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NTSB · Safety Recommendation

Safety Recommendation A-21-021

Recommendation

TO FOREFLIGHT: Update your traffic alerting algorithms so that traffic targets for which there is no altitude information are assumed to be at the same altitude as the ownship (that is, the aircraft receiving the target data).

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

December 13, 2024 · NTSB Correspondence · ForeFlight

We note that you have updated ForeFlight’s traffic alerting logic so that traffic targets with missing altitude information are assumed to be at the same altitude as the aircraft receiving the target data, and that an alert indicates that the target’s altitude is unknown. We also note that you have updated your Pilot’s Guide to include this information.

We believe these actions satisfy the intent of Safety Recommendation A-21-21, which is classified CLOSED-- ACCEPTABLE ACTION.

Thank you for your efforts to improve aviation safety.

November 1, 2024 · Recipient Response · ForeFlight

-From Kevin Sutterfield, Chief Revenue Officer, ForeFlight: I am pleased to report that we did take action back in 2021 regarding the NTSB safety recommendation we received (but we likely failed to update you on our progress). I’m including details below and have attached a screenshot for your visualization. Thank you again for your time and for the productive dialogue on the future of aviation safety. We look forward to our ongoing collaboration in pursuit of safer skies.

In 2021, the ForeFlight Mobile application was updated to: (1) display traffic targets not reporting altitude on the map (even with the "Hide Distant Traffic" setting enabled), and (2) produce visual and aural alerts for traffic targets with missing altitude, as depicted in the attached screenshot. As recommended by the NTSB, the updated alerting logic assumes traffic targets with missing altitude information are at the same altitude and the alert indicates that the target's altitude is unknown.

May 21, 2021 · NTSB Correspondence · ForeFlight

The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters.

Read Recommendation

Recommendation Facts

Status
Closed - Acceptable Action
Issued
May 13, 2021
Priority
CLASS II
Recipient
ForeFlight
Adopted
April 20, 2021
Closed
December 13, 2024
Related Investigation
CEN19MA141AB
Related Report
AAR-21-04

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 recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary.

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 recommendation by number (for example, A-21-21). 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.

All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov.

The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters.

We are providing the following information to urge ForeFlight to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary.

This letter also includes information about our 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. 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 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 recommendation to ForeFlight. Additional information regarding this recommendation can be found in the noted section of the report.

• Update your traffic alerting algorithms so that traffic targets for which there is no altitude information are assumed to be at the same altitude as the ownship (that is, the aircraft receiving the target data). (A-21-21) (See section 2.6.1.)

The NTSB is vitally interested in this recommendation because it is 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 this recommendation. When replying, please refer to the safety recommendations by number (Safety Recommendation A 21 21). 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 on how to send larger documents. Please do not submit both an electronic copy and a hard copy of the same response.

All communications regarding safety recommendations are stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. In the likely event that your company uses auto generated and/or preformatted confidentiality statements on letterhead or outgoing e-mails, please include a statement in your letter indicating that the information can be publicly released. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov.