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.