NTSB · Safety Recommendation
Safety Recommendation A-21-049
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: Notify principal operations inspectors and frontline managers about the circumstances of this accident and emphasize the importance of existing Federal Aviation Administration guidance for detecting and mitigating the safety risks that can result when certificate holders experience significant organizational change, such as high personnel turnover, a reduction to route structures or flight schedules, bankruptcy, acquisition, and merger.
Safety Issue and Context
This report discusses the October 17, 2019, accident involving a Saab SA-2000 airplane, operated by Peninsula Aviation Services Inc. d.b.a. PenAir flight 3296, which overran the end of runway 13 at Unalaska Airport, Unalaska, Alaska. The airplane was substantially damaged during the runway overrun; as a result, of the 3 crewmembers and 39 passengers aboard, 1 passenger sustained fatal injuries, and 1 passenger sustained serious injuries. Eight passengers sustained minor injuries, most of which occurred during the evacuation.
Safety issues identified in this report include the potential for cross-wiring of airplane antiskid brake systems; insufficient Federal Aviation Administration (FAA) guidance to identify safety risks for air carriers experiencing significant organizational changes, including bankruptcy, acquisition, and merger; lack of FAA consideration of runway safety area dimensions during the process of authorizing an air carrier to operate its aircraft at a specific Title 14 Code of Federal Regulations Part 139 certificated airport, and the benefits of safety management systems for design, manufacturing, and maintenance organizations.
As a result of this investigation, the National Transportation Safety Board makes six new safety recommendations to the FAA, three new safety recommendations to the European Union Aviation Safety Agency, and one new recommendation to the Saab Group.
Response History
July 30, 2026 · NTSB Correspondence · FAA
Aviation Investigation Report AIR-26-05 “In-Flight Loss of Control and Impact with Pack Ice Bering Air Flight 445 Textron Aviation 208B, N321BA, Near Nome, Alaska February 6, 2025” published on July 30, 2026:
2.4.2 Federal Aviation Administration Oversight
Oversight of the Bering Air certificate was performed by a certificate management team of three inspectors out of the Fairbanks FSDO, located about 520 miles from Nome. At the time of the accident, Bering Air had 54 pilots and 40 aircraft (30 airplanes and 10 helicopters), reflecting a period of growth that began in 2020 following the bankruptcy of its primary competitor carrier, Ravn Alaska.
FAA Order 8900.1, Volume 10, “SAS Policy and Procedures,” requires reassessment of a Part 135 certificate holder’s risk profile at least once a year and specifically identifies operational complexity and rapid growth or downsizing as risk factors that could affect a risk profile. The NTSB’s review of SAS data for Bering Air indicated that multiple CHAT assessments were performed between 2022 (when the front-line manager and POI assumed their respective oversight roles for the operator) and 2025, and that none identified operational complexity or rapid growth as risk factors despite both being present.
Every assessment during this period indicated no action was required, and Bering Air’s risk profile remained unchanged. Footnote: During postaccident interviews, the POI framed Bering Air’s growth as “solidification of their existing route structure” rather than expansion and regarded it as “responsible, measured.” The front-line manager for the certificate management team described being aware of the company’s growth as a feature but not necessarily a specific focus.
Bering Air’s president and the director of safety both described the period of growth in the context of the 2020 pandemic and bankruptcy of Ravn Alaska. Becoming the only passenger-carrying operator in the region, the company strove to meet increased demand for cargo service while also accommodating increased passenger demand as travel restrictions eased. These pressures required additional personnel in all departments, new types of aircraft, and new facilities.