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  3. NTSB A-18-016
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NTSB · Safety Recommendation

Safety Recommendation A-18-016

Recommendation

TO THE FEDERAL AVIATION ADMINISTRATION: Install communications equipment throughout Alaska, after determining what would be most effective, to allow increased access to the instrument flight rules system, giving priority to those areas used by Title 14 Code of Federal Regulations Part 135 operators.

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

On October 1, 2024, your staff provided the following update on the FAA’s work related to remote communications outlet (RCO) facilities, self-sustaining outlet (SSO) facilities, and air/ground communications facilities in Alaska:

• 11 new RCO facilities have been established in the last 12 years • 1 new SSO facility has been established in the last 12 years • 7 existing SSOs have received infrastructure (building, shelter, and tower), power system (solar), and radio equipment upgrades in the last 10 years • 58 air/ground communications facility improvement and relocation projects have been completed in the last 12 years • 9 air/ground communications facility improvement and relocation projects have been funded

We believe your ongoing work to establish or enhance RCO, SSO, and air/ground communications facilities in Alaska is positive and will improve the IFR system in the state by making it more accessible to Part 135 operators. Pending completion of this work, Safety Recommendation A-18-16 remains classified OPEN--ACCEPTABLE RESPONSE.

October 3, 2023 · Recipient Response · FAA

-From Kathryn B. Thomson, Deputy Administrator: The Board provided a series of questions to the Federal Aviation Administration (FAA) in its February 22, 2023, letter. To answer the Board’s question on how the FAA determined what communications equipment would be most effective, we believe our June 30, 2022, letter describing the criteria the FAA uses to prioritize communications requirements sufficiently answers this question.

The Board also asked for more detailed information about Alaska communications requirements. As previously stated, Alaska communications requirements are ranked nationally among other National Airspace System requirements competing for Communication Facilities Sustainment funding (CFS). Due to limited CFS funding, we feel the following discussion better addresses the intent of the Board’s remaining questions.

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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

The FAA has established ten new Remote Communications Outlet (RCO) facilities and one new Self-Sustaining Outlet (SSO) facility in the last twelve years in Alaska. These facilities include:

1. Ruby RCO 2. King Cove RCO 3. Chignik RCO 4. Chickaloon RCO 5. Point Lay RCO 6. Anaktuvuk RCO 7. Elim RCO 8. Girdwood RCO 9. Nikolski RCO 10. Yukon River RCO 11. Taylor Mt. SSO

Additionally, there have been 58 air/ground communications facility improvement and relocation projects due to coverage and other issues over the last twelve years. Currently, the FAA has funded seven air/ground communications facility improvement and relocation projects. Since the process is dynamic, the unfunded projects on the list may or could possibly be reshuffled in future years, or fall off the list for unforeseen reasons. The following is the current list of funded projects:

1. Klawock Remote Control Air/Ground (RCAG) (new) 2. Williams Mt. SSO (new) 3. Eyak RCO (improvement) 4. Mekoryuk RCO (improvement) 5. McCathy RCO (new) 6. Galbraith RCO (new) 7. Galena RCAG (improvement)

The average cost for each project was $1 - $1.5 million. Since program implementation, the FAA spent an estimated $2 million per year for air-to-ground communications projects in support of Alaskan aviation, including Part 135 operations. The FAA will continue its work to update these facilities and keep the Board informed of its progress.

February 22, 2023 · NTSB Correspondence · FAA

We note that Alaska communications requirements are ranked nationally among other National Airspace System (NAS) requirements competing for Communication Facilities Sustainment (CFS) funding.

In your March 2021, letter, you said that each year you consider over 280 requests for requirements, which are submitted by service areas across the NAS, and only between 8 and 10 of those requests receive CFS funding. You also reported that Alaska had requested 33 requirements related to expanding communication coverage and that 4 of those had been funded. To help us determine if your actions are responsive, we would like to know how many communications requirements Alaska has requested, how many of those requirements have received CFS funding (for each year since 2012), and how many of those funded requirements are in areas used by Part 135 operators.

Finally, we would like to know how you determined what communications equipment would be most effective. Pending our review of this additional information and completion of the recommended actions, Safety Recommendation A-18-16 remains classified OPEN-- ACCEPTABLE RESPONSE.

June 30, 2022 · Recipient Response · FAA

-From Billy Nolen, Acting Administrator: The Federal Aviation Administration’s (FAA) Alaska communications requirements are ranked nationally among other National Airspace System (NAS) requirements competing for Communication Facilities Sustainment funding mentioned in our previous letter. We considered the following in determining the prioritization of the communications requirement need:

1. Congressionally mandated or Office of the Secretary of Transportation directed.

2. Urgent or immediate operational impact (i.e., requirements critical to NAS operations, prevents the accomplishment of an operational requirement that degrades safety).

Requirement Criteria: i. Regional ranking; and ii. Justification is based upon the following NAS operational factors: a. Aircraft near-miss event (safety); b. Delays; c. Facility relocation (lease terminated or terminating during the current fiscal year); d. Business case; and e. Approved unsatisfactory condition report.

3. Significant and non-operational sensitive (i.e., requirements that affect the efficiency and capacity of the NAS). Requirement Criteria: i. Regional ranking; and ii. Sufficient justification based upon NAS efficiency and capacity factors: a. Coverage [en route/terminal/Automated Flight Service Station (AFSS)]; b. Congestion (en route/terminal/AFSS); c. Facility relocation (lease expiration within three years or due to airport expansion); d. Frequency interference; e. Diversity; f. Operations cost reduction/cost benefit; and g. Equipment enhancement.

August 24, 2021 · NTSB Correspondence · FAA

We note that, during the FAA’s Air Traffic Organization’s annual Air-Ground Integrated Requirement Team meeting, service areas (including Alaska) present their top 20 requirements, which are then prioritized and between 8 and 10 (out of 280 nationwide) are funded. We also note that 33 requirements have been submitted that would expand communication coverage in Alaska, 4 of which have been funded, including: installing communication equipment at the Tanana Remote Communications Outlet, Galbraith Lake Remote Communication Air-ground Facility, Talkeetna Remote Communications Outlet, and the Klawock Remote Communication Air-ground Facility.

We are encouraged to learn about your efforts to expand communication coverage in Alaska; however, we would like to know how you determine what equipment would be most effective and how you are prioritizing those areas used by Part 135 operators in Alaska when deciding which requirements to fund. Pending our review of this additional information and completion of the recommended actions, Safety Recommendation A-18-16 is classified OPEN-- ACCEPTABLE RESPONSE.

March 25, 2021 · Recipient Response · FAA

-From Steve Dickson, Administrator: The Federal Aviation Administration’s (FAA) Air Traffic Organization hosts an annual Alaska Communications Requirements meeting during which the FAA’s Alaskan Region has the opportunity to identify new requirements for prioritization. The Alaskan Region requirements are part of over 280 requirements across the National Airspace System competing for Communication Facilities Sustainment (CFS) funding. During the annual Air-Ground Integrated Requirement Team meeting, the service areas (including the Alaska Region) present their top 20 requirements, which are then prioritized nationally.

The CFS program typically funds 8 to 10 out of the over 280 nationwide requirements annually.

There are 33 requirements in Alaska related to expanding communication coverage, four of which have received CFS funding. The FAA is currently installing communication equipment at the Tanana Remote Communications Outlet, Galbraith Lake Remote Communication Air-ground Facility, Talkeetna Remote Communications Outlet, and the Klawock Remote Communication Air-ground Facility.

October 16, 2018 · NTSB Correspondence · FAA

You reported that additional coordination is needed before you can propose a plan of action. Pending our receipt and review of a plan for addressing these recommendations, Safety Recommendations A-18-16 and -17 remain classified OPEN--AWAIT RESPONSE.

July 20, 2018 · Recipient Response · FAA

-From Daniel K. Elwell, Acting Administrator: These recommendations require review, coordination, and the possible action by multiple FAA lines of business. Before we propose any plan of action, we must review these recommendations more carefully and determine which organizations should be involved. Based on this review, we will determine whether action is required and, if so, how best to proceed.

I will keep the Board informed of the FAA’s progress on these safety recommendations and provide an update by July 2019.

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.