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  3. NTSB A-18-014
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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

Read Recommendation

Recommendation Facts

Status
Open - Unacceptable Response
Issued
April 26, 2018
Priority
CLASS II
Recipient
FAA
Adopted
April 17, 2018
Related Investigation
ANC17MA001
Related Report
AAR-18-02
23003

In its response to the FAA, dated March 11, 2022, the Board asked how we plan to verify that operators have voluntarily developed procedures appropriate for their operations and incorporated them into their approved flight procedures. We note that InFO guidance is voluntary for operators, and the FAA does not believe the Board’s recommendation rises to the level of verification through the creation of a custom data collection tool in our Safety Assurance System to specifically track this action.

I believe the FAA has effectively addressed Safety Recommendation A-18-14 and consider our actions complete with no further action planned.

March 11, 2022 · NTSB Correspondence · FAA

We note that you are finalizing Safety Alert for Operators (SAFO), “Terrain Awareness and Warning Systems (TAWS) Nuisance Alerts,” which will include guidance for Part 135 operators on developing and implementing policies and procedures for determining the proper use of the TAWS terrain aural inhibit feature into their training programs, and will encourage operators to provide flight crews with inflight procedures to minimize nuisance alerts and their associated risks.

We continue to believe that your planned SAFO is responsive to the first part of this recommendation and has the potential to satisfy the second part of this recommendation. However, we request additional information about how you plan to verify that operators have voluntarily developed procedures appropriate for their operations and incorporated them into their approved flight procedures. Pending our review of this information and the published SAFO, Safety Recommendation A-18-14 remains classified OPEN-- ACCEPTABLE RESPONSE.

October 13, 2021 · Recipient Response · FAA

-From Steve Dickson, Administrator: The Federal Aviation Administration (FAA) is finalizing the Safety Alert for Operators (SAFO), Terrain Awareness and Warning Systems (TAWS) Nuisance Alerts that addresses the operational risks associated with TAWS. Currently, the draft SAFO is in final internal coordination and is anticipated to be available for publication by June 30, 2022.

The SAFO will guide part 135 operators to develop and implement policies and procedures for determining the proper utilization of the TAWS terrain aural inhibit feature into their training programs. The SAFO will also encourage operators to provide flight crews with inflight procedures to minimize nuisance alerts and risks such as flight crew distraction and complacency brought about by repetitive use of the TAWS terrain aural inhibit feature.

Through voluntary efforts by part 135 operators and the FAA’s ongoing review of their training programs conducted during routine operator surveillance, the awareness and mitigation of TAWS nuisance alerts will be improved.

I anticipate providing an update to this safety recommendation by November 30, 2022.

October 16, 2018 · NTSB Correspondence · FAA

We note that you are developing a safety alert for operators (SAFO) that will discuss the risks associated with nuisance alerts; encourage operators to ensure all pilots are aware of the risks associated with distraction and complacency brought about by routinely using the terrain inhibit feature; recommend that operators incorporate policies and procedures into their training programs to mitigate terrain inhibit features; include plans to minimize nuisance alerts; and minimize the risk associated with distraction and complacency brought about by routinely using the terrain inhibit feature.

We believe that a SAFO is an appropriate way to alert management and pilots to the risks associated with continuous nuisance alerts and routine use of the terrain inhibit feature. However, we remain concerned that operators’ procedures (which you have approved) allow normal flight operations at altitudes where equipment (which you require) warns pilots of an unsafe condition. To address this concern and satisfy the second and third parts of this recommendation, we believe that you should work with operators to develop procedures that mitigate these risks, then ensure that those procedures are incorporated into operators’ approved flight procedures.

Pending our review of the SAFO and of your plan to address the remaining parts of this recommendation, Safety Recommendation A-18-14 is classified OPEN--ACCEPTABLE RESPONSE.

July 20, 2018 · Recipient Response · FAA

-From Daniel K. Elwell, Acting Administrator: The FAA has initiated development of a Safety Alert for Operators that will – • Address risks associated with nuisance alerts and encourage operators to ensure all pilots are aware of the risks associated with distraction and complacency brought about by routine use of the terrain inhibit feature: and • Recommend operators incorporate policies and procedures into their training programs that will reduce terrain inhibit features, include plans to minimize nuisance alerts, and minimize risk associated with dis traction and complacency brought about by routine use of the terrain inhibit feature.

April 26, 2018 · NTSB Correspondence · FAA

On April 17, 2018, the NTSB adopted its report, Collision with Terrain, Hageland Aviation Services, Inc., dba Ravn Connect Flight 3153, Cessna 208B, N208SD, Togiak, Alaska, October 2, 2016, NTSB/AAR-18/02. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. Among the Safety Recommendations, five are issued to Federal Aviation Administration (FAA) and can be found on page 71 of the report; eight are reiterated to the FAA and can be found on pages 72-73 of the report.

The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number. We encourage you to submit your response.