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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: 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.
Original recommendation transmittal letter:
Open - Acceptable Response
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 (Open - Acceptable Response)
Safety Recommendation History
You indicated that you are addressing this recommendation in your bi-annual air tour safety meetings, mentioned above, and through your CFIT initiative, avionics training assistance videos, and cue-based training. You also wrote that, during the remainder of the 2017 and the entirety of the 2018 air tour seasons, you plan to conduct customized surveillance that focuses on operator training programs and the manner in which the training is implemented and delivered. Although we believe that your efforts are positive and could ultimately address this recommendation, we would like to know how they will address the specific concerns that are outlined in this recommendation. Pending our review of this additional information and completion of the recommended actions, Safety Recommendation A-17-37 is classified OPEN--ACCEPTABLE RESPONSE.
-From Michael P. Huerta, Administrator: The FAA is addressing this recommendation through many avenues, including bi-annual Air Tour Safety Meetings, as discussed above in our response to recommendation A-17-36, and the following safety campaigns: CFiT Ini tiative The CFiT initiative, which is being carried out by all Alaskan Region Flight Standards District Offices, will provide ongoing di scussions with air carrier part 119 personnel regarding their safety culture and issue proposals for best practices that operators can adopt to enhance aviation safety. Avionics Training Assistance Videos This past winter we produced and distributed detailed videos providing in-depth training on the efficient and operational use of the advanced avionics packages installed in nearly all aircraft operating in the southeast Alaskan air tour industry. These videos are available for use by all operators and can be accessed via YouTube. Each operator has been provided with the appropriate URL links to view them. Initial feedback indicates that many operators are utilizing these videos, and some operators are considering adopting the videos into their approved training programs. Cue-Based Training In addition, cue-based training is a long-standing Alaskan initiative that provides weather dependent training for pilots, who have the opportunity to make decisions based on visual weather depiction cues as they change. Cue-based training has been established as a best practice and has been incorporated into the training programs of all Southeast Alaskan Air Tour operators. The FAA will conduct customized surveillance specifically focused on operator training programs and the manner in which the training is implemented and delivered. To ensure comprehensive oversight of these training programs, we will provide this oversight throughout the remainder of the 2017 and the entirety of the 2018 air tour season.
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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