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NTSB · Safety Recommendation

Safety Recommendation A-18-015

Recommendation

TO THE FEDERAL AVIATION ADMINISTRATION: Modify the terrain awareness and warning system requirements in Technical Standard Order C151 such that, once the alerts are manually inhibited, they do not remain inhibited indefinitely if the pilot does not uninhibit them.

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

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.

Read Recommendation

Recommendation Facts

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

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.

October 16, 2018 · NTSB Correspondence · FAA

We note that you plan to work with manufacturers and operators to determine the standards, opportunities, and potential technical implementation paths for automatically uninhibiting alerts that were previously manually inhibited by the pilot. We believe this is a necessary first step toward addressing this recommendation. Pending updates on your progress and a plan for modifying the TAWS requirements in the TSO, Safety Recommendation A-18-15 is classified OPEN--ACCEPTABLE RESPONSE.

July 20, 2018 · Recipient Response · FAA

-From Daniel K. Elwell, Acting Administrator: The FAA plans to work with manufacturers and operators to determine the standards, opportunities, and potential technical implementation paths for automatically uninhibiting alerts previously manually inhibited by the pilot. Once the FAA completes this work. we will determine the best path forward to address the safety issues identified by this recommendation.

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.