NTSB · Safety Recommendation
Safety Recommendation A-18-014
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: Work with Title 14 Code of Federal Regulations Part 135 certificate holders that operate under visual flight rules in the aircraft’s required terrain awareness and warning system (TAWS) class to (1) ensure that management and pilots are aware of the risks associated with distraction (from continuous nuisance alerts) and complacency (brought about by routine use of the terrain inhibit feature); (2) develop plans for mitigating those risks and minimizing nuisance alerts; and (3) develop procedures that specifically address when pilots should test, inhibit, and uninhibit the TAWS alerts, considering the operator’s typical operations and the TAWS manufacturer’s guidance.
Safety Issue and Context
On October 2, 2016, about 1157 Alaska daylight time, Ravn Connect flight 3153, a turbine-powered Cessna 208B Grand Caravan airplane, N208SD, collided with steep, mountainous terrain about 10 nautical miles northwest of Togiak Airport (PATG), Togiak, Alaska. The two commercial pilots and the passenger were killed, and the airplane was destroyed. The scheduled commuter flight was operated under visual flight rules (VFR) by Hageland Aviation Services, Inc., Anchorage, Alaska, under the provisions of Title 14 Code of Federal Regulations (CFR) Part 135.
The National Transportation Safety Board’s (NTSB) investigation determined that instrument meteorological conditions (IMC) were likely in the vicinity of the accident site at the time of the accident. The flight departed Quinhagak Airport, Quinhagak, Alaska, at 1133 and was en route to PATG. Data available for the accident flight showed that, after departure in visual meteorological conditions, the airplane proceeded along a generally direct route toward the destination at an altitude of about 1,000 ft mean sea level (msl), which resulted in terrain clearances between 500 and 700 ft above ground level (agl).
During the last 4 minutes of the flight, the airplane climbed as it approached the mountain ridge that it eventually struck at an elevation of about 2,300 ft msl after having likely entered IMC. The airplane was equipped with a Class B terrain awareness and warning system (TAWS) that had an en route required terrain clearance (RTC) of 700 ft agl; flight at altitudes below the RTC (and not within 15 miles of an airport, given certain criteria) would result in TAWS terrain alerts. Hageland flights operated under VFR were allowed to fly as low as 500 ft agl, as was seen with this flight, which was flown en route below the TAWS alerting threshold.
The system was equipped with a terrain inhibit switch that allowed the pilot to manually inhibit all TAWS aural and visual caution and warning alerts. A TAWS simulation that used an estimated flightpath for the accident airplane (assuming a level cruise altitude between known data points and a climb after the last data point to the accident elevation) showed that, if the alerts were not inhibited, the TAWS would have provided continuous alerts for most of the assumed flight. The investigation concluded that the TAWS alerts were likely inhibited for most, if not all, of the flight, eliminating a margin of safety.
Response History
December 13, 2024 · NTSB Correspondence · FAA
We note that you did not publish a safety alert for operators, as you had previously reported, but instead, on March 23, 2023, you published Information for Operators [InFO], TAWS Nuisance Alerts, which describes this safety issue and encourages operators to develop procedures and training on using the terrain inhibit aural warning switches associated with nuisance alerts. We also note that you do not intend to verify that operators have voluntarily incorporated the recommended procedures because you do not believe this safety issue rises to the level of verification through the creation of a custom data collection tool in your safety assurance system.
Although we believe the published InFO is responsive to the first part of this recommendation, we do not believe it addresses the second or third parts. We remain concerned that, without pilot procedures on when TAWS alerts should be uninhibited, alerts may be left inhibited for longer than intended, creating a potential scenario where a pilot who did not initially inhibit the system would need to first recognize the system status and then make it functional. Although you indicated that your actions are complete, we urge you to reconsider your position and to ensure that operators have incorporated the recommended procedures into their approved flight procedures.
In the meantime, pending completion of this action, Safety Recommendation A-18-14 is classified OPEN-- UNACCEPTABLE RESPONSE.
August 29, 2023 · Recipient Response · FAA
-From Kathryn B. Thomson, Deputy Administrator: The Federal Aviation Administration (FAA) is no longer pursuing guidance in the form of a safety alert for operators and instead has issued an information for operators (InFO) that addresses the operational risks associated with TAWS. The FAA published the InFO, Terrain Awareness and Warning Systems (TAWS) Nuisance Alerts, on March 23, 2023, which is available at the following website: https://www.faa.gov/other_visit/aviation_industry/airline_operators/airline_safety/info/all_infos/info