NTSB · Safety Recommendation
Safety Recommendation A-21-020
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: 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.
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
July 11, 2024 · NTSB Correspondence · FAA
You previously informed us that you had published revisions to the AIM that included, in Section 4-4-15, “Use of Visual Clearing Procedures and Scanning Techniques,” benefits and best practices of using CDTI to supplement visual scans. We note that, in July 2023, you published revisions to the PHAK that include, in Chapter 14, “Airport Operations, Collision Avoidance,” similar information to what is in the AIM.
We believe the information that you have included in the AIM and PHAK is responsive to this recommendation. Consequently, Safety Recommendation A-21-20 is classified CLOSED--ACCEPTABLE ACTION.
October 24, 2023 · NTSB Correspondence · FAA
We note that, in November 2022, you published revisions to the AIM that include, in Section 4-4-15, “Use of Visual Clearing Procedures and Scanning Techniques,” benefits and best practices of using CDTI to supplement visual scans. We also note that you intend to make similar revisions to the PHAK during the next revision cycle.
We believe the information that has been included in the AIM is responsive to this recommendation. Pending similar revisions to the PHAK, Safety Recommendation A-21-20 is classified OPEN-- ACCEPTABLE RESPONSE.
September 26, 2023 · Recipient Response · FAA
-From Kathryn B. Thomson, Deputy Administrator: The Federal Aviation Administration (FAA) updated the Pilot’s Handbook of Aeronautical Knowledge (PHAK) on July 10, 2023. The updated PHAK incorporates changes addressing the above safety recommendations, which include:
• A-14-109 – Chapter 8, Flight Instruments, Attitude Indicator, Page 8-19 • A-20-12 – Chapter 17, Aeromedical Factors, Drugs, Page 17-17 • A-21-20 – Chapter 14, Airport Operations, Collision Avoidance, Pages 14-28 through 14-30