Alaskan Aviation Safety is unique and Reexamination of its Regulating Regime is required

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Federal investigators cite FAA failures in 2018 floatplane crash near Ketchikan

Alaska’s operating environment and regulatory requirements are unique 

Past results have been disappointing

Time to review basic regulatory construct?

A new report from the National Transportation Safety Board released Thursday describes gaps in the Federal Aviation Administration’s oversight of Taquan Air Service operations discovered during the investigation into a July 2018 floatplane crash near Ketchikan.

The report includes passenger interviews also notes that the FAA allowed Taquan to keep an operations director who was at times too busy to oversee flight safety because another aviation job took him out of Ketchikan.

The report, which includes links to hundreds of pages of documents, is basically “a factual data dump” of everything the NTSB team discovered during the investigation, said Clint Johnson, the Board’s Alaska chief.

“One of the areas we look at is FAA oversight,” Johnson said.

From the Board’s report:

 “ORGANIZATIONAL AND MANAGEMENT INFORMATION

Taquan Air was a 14 CFR Part 135 air carrier that held on-demand and commuter operations specifications … The company operated 15 airplanes of which 3 were DHC-3T Turbine Otters, and employed about 25 pilots, with most working on a seasonal basis…

Director of Operations

The DO was hired as DO at Taquan in January 2016. In October 2017, he was hired as the chief pilot for Grant Aviation, a large scheduled Part 135 air carrier that also held commuter and on-demand operations specifications; he was promoted to DO at Grant Aviation in April 2018. Although this new position was based in Anchorage, Alaska, where he moved in October 2017, he continued to hold the DO position at Taquan. In addition, he was also a contract simulator instructor for Alaska Airlines.

According to numerous company personnel, the DO would visit Taquan’s Ketchikan base about once a month but was available by phone, if necessary. The president of the company said that the chief pilot had taken over “officer of the deck” and “we’re just basically using him [DO] for his recordkeeping, as … we need a DO.”

Chief Pilot

According to the chief pilot, due to the absence of the DO, he had assumed a large number of his responsibilities. He said both positions could be accomplished by one person during the wintertime, but it was more difficult during the summer months.

Operational Control

The Taquan General Operations Manual (GOM) does not explain the procedures used for the initiation or conduct of flight movements. The GOM did not list anyone by name as having operational control other than the DO, chief pilot, and president. The DO, chief pilot, flight coordinator, safety officer, and check airmen all stated that operational control could be and was routinely delegated to senior pilots in the absence of the chief pilot.

The GOM stated that “The Director of Operations routinely delegates the duty of Operational control to the Flight Coordinator on duty. However, the flight coordinator on duty at the time of the accident stated that she had no operational control as she was “the flight follower” (a term not defined by the GOM). She added that she did have the authority to cancel a flight for weather or profitability concerns, in addition to, arranging a flight “with concurrence with the person that’s in operational control.”

The president of the company described operational control as “having someone…that has the ability to check the weather.” He stated that the person with operational control was there to assist the pilot and flight coordinator when trying to make a launch decision, whether for weight, pilot experience or weather concerns. When asked who had the ultimate authority for operational control, he said the DO did and added “but he’s not here.”

Flight Risk Assessment

The Taquan Flight Operations Manual, Operations Specifications, and Training Manual did not include mention of a risk assessment process. Details on the risk assessment process was found in a document titled “Medallion Operational Risk Management (ORM) Implementation Manual” and stated in part:

Taquan Air has provided a form to assess the total risk involved for each flight.

One pilot viewed the form as “…just a piece of paper with some ink on it” and based go/no-go decisions on his experience and research instead.

Line pilots, management, and flight coordinators all stated that the pilot has the authority to change, add, or update information to the form.

ADDITIONAL INFORMATION

Federal Aviation Administration Oversight

The Juneau Flight Standards District Office (JNU FSDO) was assigned oversight of 102 commercial certificates at the time of the accident. The office manager stated in an interview that there were a total of 12 inspectors assigned to the JNU FSDO. Two of those 12 were principal operations inspectors (POIs); one was in JNU and the other was in Kenai. He said that the FSDO was allocated 5 POIs, but were unable to attract applicants for the position.

The POI for Taquan stated that his workload was “heavy” and he did not have time to complete all his oversight tasks. According to a work assignment letter, he was responsible for the oversight of 24 Part 135 certificates, seven Part 133 certificates and two Part 137 certificates.

Director of Operations Approval

Numerous interviews with FAA management personnel and inspectors responsible for the Grant Aviation and the Taquan air carrier certificates revealed that the FAA was made aware, on multiple occasions, that the DO for Taquan was serving as a management official for two Part 135 certificates; however, there was a belief by the FAA’s inspectors and management personnel responsible for the certificates, that this was not contrary to the Federal Aviation Regulations or guidance contained in FAA Order 8900.1. In addition, little to no coordination or communication was established between the POIs responsible for the two certificates.

FAA Order 8900.1, Volume 2, Chapter 2, Section 3, 2-158D, Management Personnel Serving Multiple Certificate Holders, D, states, in part:

NOTE: Headquarters (HQ) will not approve part 135 commuter operations or part 121 operations to share part 119 management personnel, as provided for in this paragraph.

For further operations or human performance information, see the Operational Factors/Human Performance Factual Report located in the public docket for this investigation.


Alaska is unique in operational environment for flight. In much of the state airplanes are the only and/or primary form of transportation. Add to that factor, the 49th state has the most difficult terrain and the most severe and changing weather experienced anywhere in the US. Over time those factors have contributed to a pilot culture that accepts a higher level of risk.

Those same elements elevate the regulatory needs. The numbers of certificates under the JNU FSDO supervision are high and that burden translates to the workload for ASIs, POIs, PMIs and other aviation safety personnel. The operators are heavily entrepreneurial and lightly staffed in the supervisory/administrative functions. That second line in carriers tend to be key positions for risk reduction, safety discipline and caution.  As noted by the NTSB’s recitation, many of those with these responsibilities are also multi-tasking.

 

 

 

 

 

 

 

 


Medallion Aviation Foundation served practically as an FAA Auxiliary, like the Coast Guard equivalent, which supplements the federal staff. For reasons that are unclear, the Foundation died.

The NTSB’s comments in the Taquan case are not new. Chairman Sumwalt has held hearings on Alaska Aviation Safety and has argued for champions for the need of additional resources. His specific concerns are repeated in this Report:

controlled flight into terrain,

loss of control in flight,

midair,

and

unintended flight into instrument meteorological conditions.

Repetition is a useful tool for learning, but those words have not moved the AK safety needle yet.

One of the principles of SMS is that in response to a specific risk, a precise solution must be designed for that distinct problem. The resolution of the issue focuses on the individual weakness identified and the strengths from which to address the risk.

The risks found in Alaska, as found both in the operators’ and the regulators’ profile, should exercise the same individuation analytical rubric. The governmental staffing and structures, in particular, need to focus on how the regulator can best assess the weather, topography, critical air need and operators of this state. Once a more holistic FAA approach is defined, and authorized, then the aviation safety team can begin to collaborate with the operators to identify individual issues and then jointly define a means of reducing risks.



 

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