TO THE FEDERAL AVIATION ADMINISTRATION: 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. (Supersedes Safety Recommendation A-17-37)
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-22-26 from the report "Implement Special Federal Aviation Regulation for Air Tours near Ketchikan, Alaska," August 5, 2021:
Weather-Related Training
In 2008, the NTSB issued Safety Recommendations A-08-61 and -62, which asked the FAA to develop a cue-based training that addressed Ketchikan weather hazards and to require that local operators regularly provide that training to their pilots. Cue-based training programs expose pilots to realistic depictions of deteriorating in-flight weather to foster an ability to accurately assess and respond appropriately to cues associated with deteriorating weather.
In response to those safety recommendations and in cooperation with the Medallion Foundation, the FAA developed cue-based training that was conducted in Medallion’s approved basic aviation training device (BATD), and air tour operators voluntarily incorporated these concepts into their FAA-approved training programs. The Medallion Foundation, a non-profit Alaskan safety organization, was established by a state industry group of air carriers to improve pilot safety awareness and reduce air carrier insurance rates.
Between 2002 and 2019, it received funding from the FAA to, among other things, administer safety initiatives including the purchase and maintenance of flight training devices, passenger safety awareness campaigns, and management of the Aviation Safety Action Program. The Medallion Foundation ceased operation in 2019. As a result, the NTSB classified Safety Recommendations A-08-61 and -62 “Closed—Acceptable Action” and “Closed—Acceptable Alternate Action,” respectively.
We issued similar cue-based training recommendations in 2007 for Hawaii air tour operations.
The Medallion Foundation, a non-profit Alaskan safety organization, was established by a state industry group of air carriers to improve pilot safety awareness and reduce air carrier insurance rates. Between 2002 and 2019, it received funding from the FAA to, among other things, administer safety initiatives including the purchase and maintenance of flight training devices, passenger safety awareness campaigns, and management of the Aviation Safety Action Program. The Medallion Foundation ceased operation in 2019.
The FAA’s March 8, 2011, response to the Hawaii air tour recommendations indicated that it had established a cue based weather training project management team to develop and produce “high quality, comprehensive, expert-vetted, cue-based weather and in-flight decision-making visual training aids” for air tour operators in both Hawaii and Alaska. However, during the investigation of the December 2019 air tour helicopter accident in Hawaii noted previously, we found the FAA’s commitment to taking such action had diminished over time, and it instead attempted to shift responsibility for developing cue-based training to the air tour operators.
As part of the December 2019 accident investigation, we classified Safety Recommendations A 07-18 and -19 as “Open—Unacceptable Response.”
We have expressed similar concerns to the FAA regarding the cue-based training in Ketchikan developed by Medallion. During the NTSB’s investigation of the June 2015 air tour accident in Ketchikan, investigators discovered that the cue-based training module that the accident pilot had completed using Medallion’s BATD had limited effectiveness because the ceiling height and forward visibility depicted on the BATD did not portray the dynamic, variable, and localized patterns that often characterize real-w