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NTSB · Safety Recommendation

Safety Recommendation A-21-015

Recommendation

TO THE FEDERAL AVIATION ADMINISTRATION: Identify high-traffic air tour areas and require, through a special federal aviation regulation or other means, that Title 14 Code of Federal Regulations Parts 91 and 135 air tour operators that operate within those areas be equipped with an Automatic Dependent Surveillance-Broadcast Out- and In-supported (ADS-B) traffic advisory system that 1) includes both visual and aural alerts, 2) is driven by an algorithm designed to minimize nuisance alerts, and 3) is operational during all flight operations.

Safety Issue and Context

On May 13, 2019, about 1221 Alaska daylight time, a float-equipped de Havilland DHC-2 (Beaver) airplane, N952DB, and a float-equipped de Havilland DHC-3 (Otter) airplane, N959PA, collided in midair about 8 miles northeast of Ketchikan, Alaska. The DHC-2 pilot and four passengers sustained fatal injuries. The DHC-3 pilot sustained minor injuries, nine passengers sustained serious injuries, and one passenger sustained fatal injuries. The DHC-2 was destroyed and the DHC-3 sustained substantial damage.

The DHC-2 was registered to and operated by Mountain Air Service LLC, Ketchikan, Alaska, under the provisions of Title 14 Code of Federal Regulations (CFR) Part 135 as an on-demand sightseeing flight. The DHC-3 was registered to Pantechnicon Aviation LTD, Minden, Nevada, and operated by Venture Travel, LLC, dba Taquan Air, Ketchikan, Alaska, under the provisions of Part 135 as an on-demand sightseeing flight. Visual meteorological conditions prevailed in the area at the time of the accident.

According to information provided by the operators, both airplanes had been conducting sightseeing flights and were both converging on a scenic waterfall before returning to the Ketchikan Harbor Seaplane Base (5KE), Ketchikan, Alaska, when the accident occurred. Automatic dependent surveillance-broadcast (ADS-B) tracking data for both airplanes revealed that, at 1217:15, the DHC-3 was about level at 4,000 ft mean sea level (msl) on a track of 225°, and the DHC-2 was 4.2 nautical miles (nm) south of the DHC-3, climbing through 2,800 ft msl, on a track of 255°.1 About 1219, the DHC-3 started a descent from 4,000 ft, and the DHC-2 was at 3,175 ft and climbing.

During the next 1 minute 21 seconds, the DHC-3 continued to descend on a track between 224° and 237°, and the DHC-2 leveled out at 3,350 ft on a track of about 255°. The airplanes collided at 1221:14 at an altitude of 3,350 ft, 7.4 nm northeast of 5KE.

Response History

February 17, 2026 · NTSB Correspondence · FAA

From the Aviation Investigation Report AIR-26-02, “Midair Collision over the Potomac River PSA Airlines Flight 5342, Mitsubishi Heavy Industries (MHI) RJ Aviation CL-600-2C10 (CRJ700), and US Army Priority Air Transport Flight 25, Sikorsky UH-60L Washington, DC January 29, 2025”

1.15.3 ADS-B The NTSB also has a long history of supporting the use of technologies, such as ADS-B, that provide identification and location information for aircraft due to the ability of these technologies to improve safety. Between 2006 and 2007, we recommended requirements for equipment that could provide increased aircraft identification, location, and communication capabilities for aircraft operations in the Gulf of America and remote areas of Hawaii and Alaska, with the intent of enhancing flight location, collision avoidance, and weather information services for these operations (see Safety Recommendations A-06-21 and -22, and A-07-025 and -26; NTSB, 2006; NTSB, 2007a).

Following the 2006 midair collision involving a business jet and a transport category airplane over Brazil that claimed 154 lives, we recommended requirements for equipment that could provide pilots with enhanced alerts regarding the status of transponder and traffic collision avoidance capabilities (Safety Recommendations A 07-35 through -37; NTSB, 2007b).

Following the 2007 fatal midair collision of two news-gathering helicopters over Phoenix, Arizona, the NTSB sought to enhance the traffic-avoidance logic for helicopters’ onboard equipment by recommending the development of standards and requirements for the incorporation of specific criteria for the types of maneuvers and environments unique to helicopters (Safety Recommendations A 09 4 and -5, superseded by Safety Recommendations A 10 127 and -128; NTSB 2009; NTSB, 2010).

In an October 2007 notice of proposed rulemaking to require ADS B Out, the FAA stated that it did not plan to also require ADS-B In capability because ADS-B In “has not been identified as a requirement for maintaining the safety and efficiency of NAS operations.” In a letter dated February 14, 2008, in response to this notice of proposed rulemaking, the NTSB expressed our belief that this assessment was incorrect and stated that equipping aircraft with ADS-B In capability would

Read Recommendation

Recommendation Facts

Status
Open - Unacceptable Response
Issued
May 13, 2021
Priority
CLASS II
Recipient
FAA
Adopted
April 20, 2021
Related Investigation
CEN19MA141AB
Related Report
AAR-21-04
“provide an immediate and substantial contribution to safety,”
especially near airports.

The NTSB further stated in our response to the FAA’s proposed rule that “the FAA's failure to expedite the adoption of full ADS-B capability (both ADS-B In and ADS-B Out) would be unfortunate and would result in missing or unnecessarily delaying an opportunity to remedy a serious and notorious safety issue” (NTSB, 2008).

The FAA Modernization and Reform Act of 2012 required the FAA to identify the type of avionics required for all classes of airspace. It also specifically required the FAA to initiate rulemaking to require aircraft operating in capacity-constrained airspace, at capacity-constrained airports, or in “any other airspace deemed appropriate by the administrator” be equipped with ADS-B In technology by 2020. An aviation rulemaking committee chartered in April 2012 recommended that the FAA focus on the development of key ADS-B In applications, including airborne traffic awareness systems, that would provide benefits to operators.

In 2014, the FAA developed a rulemaking action plan to issue a notice of proposed rulemaking by 2018 and a final rule in 2022.

In 2014, an RTCA committee chartered by the FAA completed the development of standards for ADS-B-supported aircraft surveillance applications, DO-317B (RTCA, 2014). However, the FAA Reauthorization Act of 2018 repealed the requirement that the FAA initiate rulemaking to require ADS-B In technology and instead directed the FAA to ensure that any regulations resulting from that rulemaking had no effect. Because the FAA had not yet issued any regulations, no action was required to change any regulations.

In May 2021, the NTSB issued several safety recommendations (A-21-15 through -17) regarding ADS B following the investigation into a midair collision between two air tour airplanes in Ketchikan, Alaska, in 2019 (NTSB, 2021a). Safety Recommendation A 21-15 asked the FAA to identify areas with a high concentration of air tour traffic and to require that 14 CFR Parts 91 and 135 air tour operators who operate within those areas be equipped with an ADS-B Out- and In-supported traffic advisory system that includes visual and aural alerts.

Safety Recommendation A-21-16 asked that the FAA require that all non-air tour aircraft operating within the airspace identified as a high traffic tour area in Safety Recommendation A-21-15 be equipped with ADS-B Out. Safety Recommendation A-21-17 asked that the FAA require the installation of ADS-B Out and In supported airborne traffic advisory systems that include aural alerting functions in all aircraft conducting operations under 14 CFR Part 135.

In a July 2021 response, the FAA requested a meeting with NTSB staff to further clarify the intent of the recommendations. However, as noted in NTSB correspondence dated February 4, 2022, when the NTSB attempted to schedule this meeting, FAA staff stated that a meeting was no longer necessary. In May 2022, the NTSB reiterated Safety Recommendation A-21-15 in our report on the fatal helicopter air tour accident that occurred in Kekaha, Hawaii, in December 2019 (NTSB, 2022).

In correspondence dated June 26, 2023, the FAA stated that its Air Traffic and Aviation Safety Organizations met to discuss the NTSB recommendations and determined that the agency’s current ADS-B requirements adequately addressed the needs of aviation safety and it would not pursue additional requirements. The FAA stated that its current guidance and requirements were sufficient to meet the intent of the recommendations. In addition, the FAA stated that the previously requested meeting with NTSB staff was no longer needed.

In an October 24, 2023, follow-up letter regarding Safety Recommendation A 21-17, the NTSB emphasized that the absence of an ADS-B In requirement for Part 135 passenger-carrying operations fails to take advantage of the demonstrated safety benefit of ADS-B In traffic awareness and alerting and is inconsistent with the “appropriate level of public safety” the FAA itself expects for operations in which passengers bear no responsibility for the aircraft’s operation (NTSB, 2023).

In its most recent response to Recommendation A-21-15, on November 6, 2024, the FAA repeated that current ADS-B requirements continue to adequately address the needs of aviation safety and that it would not pursue additional ADS B operator requirements at this time (FAA, 2024f). During the investigative hearing for the DCA midair collision, however, the FAA ATO’s acting deputy COO stated that the agency supported requiring newly manufactured aircraft in the United States be equipped with ADS-B In. He also stated that the agency supported requiring the installation and operation of ADS-B In for aircraft operating in airspace where they are required to transmit ADS B Out.

February 9, 2026 · NTSB Correspondence · FAA

As discussed in our previous meeting, we are currently reviewing several FAA letters submitted during the previous administration and would like to confirm that those letters still reflect the FAA position.

We issued Safety Recommendations A-21-15 through -19 as a result of our investigation of the 2019 midair collision in Ketchikan Alaska.

A-21-15: Identify high-traffic air tour areas and require, through a special federal aviation regulation or other means, that Title 14 Code of Federal Regulations Parts 91 and 135 air tour operators that operate within those areas be equipped with an Automatic Dependent Surveillance-Broadcast Out- and In-supported traffic advisory system that 1) includes both visual and aural alerts, 2) is driven by an algorithm designed to minimize nuisance alerts, and 3) is operational during all flight operations.

A-21-16: In the high-traffic air tour areas identified in Safety Recommendation A-21-15, require that all non–air tour aircraft operating within the airspace be equipped with Automatic Dependent Surveillance-Broadcast Out.

A-21-17: Require the installation of Automatic Dependent Surveillance-Broadcast Out- and In-supported airborne traffic advisory systems that include aural and visual alerting functions in all aircraft conducting operations under Title 14 Code of Federal Regulations Part 135.

A-21-18: Review current and future supplemental type certificate installation instructions and flight manual supplements to ensure they provide provisions to prevent the inadvertent disabling of the broadcast of pressure altitude data, by design, where practicable.

In his November 6, 2024, letter, former Administrator Whitaker told us that the FAA actions on these recommendations were compete.

A-21-19: Ensure that checklists for all Capstone Program (phase 2) aircraft include verification that the Garmin GSL 71 control head selector knob is in the ON position and that the unit is in ALT mode before takeoff.

In his April 25, 2025, letter, former Acting Administrator Rocheleau told us that the FAA actions on these recommendations were compete.

Can you confirm whether FAA’s position on these recommendations has changed?

November 6, 2024 · Recipient Response · FAA

-Michael G. Whitaker, Administrator: As previously stated, the Federal Aviation Administration’s (FAA) Air Traffic and Aviation Safety Organizations met to discuss these recommendations and reviewed all guidance and requirements associated with 14 CFR Parts 91 and 135 air tours and Automatic Dependent Surveillance-Broadcast (ADS-B) Out and In. Based on that discussion, it was determined that our current ADS-B requirements continue to adequately address the needs of aviation safety. The FAA will not pursue additional ADS-B operator requirements at this time.

The FAA published the Safety Management Systems (SMS) Final Rule on April 26, 2024 (89 FR 33068). This rule extends the requirement for an SMS in Part 5 to all Part 135 certificate holders operating under the rules for commuter and on-demand operations, commercial air tour operators, production certificate holders that are holders or licensees of a type certificate for the same product, and holders of a type certificate that license out that type certificate for production. The publishing of this SMS rule also fulfills a Congressional mandate as well as recommendations from the National Transportation Safety Board and two aviation rulemaking committees.

Additionally, the SMS rule more closely aligns the United States with Annex 19 to the Convention on International Civil Aviation. Finally, the SMS rule will improve aviation safety by requiring certificate holder organizations to implement a proactive approach to managing their air transportation safety.

October 24, 2023 · NTSB Correspondence · FAA

We note that you do not intend to take the recommended actions because you believe these recommendations are sufficiently addressed by existing guidance and requirements.

We have reviewed Orders 1800.56W and 8900.1, which contain guidance for inspectors on conducting surveillance, as well as Parts 91.225 and 91.227, which pertain to ADS-B Out equipment and its use. We have also reviewed the safety management system (SMS) notice of proposed rulemaking (NPRM), which was published earlier this year and proposed requiring Part 135 operators and Part 91.147 air tour operators to implement an SMS. However, we did not find anything in these documents that addresses the specific concerns discussed in these recommendations.

We issued these recommendations because we believe technology that supplements pilots’ traffic scans by providing aural and visual alerts can mitigate the risk of midair collisions. Although ADS-B-supported airborne traffic advisory systems can mitigate the risk of midair collision accidents, ADS-B Out is only required in certain airspace and there is no requirement for ADS-B In, which can provide pilots awareness of nearby traffic by displaying targets on the cockpit display of traffic information (CDTI). We remain concerned that, due to the high concentration of traffic in popular air tour areas, the risk of a collision is higher than in the general national airspace.

Therefore, we continue to believe that you should identify high-traffic air tour areas and require Parts 91 and 135 air tour operators that operate within those areas to install an ADS-B Out- and In-supported airborne traffic advisory system. Pending our review of a plan to address these concerns and completion of the recommended actions, Safety Recommendation A-21-15 is classified OPEN-- UNACCEPTABLE RESPONSE.

Because some of the high-traffic air tour areas identified in response to Safety Recommendation A-21-15 may involve operations conducted below radar coverage or outside the range of an ADS-B ground station, we are concerned that air tour aircraft equipped with ADS-B traffic advisory systems may not receive alerts for aircraft that are not equipped with ADS-B Out and are operating within the air tour areas. Therefore, we continue to believe that all aircraft operating within high-traffic air tour areas should be equipped with ADS-B Out. Pending this action, Safety Recommendation A-21-16 is classified Open—Unacceptable Response.

The lack of a requirement for ADS-B In-based traffic awareness displays for all aircraft conducting Part 135 operations fails to take advantage of the demonstrated benefit of this technology in mitigating the midair collision hazard. In the FAA’s NPRM for fractional aircraft ownership, the FAA stated that aircraft owners flying aboard aircraft that they own or lease “exercise full control over and bear full responsibility for the airworthiness and operation of their aircraft.”

In contrast, the FAA stated that passengers who are transported under Parts 121 and 135 “exercise no control over and bear no responsibility for the airworthiness or operation of the aircraft aboard which they are flown.” The FAA concluded that the “appropriate level of public safety is provided by . . . very stringent regulations and oversight under Part 121 and Part 135.” We point out that aircraft without ADS-B do not demonstrate the “appropriate level of safety” for passenger-carrying operations conducted under Part 135 regulations.

Therefore, we continue to believe that all aircraft operating under Part 135 should be equipped with ADS-B Out- and In-supported airborne traffic advisory systems. Pending this action, Safety Recommendation A-21-17 remains classified Open—Unacceptable Response.

September 6, 2023 · NTSB Correspondence · FAA

On August 4, 2023, the Federal Aviation Administration (FAA) announced the publication of draft Advisory Circular (AC) 136-B048, Supplemental Information for the Creation of Operating Procedures and Pilot Training Subjects Related to OpSpec [operations specification]/LOA [letter of authorization] B048, and invited public comment on the document. The NTSB has a longstanding interest in air tour safety in the state of Hawaii, having investigated numerous Hawaii air tour accidents and issued many related safety recommendations and we offer our comments below.

We note that, based on the contents of the draft AC, it appears that the FAA’s intent is that it will replace FAA document AWP13-136, the Hawaii Air Tour Common Procedures Manual (HATCPM), which the FAA issued in 2008 for use by operators that obtained authorization (through OpSpec B048 or LOA B548) to deviate from the minimum altitude specified in 14 Code of Federal Regulations (CFR) Part 136, Appendix A. For those operators that obtained authorization through OpSpec B048/LOA B548, compliance with the provisions of the HATCPM was mandatory.

In our 2022 report on our investigation of the December 26, 2019, fatal air tour helicopter accident in Kekaha, Hawaii, we noted that the HATCPM had not been revised since it was issued and that the FAA informed us that it had been working on a replacement for about 7 years.

During our investigation, an air tour subject matter expert from the FAA’s Air Transportation Division, [14 CFR] Part 135 Air Carrier Operations Branch, informed us that the FAA’s vision for the new document was for it to be up to date; incorporate NTSB safety recommendations, congressional input, and National Park Service input; and be simpler, safer, and easier to manage. They also said that the document would likely address the use of Hawaii weather camera systems and operator implementation of safety management systems (SMSs).

We have examined the draft AC and are providing comments related to these issues and open NTSB recommendations related to air tour safety in Hawaii. We note that, although ACs, generally, are not regulatory documents, we presume that operators that obtain authorization through OpSpec/LOA B048 will be required to comply with the AC’s provisions (similar to the mandatory compliance with the HATCPM for those operators that held deviation authority).

Automatic Dependent Surveillance-Broadcast Equipment Applications

During our investigation of a 2019 fatal midair collision involving two air tour airplanes in Ketchikan, Alaska, we observed that high-traffic air tour areas have a higher midair collision risk than the general National Airspace System.3 As a result, in 2021, we issued Safety Recommendation A-21-15, which urged the FAA to do the following:

Identify high-traffic air tour areas and require, through a special federal aviation regulation (SFAR) or other means, that 14 CFR Parts 91 and 135 air tour operators that operate within those areas be equipped with an automatic dependent surveillance-broadcast (ADS-B) Out- and In-supported traffic advisory system that 1) includes both visual and aural alerts, 2) is driven by an algorithm designed to minimize nuisance alerts, and 3) is operational during all flight operations.

Due to the presence of similar risks in high-traffic air tour areas in Hawaii, as well as the usefulness of ADS-B broadcast data for monitoring air tour flights and potentially detecting deviations from safe operating practices (discussed further below), we reiterated Safety Recommendation A-21-15 in our 2022 report on the Kekaha accident. However, the FAA recently informed us that it determined that current ADS-B requirements adequately address the needs of aviation safety and that it did not plan to pursue any additional ADS-B requirements at this time.

In 2022, we issued Safety Recommendation A-22-13 (also from our report on the Kekaha accident), which urged the FAA to require, as an interim measure until the completion of action to satisfy Safety Recommendation A-21-15, that Hawaii air tour operators install ADS-B Out equipment in their aircraft to enable real-time flight position tracking. In August 2022, the FAA informed us that it was revising OpSpec B048/LOA B548 and that it was continuing to evaluate requirements for the use of ADS-B Out equipment in air tour operators’ aircraft as a requirement to obtain the revised OpSpec B048/LOA B548.

Pending review of the revised OpSpec and LOA and completion of the recommended action, Safety Recommendation A-22-13 is classified Open—Acceptable Response.

We note that, although the draft AC recommends that Hawaii air tour operators install ADS-B equipment with In and Out capability and inform the FAA about its use, the AC does not state that such equipment will be required. Therefore, after the AC is issued, the FAA will still need to complete the revisions to OpSpec B048/LOA B548 to satisfy Safety Recommendation A-22-13.

June 26, 2023 · Recipient Response · FAA

-From Polly Trottenberg, Acting Administrator: The Federal Aviation Administration’s (FAA) Air Traffic and Aviation Safety Organizations met to discuss these recommendations and review all guidance and requirements associated with 14 CFR Parts 91 and 135 air tours and Automatic Dependent Surveillance- Broadcast (ADS-B) Out and In. We determined that our current ADS-B requirements adequately address the needs of aviation safety and will not pursue any additional ADS-B requirements at this time. Our previous request to meet with National Transportation Safety Board staff is no longer needed.

The FAA also believes that current guidance and requirements are sufficient to meet the intent of these safety recommendations. Collectively, the following guidance and requirements provide a systematic approach to ensuring safe flight and operation:

• FAA Order 1800.56W, National Flight Standards Work Program Guidelines; • § 91.225, Automatic Dependent Surveillance-Broadcast (ADS-B) Out Equipment and Use; • § 91.227, Automatic Dependent Surveillance-Broadcast (ADS-B) Out Equipment Performance Requirements; and • FAA Order 8900.1, Flight Standards Information Management System, with revision to five relevant sections currently in FAA internal review.

In addition, the FAA published the Safety Management Systems (SMS) Notice of Proposed Rulemaking on January 11, 2023 (88 FR 1932). The FAA is proposing to update and expand the requirements for SMS and require certain certificate holders and commercial air tour operators to develop and implement an SMS.

May 26, 2022 · NTSB Correspondence · FAA

From Aviation Investigation Report AIR-22-05 “Collision into Terrain Safari Aviation Inc. Airbus AS350 B2, N985SA Kekaha, Hawaii, December 26, 2019” published on May 26, 2022: 2.4.2.2 Improved ADS-B-Supported Service Capabilities

At the time of the accident, Safari did not have ADS-B equipment on any of its helicopters but has since installed ADS-B Out and In equipment on its fleet, primarily to enable real-time tracking of its tour flights. However, due to signal obstruction by the high terrain in the center of Kauai, Safari and other operators with ADS-B Out-equipped fleets still cannot continuously track the location of their low-flying tours. For example, ADS-B coverage remains unavailable for low-flying aircraft west and north of Waimea Canyon.

Although different types of flight-tracking equipment exist, the NTSB has long recommended the use of ADS-B Out technology because of the variety of safety benefits it can provide and its compatibility with other technologies used elsewhere in the National Airspace System. For example, the aircraft position (and velocity) data broadcast by ADS-B Out-equipped aircraft are used by ATC facilities in providing traffic separation services.

In addition, ADS-B In-equipped aircraft receive that data and, depending on the type of avionics installed, process it to provide pilots with traffic position information, traffic advisories, and other safety services (such as weather and aeronautical information advisories) without any subscription or usage fees.

In 2007, as a result of our investigation of another fatal air tour helicopter accident on Kauai, we recommended that the FAA accelerate the implementation of ADS-B infrastructure in Hawaii to include high-quality ADS-B services to low-flying aircraft on tour routes and require Hawaii air tour operators to equip their aircraft with compatible ADS-B technology within 1 year of the installation of a functional infrastructure (NTSB 2007).

On March 18, 2014, the FAA provided us with information on its progress and acknowledged that “investments in expanding the ground infrastructure would not yield any safety improvements unless the tour operators have the appropriate avionics” (FAA 2014). On October 14, 2015, the FAA informed us that it had completed installation of ADS-B infrastructure in some areas of Hawaii and was continuing to integrate ADS-B services.

The FAA noted that ADS-B pilot advisory services (which provide increased situation awareness and safety benefits to ADS-B In-equipped aircraft within a covered airspace) had been available since September 2014 within a large percentage of Hawaii’s surrounding airspace and that initial operating capability for ATC separation services had begun on August 18, 2015.

However, the NTSB notes that the covered airspace for ADS-B services in Hawaii benefits primarily aircraft flying at higher altitudes rather than the typical air tour. Further, the FAA informed us that it had decided not to require Hawaii air tour operators to install any ADS-B equipment on their aircraft.54 FAA said that it had sought a memorandum of agreement with the operators to achieve their voluntary commitment to the installations but that the operators “have not shown interest in equipping with ADS-B” (FAA 2014).

In our April 14, 2014, response to the FAA, we expressed concern that the FAA, rather than taking the recommended measures to extend the safety benefits of ADS-B-supported services to Hawaii air tour operators, instead decided to reduce the ADS-B ground infrastructure. During our investigation of a 2019 fatal midair collision involving two air tour airplanes in Ketchikan, Alaska, we observed that high-traffic air tour areas have a higher midair collision risk than the general National Airspace System and that the safety of air tour flights in such areas could be enhanced through the use of an ADS-B Out- and In-supported traffic advisory system (NTSB 2021b).

As a result, on May 13, 2021, we recommended that the FAA do the following: Identify high-traffic air tour areas and require, through a special federal aviation regulation or other means, that Title 14 Code of Federal Regulations Parts 91 and 135 air tour operators that operate within those areas be equipped with an Automatic Dependent Surveillance-Broadcast Out- and In-supported traffic advisory system that 1) includes both visual and aural alerts, 2) is driven by an algorithm designed to minimize nuisance alerts, and 3) is operational during all flight operations. (A-21-15)

We note that the circumstances of this accident highlight the potential risk for midair collisions in air tour areas on Kauai, particularly as the adverse weather conditions affected part of the tour route, resulting in a disruption in the standard flow of tour traffic. For example, the Company 3 pilot (who was flying a tour in an airplane) diverted his tour to the east side of the island after hearing radio reports from other tour pilots describing adverse weather on the Napali Coast.

The Company 3 pilot initially reversed course and followed the standard route in the opposite (counterclockwise) direction but soon became uncomfortable because the volume of traffic that was diverting from the Napali Coast was converging in the area where he was flying. He decided to end his tour and return to LIH.

We continue to believe that ADS-B-supported services, including flight tracking for operators and traffic advisories for pilots, are critical for the safety of low-flying air tour operations in Hawaii. However, as described previously, without ADS-B infrastructure that can adequately enable ADS-B-supported services, operators of appropriately equipped aircraft will not receive the full safety benefits such services can provide.

Thus, the NTSB concludes that the ADS-B infrastructure in Hawaii is insufficient to adequately enable ADS-B Out- and In-supported services, such as real-time flight position tracking and onboard traffic advisories, that are essential for the safety of low-flying air tour aircraft throughout their entire tour routes. Therefore, the NTSB recommends that the FAA implement ADS-B infrastructure improvements in Hawaii, such as additional ADS-B ground stations, that provide adequate coverage to enable real-time flight tracking and traffic advisory services for ADS-B Out- and In-equipped, low-flying air tour aircraft throughout their entire tour routes.

In addition, because of the safety benefits that an ADS-B Out- and In-supported traffic advisory system optimized for use in high-traffic air tour areas can provide for operations in Hawaii, the NTSB reiterates Safety Recommendation A-21-15.

Further, the recorded ADS-B flight-tracking data generated by ADS-B Out-equipped tour aircraft can be used an essential part of a systemic approach to preventing Hawaii air tour accidents involving continued flight under VFR into IMC. Such an approach includes providing not only the flight tracking functions needed to enable real-time support for pilots from ground personnel but also the data that can be used to support operational safety assurance functions, such as part of an operator’s SMS or FDM program. (See section 2.5.3 for more information about SMS and FDM programs and section 2.5.4 for more information about how ADS-B data can support safety assurance reviews.)

Although the traffic advisory system equipment we recommended in Safety Recommendation A-21-15 would inherently provide the real-time flight position data that air tour operators in Hawaii could use for flight tracking and safety assurance functions, it may take some time before such systems are developed and required. We note that relatively inexpensive ADS-B Out equipment that can transmit such data is already widely available. Therefore, the NTSB recommends that the FAA, as an interim measure until completion of the action to satisfy Safety Recommendation A-21-15, require Hawaii air tour ope

February 4, 2022 · NTSB Correspondence · FAA

You reported that, before committing to taking the actions described in these recommendations, your staff wanted to meet to discuss the intent of these recommendations. When we reached out to schedule a meeting, your staff informed us that a meeting was no longer necessary. Because you have not committed to taking the recommended actions and you have not informed us of the specific activities that you are taking to review these recommendations, we do not have enough information to determine if your actions are responsive.

Therefore, pending our receipt of this additional information and completion of the recommended actions, Safety Recommendations A-21-15 and -16 remain classified OPEN-- AWAIT RESPONSE.

July 21, 2021 · Recipient Response · FAA

-From Steve Dickson, Administrator: The Federal Aviation Administration’s (FAA) Air Traffic Organization and Aviation Safety Organization met to discuss these recommendations, and determined that prior to the FAA committing to the requested set of actions, a meeting with NTSB staff is needed to further clarify the intent of the recommendations. The FAA is currently in the process of setting up this meeting.

May 13, 2021 · NTSB Correspondence · FAA

The attached letter from the NTSB Chairman provides information about the NTSB’s April 20, 2021, report Midair Collision over George Inlet, de Havilland DHC-2, N952DB, and de Havilland DHC-3, N959PA, Ketchikan, Alaska, May 13, 2019, NTSB/AAR-21-04. 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.

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 of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (for example, A-21-15 thru -20 and A-16-36 ). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply exceeds 20 megabytes, including attachments, please e mail us at the same address for instructions on how to send larger documents.

Please do not submit both an electronic copy and a hard copy of the same response.

This letter provides information about the National Transportation Safety Board’s (NTSB) April 20, 2021, report Midair Collision over George Inlet, de Havilland DHC-2, N952DB, and de Havilland DHC-3, N959PA, Ketchikan, Alaska, May 13, 2019, AAR-21-04. 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.

As a result of this investigation, we identified the following safety issues:

• The inherent limitations of the see-and-avoid collision avoidance concept. • The benefit of Automatic Dependent Surveillance-Broadcast (ADS-B) Out- and In supported traffic advisory systems in high-traffic tour areas. • The lack of an ADS-B In requirement for Title 14 Code of Federal Regulations Part 135 operations. • The lack of cockpit display of traffic information alerting on both aircraft. • The loss of alerting capabilities with ADS-B systems installed as part of the Federal Aviation Administration’s (FAA) post-Capstone upgrade program. • An inadequate checklist used in Taquan Air’s operation. • Lack of a requirement for safety management systems in Part 135 operations.

Accordingly, the NTSB makes the following safety recommendations to the FAA. Additional information regarding these recommendations can be found in the noted sections of the report.

• Identify high-traffic air tour areas and require, through a special federal aviation regulation or other means, that Title 14 Code of Federal Regulations Parts 91 and 135 air tour operators that operate within those areas be equipped with an Automatic Dependent Surveillance-Broadcast Out- and In-supported traffic advisory system that 1) includes both visual and aural alerts, 2) is driven by an algorithm designed to minimize nuisance alerts, and 3) is operational during all flight operations. (A-21-15) (See section 2.4)

• In the high-traffic air tour areas identified in Safety Recommendation A-21-015, require that all non–air tour aircraft operating within the airspace be equipped with Automatic Dependent Surveillance-Broadcast Out. (A-21-16) (See section 2.4)

• Require the installation of Automatic Dependent Surveillance-Broadcast Out- and In supported airborne traffic advisory systems that include aural and visual alerting functions in all aircraft conducting operations under Title 14 Code of Federal Regulations Part 135. (A-21-17) (See section 2.5)

• Review current and future supplemental type certificate installation instructions and flight manual supplements to ensure they provide provisions to prevent the inadvertent disabling of the broadcast of pressure altitude data, by design, where practicable. (A-21-18) (See section 2.6.2)

• Ensure that checklists for all Capstone Program (phase 2) aircraft include verification that the Garmin GSL 71 control head selector knob is in the ON position and that the unit is in ALT mode before takeoff. (A-21-19) (See section 2.7)

• Update the Aeronautical Information Manual and the Pilot’s Handbook of Aeronautical Knowledge to include the limitations inherent in visual scans for traffic and the benefits and best practices of using cockpit displays of traffic information to supplement visual scans to help overcome these limitations. (A-21-20) (See section 2.8)

In addition, the NTSB reiterates the following recommendations to the FAA:

• Require all 14 Code of Federal Regulations Part 135 operators to establish safety management system programs. (A-16-36) (See section 2.9)

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 of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (Safety Recommendations, A-21-15 through -20). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply, including attachments, exceeds 20 megabytes, please e mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response.