operations Control Center for Helicopter Air Ambulance Operations,” which could be used to develop similar guidance for all Part 135 operators. Pending the timely issuance of the recommended AC, Safety Recommendation A-17-40 is classified OPEN-- UNACCEPTABLE RESPONSE.

September 21, 2022 · Recipient Response · FAA

From Billy Nolan, Acting Administrator, Federal Aviation Administration: This is in further response to Safety Recommendation A-17-40, issued by the Board on May 9, 2017, and supplements our previous letters.

The Federal Aviation Administration (FAA) previously stated that it completed an evaluation of commercial air tour accidents occurring between January 2008 and June 2017. The FAA further evaluated air tour accidents occurring between July 2017 and March 2022 and found no significant trends indicating that an operations control center would have had a significant impact on the number of air tour accidents occurring between January 2008 and March 2022.

As a result, the FAA is continuing to develop an advisory circular (AC) that will address this safety recommendation. The AC publication date was extended to September 2024, from our original July 2021 date, to allow for additional internal coordination.

I will keep the Board informed of the FAA’s progress on Safety Recommendation A-17-40 and anticipate providing an update by September 30, 2023.

May 26, 2021 · NTSB Correspondence · FAA

We note that, based on your evaluation of air tour accidents that occurred between 2008 and 2017, you have developed a new draft AC that includes guidance on operational control best practices, including risk mitigation strategies, joint flight safety responsibilities, and operational control personnel’s prior experience and duty-time limitations. Pending our review of the published AC, Safety Recommendation A-17-40 is classified OPEN-- ACCEPTABLE RESPONSE.

November 3, 2020 · Recipient Response · FAA

-From Steve Dickson, Administrator: The Federal Aviation Administration (FAA) determined that an advisory circular (AC) providing guidance for air tour operators on operational control best practices addressing topics such as risk mitigation strategies, joint flight safety responsibilities, prior experience of operational control personnel, and operational control personnel duty time limitations is the best plan of action. This determination is in response to our evaluation of air tour accidents occurring from 2008 to 2017, which found no significant trend indicating that an operations control center would have had any significant impact on the number of air tour accidents.

The FAA is currently reviewing a draft version of the AC that includes input from operators. The anticipated publication in July 2021 includes time for internal legal review and document control board approval.

I will provide the Board with an update on our efforts by September 30, 2021.

July 22, 2020 · NTSB Correspondence · FAA

In your July 21, 2017, initial response to this recommendation, you indicated that you were evaluating statistical data from air tour accidents in which operational control was a contributing factor to determine if a new AC is needed that provides guidance on operational control best practices. You also said that you were considering other policy documents to familiarize operators with existing operational control guidance and industry best practices.

Again, we normally expect actions to address our recommendations to be completed within 3 to 5 years; however, this recommendation was issued more than 3 years ago, and we have not received any additional information regarding your actions to address it. We would appreciate receiving an update. In the meantime, pending our timely receipt of a plan for developing the recommended AC, Safety Recommendation A-17-40 is classified OPEN--UNACCEPTABLE RESPONSE.

October 26, 2017 · NTSB Correspondence · FAA

We note that you are evaluating statistical data from air tour accidents in which operational control was a contributing factor to determine if a new AC is needed that provides guidance on operational control best practices. We also note that you are considering other policy documents to familiarize operators with existing operational control guidance and industry best practices. Pending our review of the results of your evaluation and a plan for developing the recommended AC, Safety Recommendation A-17-40 is classified OPEN--ACCEPTABLE RESPONSE.

July 21, 2017 · Recipient Response · FAA

-From Michael P. Huerta, Administrator: The FAA understands the impo11ance of air tour operators being familiar with the current body of knowledge relating to operational control. Accordingly, we have initiated an evaluation of air tour accident statistical data where operational control was considered a contributing factor. Following our evaluation, we will determine whether issuance of a new advisory circular is necessary. In addition, we are evaluating the feasibility of issuing an Information for Operators, a Safety Alert for Operators, or some other policy document to familiarize operators with existing operational control guidance and industry best practices material.

In the meantime, we will continue to encourage air tour operators to establish an operations control function that is appropriately scaled to the size and scope of their air tour operations.

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.