Roundtable Discussion Yields Key Insights, Critical Actions Needed for Improving Safety of Part 135 Flight Operations in Alaska

By Chairman Robert Sumwalt

On September 6, in Anchorage, Alaska, I facilitated a first-of-a-kind roundtable of industry operators, government officials, educators, and aviation associations. Troubled by investigations into too many crashes involving Part 135 flight operations (which include air medical service, air taxi, air tours, charter, and on-demand flights) in Alaska, we called together some of the brightest experts across industry, academia, and government to help answer one question: How can we improve the safety of flight operations involving these aircraft?

We had some ideas on how to answer that question already; the issue is on our Most Wanted List of transportation safety improvements. For example, we know that safety management systems (SMS), flight data monitoring (FDM), and controlled-flight-into-terrain (CFIT) training can help ensure that operators manage their planes and pilots in the safest possible way, reducing the chances of a crash. But we wanted to hear ideas from others—specifically those flying in Alaska, where Part 135 crashes are so prevalent—and urge operators and regulators to make some of the changes we believe will help.

Between January 2008 and June 2019, we investigated 204 fatal accidents in Alaska

fatal part 135 alaska accidents
Fatal Part 135 Alaska Accidents – Accident data from January 1, 2008 to August 12, 2019

involving fixed-wing aircraft and helicopters, scheduled and nonscheduled, in Part 135 operations. These accidents killed 80 people. At the roundtable, Dana Schulze, the NTSB’s Director of Aviation Safety, briefed us on the leading causes of Part 135 accidents in Alaska, reporting that nearly 80 percent of fatal accidents in Alaska are due to CFIT, loss of control in flight, midair collisions, and unintended instrument meteorological conditions.

Alaska has several challenges compared to the “lower 48,” such as unique terrain conditions, difficult weather, and congested airspace. That’s why we thought it important to talk specifically to those navigating this terrain. However, the deadly consequences of a crash are the same, regardless of where it occurs, and aviators across the country should be concerned with the issues we discussed at the roundtable.

I kicked off the roundtable of 29 experts, many of whom were operators, with a reminder that there is a business case for safety. I challenged the panel to come up with concrete solutions that we could collectively address. From the start, we agreed on one thing: the September 6 roundtable wouldn’t just be a conversation; it would be a call to action.

Chairman addresses panel about risk management
NTSB Chairman Robert Sumwalt talks with panelists about risk management during the September 6 roundtable on Alaska Part 135 Flight Operations

Our panelists discussed four key areas: training, risk management, technology, and infrastructure. We were pleased to see that many of their ideas related to these topics aligned with recommendations the NTSB has already issued, which are noted below. However, we welcome a discussion about any and all other potential improvement areas. Areas which the panelists agreed that they will evaluate further and perhaps pursue individually and collectively included:

Training

  • Cue-based (simulator) training has an impact on pilot decision-making and should be encouraged and required. Pilots taking CFIT training on a simulator performed significantly better on subsequent real-world flights than those who didn’t. (Note: the NTSB supports and has made recommendations to improve CFIT training for pilots).
  • To improve safety, operators must consider five safety principles: knowledgeable pilots, training, proficiency, reliable equipment, and culture.
  • The five things every operation must do are (1) realize it needs to change, (2) have a project champion, (3) create clearly defined standard operating procedures, (4) offer quality assurance systems, and (5) mentor/train employees.
  • We must do a better job of training the trainers.

As part of our training discussion, we talked about the recent closing of the Medallion Foundation, a flight safety advocacy organization in Alaska, and its impact on the industry. Medallion simulators will continue to be available to Alaska’s pilot community after the Federal Aviation Administration (FAA) determines where those simulators will be placed.

Risk Management

  • An SMS is important and worthwhile for improving safety, but it should be scalable
    Panelist Jens Hennig from GAMA with Corey Stephens FAA in background
    Panelists Jens Hennig, GAMA and Corey Stephens, FAA 

    depending on the size of the operator. Smaller operators may find it economically wise to outsource their safety assurance/FDM programs. (Note: As mentioned earlier in the blog, the NTSB has issued recommendations requiring SMS and FDM). One roundtable participant pointed out that there are 303 Part 135 operators in Alaska; of those, only eight are in the FAA’s SMS program.

  • Safety management requires the commitment of company leadership, but it’s just as important to involve pilots, mechanics, and management in the process so they recognize the value of an SMS, too.
  • An SMS should be a required prerequisite to participate in any federally funded programs, such as U.S. mail delivery and Medicare/Medicaid transport.
  • Useful data can be found in the FAA’s Aviation Safety Action Program. Carriers can benefit from the aggregated data collected in this information-sharing program.

Technology

  • Operators should equip their planes, either voluntarily or by requirement, with automatic dependent surveillance-broadcast (ADS-B) technology, and the FAA should consider helping smaller operators fund such an improvement. In Alaska, ADS-B is only required in the Class C airspace above Ted Stevens International Airport, and above 18,000 feet. We discussed the FAA requiring ADS-B in high-risk airspace, such as around the village of Bethel.
  • Pilots and air traffic controllers need more ground-based station coverage in strategic locations.
  • A terrain alert warning system (TAWS) should be an aid, not a navigational tool. There’s a tendency for some operators to inhibit their TAWS because of its low-altitude nuisance alerts; this is a hazard that needs to be mitigated. (Note: the NTSB has made recommendations in this area).
  • Technologies such as digital cockpit, 406 emergency locator transmitters, FDM equipment, and flight-following equipment look promising and should be considered.
  • When it comes to weather management, a meteorological automatic weather station isn’t authorized as a weather tool, but flight service will provide it as a supplement upon request. Satellite programs are showing promise for predicting icing and cloudy conditions.

Infrastructure

  • We need to enable more flights to operate under instrument flight rules and improve visual flight rules (VFR) operations (weather camera stations). Alaska should consider establishing a common traffic advisory frequency division across the state.
  • ADS-B can help in remote locations. Special VFRs and letters of agreement would also be helpful.
  • Federal money should be committed to improving infrastructure. For example, the FAA could establish a Capstone II program in Alaska, but very small carriers will need help with funding.
  • We need more pilot information reports to validate radar returns and polar satellites, and to fill in the gaps of weather station coverage.
  • Operators and pilots should better use air traffic control services.

We at the NTSB are committed to doing our part to improve Part 135 safety. Currently, the FAA does not apply the same requirements to Part 135 operators as it does to Part 121 commercial airlines. We believe that, regardless of the purpose of flight, one thing is for sure: all flights should be safe. But we don’t have to wait for the FAA to regulate; we know that operators can—and should—make the appropriate changes.

Perhaps the most significant takeaway and critical action suggested at the roundtable—upon which the entire group agreed—was related to the need for one group, organization, or entity to focus on flight operation safety issues in Alaska. I agree. FAA Administrator Stephen Dickson has also indicated that this concept of a “single focal point” in Alaska may be worthwhile. It looks like the time to act is now.

We greatly appreciate all the experts who came to this event and participated in our vigorous discussion. We are convinced that this roundtable will lead to life-saving improvements in Alaska that will then serve as models for the rest of the world.

This event would not have been successful without the dedicated NTSB staff who worked tirelessly to plan and execute it, and the great participation of the panelists.

Thanks for all for the contributions!

For more details on this event, including participants and agenda, or to learn more about Part 135 safety, watch the event recording and see our event web page.

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