TO THE NATIONAL WEATHER SERVICE: Work with the Federal Aviation Administration to develop the special federal aviation regulation in Safety Recommendation A-22-25 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.
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
July 31, 2023 · NTSB Correspondence · United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service
We note that you have received our recommendation and, on February 7, 2023, your staff informed my staff that you were in the process of setting up a meeting with the FAA to develop a plan for addressing this safety issue. Pending our review of that plan and completion of the recommended action, Safety Recommendation A-22-27 is classified OPEN-- ACCEPTABLE RESPONSE.
December 22, 2022 · Recipient Response · United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service
-From John D. Murphy, Chief Operating Officer, NOAA National Weather Service:
The NWS acknowledges receipt of this Safety Recommendation. We look forward to working with the Federal Aviation Administration (FAA) as recommended in this and companion recommendation A-22-25.
November 29, 2022 · NTSB Correspondence · United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service
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 the National Weather Service to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents.
This letter also includes information about our 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 recommendation may be found in the attached report, which can also be accessed at
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 recommendation to the National Weather Service.
• Work with the Federal Aviation Administration to develop the special federal aviation regulation in Safety Recommendation A-22-25 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. (A-22-27)
The NTSB is vitally interested in this recommendation because it was 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 recommendation by number (Safety Recommendation A-22-27). 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.
Justification for A-22-27 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. Washington, DC: NTSB.
The July 2007 accident operator maintained this more conservative visibility minimum and, on June 25, 2015, it cancelled its air tours because weather conditions were below its more restrictive voluntary minimum. However, another local operator booked passengers from those cancelled air tours that day; one of the rebooked air tour flights encountered IMC and collided with mountainous, tree-covered terrain, resulting in nine fatalities.
Following our investigation of the June 2015 accident, the NTSB issued Safety Recommendation A-17-43 asking the FAA to do the following: 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. (As pa