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General Aviation Safety
On June 25, 2015, about 1215 Alaska daylight time, a single-engine, turbine-powered, float-equipped de Havilland DHC-3 (Otter) airplane, N270PA, collided with mountainous, tree-covered terrain about 24 miles east-northeast of Ketchikan, Alaska. The commercial pilot and eight passengers sustained fatal injuries, and the airplane was destroyed. The airplane was owned by Pantechnicon Aviation, of Minden, Nevada, and operated by Promech Air, Inc., of Ketchikan. The flight was conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 135 as an on-demand sightseeing flight; a company visual flight rules flight plan (by which the company performed its own flight-following) was in effect. Marginal visual flight rules conditions were reported in the area at the time of the accident. The flight departed about 1207 from Rudyerd Bay about 44 miles east-northeast of Ketchikan and was en route to the operator’s base at the Ketchikan Harbor Seaplane Base, Ketchikan.
TO THE FEDERAL AVIATION ADMINISTRATION: Discuss at the next Ketchikan Air Safety meeting the database and software considerations for legacy Chelton systems and encourage operators to use the most current terrain database and electronic flight instrument system software.
Original recommendation transmittal letter:
Closed - Acceptable Action
Ketchikan, AK, United States
Collision with Terrain Promech Air, Inc. de Havilland DHC-3, N270PA, Ketchikan, Alaska, June 25, 2015
Addressee(s) and Addressee Status:
FAA (Closed - Acceptable Action)
Safety Recommendation History
We note that you discussed the use of updated terrain databases and current software during the 2016 postseason and 2017 preseason bi-annual air tour safety meetings, which are held in both Juneau and Ketchikan, Alaska, and involve FAA, industry stakeholders, leading aviation safety groups, and the NTSB. We also note that, although you found that operators are using the most current electronic flight instrument system software available for legacy Chelton Avionics Systems, you plan to continue to provide operator oversight to ensure systems software is used in accordance with each operator’s approved manuals and training programs. These actions satisfy the intent of Safety Recommendation A-17-36, which is classified CLOSED--ACCEPTABLE ACTION.
-From Michael P. Huerta, Administrator: The FAA is addressing these recommendations through bi-annual Air Tour Safety Meetings held in both Juneau and Ketchikan, Alaska. These bi-annual meetings are held before the spring and after the fall air tour seasons and involve FAA, industry stakeholders, leading aviation safety groups, and the Board on occasion. The intent of these meetings is to address safety concerns specific to the air tour industry in Southeast Alaska and to conduct regular presentations around topics such as: airspace changes, automatic dependent surveillance-broadcast (ADS-B), CAPSTONE equipment, mid-air avoidance via Letters of Agreement (LOA), safety cultures, and the CFJT Awareness Initiative. At the 2016 post-season and 2017 pre-season air tour safety meetings the use of updated terrain databases and current software was discussed as requested by this recommendation. As for concerns over legacy Chelton Avionics Systems, the FAA found that operators are using the most current electronic flight instrument system software available. We encourage carriers to continue using updated terrain databases as they become available and will continue to provide operator oversight to ensure systems software use is in accordance with each operator's approved manuals and training programs. We will address this topic again during the 2017 post-season air tour safety meeting. The FAA believes that by ensuring ADS-B data-driven discussions are a focus of future bi-annual safety meetings, additional safety insights will be developed. In evaluating this recommendation we determined there are several po11ions of Ketchikan air tour flight paths where ADS-B data is not available. However. discussions with industry stakeholders indicate that their use of "Spider Tracks" technology, a commercially available GPS tracking tool, allows the air carriers to have full coverage of the entire flight path. Although this coverage is available to the air carriers only, this information has been openly shared with Certificate Management Team (CMT) members and is routinely incorporated into the bi-annual air tour safety meetings. The FAA has also achieved successful results in this area through user/operator LO As, where air carriers operating in a given area voluntarily sign agreements establishing clear procedures, methods, and areas by which they will abide. This voluntary action further enhances aviation safety during the air tour season through the avoidance of both mid-air and CFiT accidents. We will ensure that a specific presentation during both the 2017 post-season and 2018 pre-season air tour safety meetings is focused on any operational hazards reflected in track data. Additionally, the CMTs will work collaboratively with industry to approve operator developed mitigation strategies for any hazards identified. I believe the FAA has effectively addressed these safety recommendations and consider our actions complete.
On April 25, 2017, the National Transportation Safety Board (NTSB) adopted its report concerning the June 25, 2015, accident in which a single-engine, turbine-powered, float-equipped de Havilland DHC-3 (Otter) airplane, N270PA, collided with mountainous, tree-covered terrain about 24 miles east-northeast of Ketchikan, Alaska.1 Additional information about this accident and the resulting recommendations may be found in the report of the investigation, which can be accessed at our website, http://www.ntsb.gov, under report number NTSB/AAR-17/02. As a result of this investigation, we issued 10 new recommendations, including 1 to the Cruise Lines International Association and the following 9 recommendations to the Federal Aviation Administration.
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