TO THE FEDERAL AVIATION ADMINISTRATION: In collaboration with the local National Weather Service, develop and issue a special federal aviation regulation for air tour airplane flights in the Ketchikan area that imposes weather minimums that are more conservative than those specified in Title 14 Code of Federal Regulations Part 135 and requires the operational elements of the Ketchikan operators’ voluntary letter of agreement such as standard tour routes, alternate routes for poor weather days, and reporting adverse weather conditions. (Supersedes Safety Recommendation A 17-43)
Safety Issue and Context
The National Transportation Safety Board (NTSB) is providing the following information to urge the Federal Aviation Administration (FAA) and the National Weather Service to take action on the safety recommendations in this report. These recommendations are derived from findings from the investigation of an August 2021 air tour airplane accident in Ketchikan, Alaska, as well as from our review of previous investigations of Title 14 Code of Federal Regulations (CFR) Part 135 air tour airplane accidents near Ketchikan since 2007.
As discussed in this report, despite the FAA’s efforts since 2008 to encourage operators to voluntarily adopt processes and procedures to improve the safety of air tour airplane flights in the Ketchikan area, these operations continue to be vulnerable to the hazards unique to the area’s terrain and weather conditions. The NTSB is issuing three new safety recommendations, two of which supersede previously issued safety recommendations.
Response History
August 15, 2023 · NTSB Correspondence · FAA
We note that you are meeting with various offices within the FAA to discuss and develop a plan to address both recommendations. In addition, on February 7, 2023, NWS staff informed my staff of plans to meet with FAA staff to discuss Safety Recommendations A-22-25 and -27. Pending our receipt and review of a detailed plan for completing the recommended actions, Safety Recommendations A-22-25 and -26 are classified OPEN-- ACCEPTABLE RESPONSE.
January 19, 2023 · Recipient Response · FAA
-From Billy Nolen, Acting Administrator: The Federal Aviation Administration (FAA) is currently meeting internally among various FAA organizations to discuss and develop a plan to address these recommendations. Additional information will be provided once this process is complete.
I will keep the Board informed of our progress on Safety Recommendations A-22-25 and -26 and anticipate providing an update by February 29, 2024.
November 29, 2022 · NTSB Correspondence · FAA
This letter provides information about the National Transportation Safety Board’s (NTSB) November 16, 2022, report Implement Special Federal Aviation Regulation for Air Tours near Ketchikan, Alaska, AIR-22-09. The details of relevant accident investigations 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 Federal Aviation Administration’s (FAA’s) current weather minimums for Title 14 Code of Federal Regulations Part 135
airplane operations and lack of required operational safety requirements for Ketchikan air tours allow pilots to regularly fly in frequently unsafe weather conditions in a geographical area with distinct operational hazards.
• The FAA has not sufficiently addressed the continued need for improved pilot training on reducing the risk of weather-related accidents for Ketchikan air tours.
Accordingly, the NTSB makes the following safety recommendations to the FAA:
• In collaboration with the local National Weather Service, develop and issue a special federal aviation regulation for air tour airplane flights in the Ketchikan area that imposes weather minimums that are more conservative than those specified in Title 14 Code of Federal Regulations Part 135 and requires the operational elements of the Ketchikan operators’ voluntary letter of agreement such as standard tour routes, alternate routes for poor weather days, and reporting adverse weather conditions. (A-22-25) (Supersedes Safety Recommendation A 17-43 and is classified “Open—Unacceptable Response”)
• Develop and require training for all Ketchikan air tour airplane pilots aimed at reducing the risk of weather-related accidents involving continuation of flight under visual flight rules into instrument meteorological conditions. The training should include (1) objective standards, such as landmarks that must be clearly visible from particular locations that pilots can use to determine whether weather conditions are safe for continued flight on a particular route; and (2) a module that helps pilots recognize dynamic local weather patterns that can place them in a dangerous situation. (A-22-26) (Supersedes Safety Recommendation A-17-37 and is classified “Open—Unacceptable Response”)
In the same report, we also classified the following two previously issued safety recommendations:
• Work with members of the Ketchikan air tour industry to improve existing training programs aimed at reducing the risk of weather-related accidents involving continuation of flight under visual flight rules into instrument meteorological conditions, with special attention paid to the human factors issues identified in this investigation, including (1) the need to help pilots better calibrate what constitutes safe weather conditions to conduct flights based on objective standards and requirements, such as set criteria for what landmarks must be clearly visible from which locations in order to proceed on a particular route; (2) the need to help pilots who are new to the area recognize dynamic local weather patterns that can place them in a dangerous situation; and (3) operational influences on pilot decision-making.
(A-17-37, classified Closed—Unacceptable Action/Superseded)
• Develop and implement special operating rules for the Ketchikan air tour industry that include en route visual flight rules weather minimums that are tailored to the industry’s unique requirements and are more conservative than those specified in 14 Code of Federal Regulations Part 135. (A-17-43, classified Closed—Unacceptable Action/Superseded)
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 this urgent recommendation. When replying, please refer to the safety recommendation by number (Safety Recommendations A-22-25 and A-22-26). 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.
Justification for A-22-25 from the report "Implement Special Federal Aviation Regulation for Air Tours near Ketchikan, Alaska," August 5, 2021:
Weather Minimums and Voluntary Operator Safety Actions
For Ketchikan-area air tours, the rapidly changing weather conditions specific to the region and the surrounding mountainous terrain represent overlapping hazards, and Part 135 VFR minimums often provide an insufficient safety margin to enable air tour pilots to avoid entering or escaping an inadvertent encounter with IMC in that environment.
Based on our findings in the investigations of several fatal air tour accidents that occurred in the Ketchikan and Southeast Alaska area, the NTSB issued 13 total safety recommendations to the FAA in 2008 and 2017 aimed at improving air tour safety in the Ketchikan area; however, many of the resulting solutions adopted by the FAA involved voluntary operator actions that have proven ineffective or are no longer in effect. Appendix B lists the NTSB’s 13 previously issued safety recommendations that addressed the weather, route, and terrain hazards in Southeast Alaska.
We issued the first four safety recommendations, A-08-59 through -62 (which focused on weather, training, and FAA oversight of safe flying practices), following a fatal July 2007 accident in Ketchikan and four similar accidents in southeast Alaska. For additional information about the five accidents near Ketchikan and Juneau referenced in the 2008 report, search the public docket for case numbers ANC99FA073, ANC99FA139, ANC01FA093, ANC06LA066, and ANC07FA068. For more information on the 2008 recommendations, see NTSB. 2008. Letter from Chairman Mark V. Rosenker to Robert A. Sturgell, Administrator, Federal Aviation Administration, issuing Safety Recommendations A-08-59 through -62, July 31.
Washington, DC: NTSB. Although we classified these four safety recommendations as either “Closed—Acceptable Action” or “Closed—Acceptable Alternate Action” based on the FAA’s actions, we later found that air tour operators in Southeast Alaska continued certain unsafe flying practices, such as conducting flights below FAA minimum altitudes and VFR weather minimums, and that some of the actions taken by the FAA in response to our recommendations, including training, were no longer in effect. Safety Recommendation A-08-60 asked the FAA to provide monthly en route and ground-based observations of air tour flights in Southeast Alaska.
In response, the FAA stated that it had permanently added en route inspections of air tour operators to FAA Order 1800.56, “National Flight Standards Work Program,” and established a special emphasis program to ensure surveillance in southeast Alaska. In 2014, the NTSB classified Safety Recommendation A-08-60 as “Closed—Acceptable Alternate Action.” Safety Recommendations A-08-61 and -62, which focused on training, are addressed in the next section. See appendix B for more information about Safety Recommendation A-08-59, which focused on weather cameras.
Following the July 2007 accident, the accident operator made voluntary operational changes, including signing the voluntary operator LOA and imposing a 4 mile flight visibility minimum for its flights in the Ketchikan area, which was more conservative than the 2-mile requirement specified in 14 CFR 135.205. For more information, see NTSB. 2017. Collision with Terrain, Promech Air, Inc., de Havilland DHC-3, N270PA, Ketchikan, Alaska, June 25, 2015. Aircraft Accident Report NTSB/AAR-17/02. Wash