CESSNA U206

Full Narrative

HISTORY OF FLIGHTOn July 27, 2017, about 0923 Alaska daylight time, a wheel-equipped Cessna U206G airplane, N1749R, impacted remote, tree-covered terrain while en route to a remote lodge on the Mulchatna River, about 12 miles northeast of Port Alsworth, Alaska, in the Lake Clark National Park and Preserve. The commercial pilot and sole occupant sustained fatal injuries, and the airplane was destroyed by a postcrash fire. The airplane was registered to Laughlin Acquisitions, LLC, Anchorage, Alaska and was being operated by Alaska Skyways, Inc., dba Regal Air, Anchorage, Alaska as a Title 14 Code of Federal Regulations (CFR) Part 135 visual flight rules (VFR) on-demand cargo flight. Instrument meteorological conditions (IMC) were reported in the vicinity of the accident site at the time of the accident, and company flight following procedures were in effect. The flight originated from the Lake Hood Seaplane Base (LHD), Anchorage, Alaska, about 0800.

The operator reported that the purpose of the flight was to deliver 334 pounds of lumber and insulation to the Kautumn Lodge on the Mulchatna River, about 29 miles northeast of Koliganek, Alaska and would conclude with a return flight to LHD with three passengers onboard. The Kautumn Lodge is about 245 miles southwest of LHD. Upon leaving LHD and departing to the southwest, the route of flight consisted of tree-covered terrain. Continuing past Tyonek, Alaska to the southwest, is the south to north oriented mountainous terrain of the Alaska Range, which also encompasses the Lake Clark National Park and Preserve. Continuing past the Lake Clark National Park and Preserve to the southwest consists mainly of hills before reaching the Mulchatna River.

The airplane was equipped with a Spidertracks Spider 6 system, which provided the operator real-time information such as location, direction, altitude, and airspeed of the airplane at 10-minute intervals. A review of the data showed that, before entering the Alaska Range, the airplane was at an altitude of 7,523 ft above mean sea level (msl) at 124 knots at 0839. The remaining three data points showed the airplane at 7,494 ft msl and 125 knots at 0849, 7,609 ft msl and 127 knots at 0859, and 3,954 ft msl and 135 knots at 0909. Figure 1 shows the various data points captured by the Spidertracks Spider 6 system.



Figure 1 – View of Spidertracks Spider 6 data points (courtesy of the operator).



The airplane was also equipped with an Automatic Dependent Surveillance – Broadcast (ADS-B) system. A review of ADS-B data showed the airplane departing LHD, traveling southwest toward the Alaska Range, and entering the airspace over the Lake Clark National Park and Preserve. The ADS-B data terminated about the same location as the second-to-last data point obtained from Spidertracks. Refer to the public docket for the Spidertracks and ADS-B data from the accident flight.

At 0924, the operator received a telephone call from the U.S. Air Force Alaska Rescue Coordination Center at Joint Base Elmendorf-Richardson, Alaska indicating a signal was received from the airplane's 406-MHz emergency locator transmitter (ELT). An aerial search mission was conducted with an airplane from the operator based at LHD, an airplane from the National Park Service based at Port Alsworth, and with a private helicopter based at Port Alsworth. The burning wreckage was discovered via aerial search in a forested area of the Miller Creek drainage about 1030. The wreckage was located about 85 miles northeast of the Kautumn Lodge. The location of the wreckage is shown in figure 2.





Figure 2 – Aerial view of the wreckage (courtesy of the NTSB).
PERSONNEL INFORMATIONPilot

The operator's pilot training records showed no deficiencies and indicated that the pilot had completed all required training and was current, including a competency check ride on May 22, 2017. This was the pilot's first season working for the operator as a pilot and his first season as a pilot in Alaska. All his experience for the operator were based out of LHD as a dockhand for two summer seasons. The pilot was qualified and current to fly the wheel and float-equipped Cessna 206 and the float-equipped de Havilland DHC-2. The pilot completed all the operator's required initial training in early to mid-May 2017. According to the operator, at the time of the accident the pilot had 20 hours total of actual instrument experience and 84 hours total of simulated instrument experience.

Director of Operations

The director of operations (DO), is listed in the Regal Air General Operations Manual (GOM) as the president and vice-president/secretary of the company. The DO is also the owner of the company. This was the DO's 18th year working for the company and was his 11th year working as a pilot and as the DO for the company. All his experience for the operator was based out of LHD. The DO was qualified and current to fly the wheel/ski/float-equipped Cessna 206, the wheel/ski/float-equipped de Havilland DHC-2, and the Piper PA-31-350. Prior to and at the time of the accident, the DO was out of the country on personal leave.

Office Manager

The office manager had been employed for the operator for 8 years and first worked as a dockhand before becoming the office manager. While the office manager held a private pilot certificate (airplane single engine land), he had never flown for the operator nor for any other commercial operators in Alaska. He did not hold an aircraft dispatcher license, nor was he required to. All his experience for the operator was based out of LHD. The DO reported that the office manager, acting as the duty officer based out of the operator's headquarters at LHD, was the individual exercising operational control (first-tier with the two-tiered operational control concept) over the accident flight since he was out of the country on personal leave. The DO further reported that either himself or the office manager are the ones that exercise operational control over the company's flights.

Principal Operations Inspector

The principal operations inspector (POI), from the Federal Aviation Administration (FAA) Anchorage Flight Standards District Office, Anchorage, Alaska had been assigned to the operator's certificate since June 2016. The POI was an experienced air transport pilot and certificated flight instructor, with flight experience in Alaska, along with holding positions as a chief flight instructor (14 CFR Part 141 pilot school operations) and as a chief pilot (14 CFR Part 135 commuter and on-demand operations) prior to working for the FAA.
AIRCRAFT INFORMATION
Figure 3 – Exemplar photograph of N1749R (courtesy of the operator).


The airplane was configured for cargo operations at the time of the accident. A belly cargo pod was installed underneath the fuselage as shown in figure 3. The airplane was not equipped with a terrain awareness and warning system or onboard weather system, nor was it required to be. The airplane was not instrument flight rules equipped or certified, nor was it required to be.
METEOROLOGICAL INFORMATIONWeather Sources

The closest official weather observation station was located at Port Alsworth Airport (TPO), Port Alsworth, Alaska about 12 miles southwest of the accident site. The Aviation Routine Weather Report (commonly referred to as a "METAR") observation at 0650 (about 2.5 hours before the accident) included calm wind, 10 statute miles visibility, few clouds at 300 ft above ground level (agl), a broken ceiling at 1,500 ft agl, temperature 55°F, dew point 54°F, and an altimeter setting of 29.94 inches of mercury with remarks, "estimate pass closed" (the remark refers to the Lake Clark Pass). Figure 4 shows a National Weather Service (NWS) flying weather graphic issued at 0400 and was valid until 1000, showing the area encompassing the route of flight and the accident site as having forecast marginal VFR conditions.



Figure 4 – View of National Weather Service flying weather graphic, issued at 0400 and valid until 1000 (courtesy of the National Weather Service).


The following are images captured from a FAA weather camera station located at Lake Clark Pass West about 30 minutes before the pilot departed from LHD. These weather cameras are located about 10 miles east of the accident site and an elevation of 261 ft as shown in figure 5. Figure 6, figure 7, and figure 8 were taken prior to the pilot's departure from LHD and indicated complete mountain obscuration conditions with low visibility underneath the overcast cloud layer with all the higher terrain references obscured by clouds.




Figure 5 – Map of the closest FAA weather camera stations and the accident site (courtesy of the NTSB).




Figure 6 – FAA weather camera image, Lake Clark Pass West – NorthEast, 0731 (courtesy of the FAA).




Figure 7 – FAA weather camera image, Lake Clark Pass West – East, 0734 (courtesy of the FAA).




Figure 8 – FAA weather camera image, Lake Clark Pass West – South, 0738 (courtesy of the FAA).


The TPO METAR observation at 0958 (about 35 minutes after the accident) included calm wind, 15 statute miles visibility, a broken ceiling at 500 ft agl, overcast at 2,000 ft agl, temperature 57°F, dew point 55°F, altimeter 29.96 inches of mercury with remarks, "estimate pass closed" (the remark refers to the Lake Clark Pass).

Figure 9, figure 10, and figure 11 were captured from the FAA weather camera station located at Lake Clark Pass West, about the time of the accident. These three figures, similar to the images captured prior to the flight's departure, indicated complete mountain obscuration conditions with low visibility underneath the overcast cloud layer with all the higher terrain refences obscured by clouds.






Figure 9 – FAA weather camera image, Lake Clark Pass West – NorthEast, 0921 (courtesy of the FAA).





Figure 10 – FAA weather camera image, Lake Clark Pass West – East, 0926 (courtesy of the FAA).





Figure 11 – FAA weather camera image, Lake Clark Pass West – South, 0918 (courtesy of the FAA).


A witness, who was a pilot and lived off Lake Clark near Port Alsworth reported that on the morning of the accident, conditions were "very foggy" with about ½ mile visibility until 0830 when the fog started to break up. He reported that by 0930, the sun was "breaking through" over Lake Clark. He departed for Anchorage in his airplane about 1000 and climbed to 4,500 ft over the fog and scattered clouds. He observed that there was still "quite a lot of fog" around which extended through Lake Clark Pass. He estimated that there was about a 300 ft ceiling under the fog in Lake Clark Pass.

Accident Weather Flight Planning

No record was found of the pilot obtaining an official weather briefing from an FAA Flight Service Station or any Direct User Access Terminal Service (DUATS) before the flight.

Prior to the flight departing, the office manager checked two sources of cameras. The office manager checked a private camera in a residential area of Port Alsworth and observed "bright blue sky." The office manager checked the FAA weather camera station located at Lake Clark Pass West and he noticed it had "some fog" but he reported, "it looked like it was just fog right over the camera because everywhere else was blue sky." The office manager also reviewed a weather report he received from the Kautumn Lodge that morning, with the destination reporting "great flying weather." The office manager reported that him and the pilot did not assess the METAR issued for TPO that morning prior to the flight departing.

The chief pilot reported that he also checked the weather at the time the pilot was conducting flight planning and did not notice any weather of concern. He further reported that, based on the weather information that he obtained, he felt that there were no weather conditions present for the flight that the pilot could not handle.

Weather Flight Planning Procedures

FAA Operations Specification A010, Aviation Weather Information, stated that the operator was approved to use NWS for those United States and its territories located outside of the 48 contiguous States, and an Enhanced Weather Information System to obtain and disseminate aviation weather information for the control of flight operations.

The Regal Air GOM discussed weather planning procedures for company pilots and stated that, before the flight to each new destination, the pilot will use whatever means he/she deems appropriate for obtaining current weather, including FAA Flight Service, DUATS or National Oceanic and Atmospheric Administration websites, or calling the destination for a current analysis of the weather. The GOM stated that the decision to embark on a flight was at the discretion of the PIC should poor weather exist; but that no flight was to be flown in weather below federal aviation regulations allowable minimums.

The Regal Air GOM did not require pilots or individuals in operational control roles to receive an official weather briefing; nor was there any requirement for the individual exercising operational control and the pilot to jointly assess current or forecast weather conditions for a flight.

FAA Advisory Circular (AC) 00-45H Aviation Weather Services discusses weather briefings and states in part:


Prior to every flight, pilots should gather all information vital to the nature of the flight. This includes a weather briefing obtained by the pilot from an approved weather source, via the Internet, and/or from an flight service station (FSS) specialist.


Refer to the NTSB Weather Study in the public docket for additional information.
AIRPORT INFORMATION
Figure 3 – Exemplar photograph of N1749R (courtesy of the operator).


The airplane was configured for cargo operations at the time of the accident. A belly cargo pod was installed underneath the fuselage as shown in figure 3. The airplane was not equipped with a terrain awareness and warning system or onboard weather system, nor was it required to be. The airplane was not instrument flight rules equipped or certified, nor was it required to be.
WRECKAGE AND IMPACT INFORMATIONOn July 28, 2017 the NTSB investigator-in-charge (IIC), an aviation safety inspector from the FAA Polaris Certificate Management Office, and the Alaska State Troopers traveled to the accident site via helicopter. The team members hiked into the accident site to conduct wreckage documentation. The accident site, about 920 ft above mean sea level, was in a forested valley, surrounded by steep, mountainous terrain. The accident site was about ¼-mile southeast of the Kijik River. The average tree height, consisting of both spruce and birch trees, at the accident site was about 35 feet tall. All of the components of the airplane were found at the main wreckage site.



Figure 12 – View of the front side of the wreckage (courtesy of the NTSB).


The airplane came to rest in a wings-level attitude on a magnetic heading about 100° as shown in figure 11. Portions of broken windscreen, the magnetic compass, and the Spidertracks unit were scattered forward of the wreckage. The wreckage aft of the firewall, extending outboard to both wing roots and to the mid-empennage area, was destroyed by fire.

The leading edges of both wings appeared relatively intact. The left wing tip was separated and found lying on the leading edge of the left wing. The right wing tip (along with the right wing tip light assembly) was separated and found about 17 ft from the right wing on a 200° heading. The outboard section of the right wing was separated and found about 8 ft forward of the right wing on a 180° heading and displayed impact damage.

Both fuel tanks were compromised by fire damage and no fuel was observed. The lower portion of the engine was buried in dirt. The top portion of the engine exhibited no signs of fluid leaks or pre-impact damage. The propeller blades exhibited varying degrees of impact damage. The propeller was attached to the crankshaft flange. The 406-MHz ELT was found just aft of the mid-empennage burn section and displayed heavy fire damage.

The wreckage was recovered from the accident site and transported to a secure facility in Wasilla, Alaska, for further examination. On October 5, 2017, a wreckage examination and layout were conducted under the direction of the NTSB IIC. Representatives from the FAA, Textron Aviation, Continental Motors, and Regal Air were also present. The examination revealed no preimpact mechanical malfunctions or failures with the airframe and engine.
ADDITIONAL INFORMATIONControlled Flight Into Terrain

FAA AC 61-134 General Aviation Controlled Flight Into Terrain Awareness discusses the risk that controlled flight into terrain (CFIT) poses for pilots and states in part:


Operating in marginal VFR/IMC conditions is more commonly known as scud running.


The importance of complete weather information, understanding the significance of the weather information, and being able to correlate the pilot's skills and training, aircraft capabilities, and operating environment with an accurate forecast cannot be emphasized enough.

Controlled Flight Into Terrain-Avoidance Training Program

While 14 CFR Part 135 helicopter operators are required to have a controlled flight into terrain-avoidance (CFIT-A) training program, 14 CFR Part 135 airplane operators are not required to have such a program.

Aviation Weather and Risk Taking

NTSB safety study, Aviation Safety in Alaska SS-95/03, discusses aviation safety issues regarding weather and risk taking in Alaska and states, in part:

Flying weather in Alaska can be quite variable depending on the climate zone and time of year. Although all parts of Alaska experience periods of instrument meteorological conditions, such conditions are frequent in the Aleutian Islands, Alaska Peninsula, southeast Alaska, and the Arctic Coast during the summer and early fall. Weather conditions can change rapidly in Alaska, and the vast distances between some reporting points will often conceal significant local variations in the weather. VFR flight into IMC usually involves poor pilot decision making, whether in initiating the flight or continuing it into adverse weather.

VFR into IMC Accidents

The FAA's report, A Human Factors Analysis of Fatal and Serious Injury Accidents in Alaska 2004-2009, discusses five factors associated with poor pilot decision-making in VFR into IMC accidents and states, in part:

Weigmann and Goh (2000) list four factors associated with poor pilot decision-making in VFR into IMC accidents.

The first factor is poor situation assessment. The pilot lacks experience in interpreting changing weather conditions, especially slowly changing weather. Tiredness, fatigue, and increased workload, or some combination of these, can also increase the likelihood of an inaccurate assessment of the weather.

The second factor associated with poor pilot decision-making is faulty risk perception of the dangers involved in flying in marginal weather conditions. Recent research by Shappell et al. (2010) supports the notion that many pilots have a poor understanding and appreciation of the hazards associated with adverse weather conditions. Contributing to this perception, many pilots might have successfully navigated during marginal conditions in the past and so have gained confidence in their ability to succeed again in similar circumstances.

The third factor associated with poor pilot decision-making is inappropriate motivations that bias the decision-making process. The term "get-home-itis" refers to the motivation of the pilot to complete the journey.

The fourth factor associated with poor pilot decision-making is called "decision framing." Decision framing refers to the idea that a person's choice between a risky or safe course of action depends on whether the choice is framed in terms of a gain or a loss. When the safer course of action is framed in terms of a loss, the decision tends to be risk-seeking. When framed in terms of a gain, the decision tends to be risk-averse. In the case of VFR flight into IMC, research has shown that framing the decision to not fly into marginal weather conditions as a loss (i.e., wasted time, money, and effort) leads to a greater likelihood of continuing the flight, but framing the decision to not fly as a gain (i.e., it is safer) leads to a greater likelihood of diverting the flight (O'Hare & Smitheram, 1995).

A fifth factor, one that is not discussed by Weigmann and Goh, is what is referred to as problem- solving set (Gick & Holyoak, 1979), which is the tendency to repeat a solution process that has been previously successful. In addition to altering one's perception of risk, successfully conducting a flight in marginal conditions by using a specific strategy (e.g., following a river while flying underneath the clouds) will increase the likelihood that the strategy will be used again under similar circumstances. Memory plays a crucial role in problem-solving, and repetition plays a crucial role in memory. So when faced with a problem (how do I make it through this weather?), humans tend to adopt a strategy that has been used successfully in the past, even if the current situation does not quite match previous events.

Flight Risk Assessment Tool Benefits

The FAA Safety Team (FAASTeam) document, Flight Risk Assessment Tools (General Aviation Joint Steering Committee Safety Enhancement Topic SE 42), explains the multiple benefits of using a FRAT and states in part:

"In the thick" is no time to try to mitigate a potentially hazardous outcome. When preparing for a flight or maintenance task, operators and maintenance technicians should take time to stop and think about the hazards involved.


Attempting this task "in our heads" usually does not take into account actual risk exposure. The mind tends to compartmentalize the individual hazards which, in turn, fails to appreciate their cumulative effects. We may also allow our personal desires to manipulate our risk assessment in order to meet personal goals. The best way to compensate for these inherent shortcomings is to take the task to paper.


Putting everything on "paper" allows us to establish our risk limits in an atmosphere free from the pressure of an impending flight or maintenance task. It also gives a perspective on the entire risk picture that we cannot get in our heads. More importantly, it sets the stage for managing risk through proactive risk mitigation strategies that are documented.


Decision Making

A Human Error Approach to Aviation Accident Analysis: The Human Factors Analysis and Classification System by Douglas Weigmann and Scott Shappell discusses preconditions for unsafe acts. This book discusses decision errors by members of an organization and states in part:

Decision errors, represents intentional behavior that proceeds as planned, yet the plan itself proves inadequate or inappropriate for the situation. Often referred to as "honest mistakes," these unsafe acts represent the actions or inactions of individuals whose "hearts are in the right place," but they either did not have the appropriate knowledge or just simply chose poorly.

Alaska Bush Syndrome

NTSB's safety study, Aviation Safety in Alaska SS-95/03, identifies and discusses what is known as the bush syndrome that affects aviation operations in Alaska. This document states that the bush syndrome is defined as an attitude of air taxi operators, pilots, and passengers ranging from their casual acceptance of risks to their willingness to take unwarranted risks. This document further states:

The demands for reliable air service in Alaska can easily place pressures on pilots and operators to perform. An underlying factor in risk-taking, or "bush syndrome," is a response by pilots and operators to powerful demands for reliable air service in an operating environment and aviation infrastructure that are often inconsistent with those demands.
FLIGHT RECORDERSThe airplane did not carry, nor was required to carry, a crashworthy flight data recorder. At the time of the accident, the operator did not have formal flight data monitoring program in place, nor was it required to have one.
MEDICAL AND PATHOLOGICAL INFORMATIONThe Alaska State Medical Examiner, Anchorage, Alaska conducted an autopsy of the pilot. The cause of death was attributed to multiple blunt force injuries with a contributing cause of thermal injuries.

The FAA's Bioaeronautical Research Sciences Laboratory, Oklahoma City, Oklahoma, performed toxicology tests on specimens from the pilot; results were negative for ethanol and drugs. Carbon monoxide and cyanide tests were not performed.
ORGANIZATIONAL AND MANAGEMENT INFORMATIONAt the time of the accident, Regal Air was headquartered at LHD and conducted cargo, charter, and sightseeing flights throughout Alaska. The operator's fleet comprised wheel-, ski-, and float-equipped Cessna 206s; wheel-, ski-, and float-equipped de Havilland DHC-2s; and a Piper PA-31-350.

Operational Control

The Regal Air GOM discussed operational control and stated in part:

Operational Control is defined in FAR 1 as "the exercise of authority over initiating, conducting, and terminating a flight". Operational Control is exercised through both active and passive means. Passive control consists of developing and publishing policies and procedures for operational control personnel and flight crews to follow in the performance of their duties and assuring adequate information and facilities are available to conduct the planned operation. Active control consists of making those decisions and performing those actions necessary to operate a specific flight such as crew scheduling, accepting charter flights from the public, reviewing weather and NOTAMs, and flight planning.

This document further stated that the president, DO, chief pilot, director of maintenance, the pilot in command, and the duty officer were authorized to act for Regal Air and exercise operational control under 14 CFR Part 135.77. The Regal Air GOM contains the individual names of company management personnel (DO, chief pilot, and director of maintenance).

The duties and responsibilities listed for the duty officer, who reported to the DO, included keeping the daily flight log updated and accurate and handling flight following with the company flight plan. According to the GOM, the duty officer "may be any company officer, management personnel, or employee."

FAA Operations Specification A006 Management Personnel (commonly referred to as an "OpSpec"), included the 14 CFR Part 119 position title, name, and company equivalent position title at the time of the accident (DO, chief pilot, and director of maintenance) for Regal Air.

FAA Operations Specification A008, Operational Control, stated that, before conducting a Part 135 flight or series of flights, at least one management person listed in operations specification A006, Management Personnel, or a designee who was a direct employee of the certificate holder other than a pilot assigned to the specific flight or series of flights, was required to determine and be knowledgeable regarding several aspects of the flight, including whether the assigned crewmember was qualified and eligible to serve as a required crewmember in the aircraft and type of operation assigned and whether the aircraft assigned for use was listed in operations specification D085 and airworthy under the certificate holder's FAA-approved maintenance, inspection, or airworthiness program.

Additionally, it stated that, before conducting a Part 135 flight or series of flights, at least the pilot assigned to the flight was required to determine whether the flight could be initiated, conducted, or terminated safely and in accordance with the certificate holder's operations specifications, GOM, and/or appropriate regulations. This determination could be made by the assigned pilot or assigned flight crewmembers.

Non-management personnel exercising operational control were to meet the requirements of 14 CFR Part 119.69 (d) and 14 CFR Part 135.77. Their names, titles, duties, responsibilities, and authorities were to be specified within the GOM.

14 CFR Part 119.69 states that anyone in a position to exercise control over operations conducted under the operating certificate must be qualified through training, experience, and expertise; to the extent of their responsibilities have a full understanding of aviation safety standards and safe operating practices, Federal Aviation Regulations, the certificate holder's operations specifications, appropriate maintenance and airworthiness requirements, and Part 135 manual; and must perform their duties in order to meet legal requirements and maintain safe operations.

14 CFR Part 135.77, which addresses responsibility for operational control, states that each certificate holder is responsible for operational control and shall list, in the manual required for 14 CFR Part 135.21, the name and title of each person authorized by it to exercise operational control.

Operational Control Training

The DO reported that the company did not have an operational control training program in place before the accident, nor were they required to. The NTSB issued Safety Recommendation A-17-039 to the FAA, which asked the FAA to, "Establish minimum initial and recurrent training requirements for personnel authorized to exercise operational control, including, but not limited to, approved subject knowledge areas, training hours, subject hours, and qualification modules."

The FAA responded to the NTSB on July 21, 2017, and stated, "The FAA agrees that guidance for terrain avoidance can be expanded to include fixed-wing operations and to emphasize the importance of operational control. However, because this operational control change would require rulemaking, we intend to evaluate our current guidance, regulations, and policy, for part 135 operators to determine potential options to satisfy these safety recommendations." At the time of writing of this accident report, the status of Safety Recommendation A-17-039 is classified as "Open-Acceptable Response." Refer to the NTSB internet website for Safety Recommendation A-17-039.

Safety Management System

At the time of the accident, Regal Air had a formal safety management system (SMS) in place. The SMS was managed by the operator's aviation safety officer, who was the company president/director of operations and owner. The SMS includes a safety management plan, incident management, safety meetings, an emergency response plan, and safety education for employees.

When asked if the company used any electronic flight risk assessment tools, the president/director of operations reported, "absolutely not, I can't stand them" and, "they're a complete waste of time."

FAA Order 8900.1 Flight Standards Information Management System

The FAA's Order 8900.1 Flight Standards Information Management System discusses the two-tiered operational control concept and states in part:

All first-tier actions must be taken by the certificate holder's direct employees. The first tier is the assignment of flightcrew member(s) and aircraft for revenue service under the operating certificate. The assignment of crew and release of aircraft to revenue service is the responsibility of the certificate holder, and must be made by the management of the certificate holder or management delegates. In order to be delegated the authority to make these decisions, the management delegates must be trained, found competent, and designated by the certificate holder, be listed in the GOM (or in OpSpec A006, A039 or A040, if applicable), and be under management supervision. . Management supervision means, for example, that the certificate holder tracks the actions of the management delegate or employee, samples the work of that employee (reviews a sample of the decisions made), and has the ability to enforce the certificate holder's standards through corrective actions such as retraining, requalification, or disciplinary actions such as disqualification, demotion, suspension, or termination. Because the certificate holder is responsible for the conduct of its employees or agents, it must have the ability to monitor and control their performance.

All second-tier actions may be taken either by the certificate holder's direct employees or by the certificate holder's agents. The second tier of operational control is more tactical. This involves the decisions made by personnel (such as the PIC) in the day-to-day conduct of operations. This may include the initiation of flights upon the PIC receiving a request from the customer directly (often the case in on-demand operations being conducted under a dedicated service contract, such as offshore operations or emergency medical service (EMS)). This is acceptable if the PIC is authorized by the certificate holder to make those decisions on behalf of the certificate holder. To do so would require that the PIC be trained, found competent by the certificate holder, designated, be listed in the GOM (or in OpSpec A006, A039, or A040, if applicable), and be under management supervision.

The GOM (or other appropriate documentation) must contain guidance which describes the certificate holder's operational control system. The training program must provide the certificate holder's personnel with the knowledge and skills required to ensure that the operational control system is effective.

The FAA's Order 8900.1 Flight Standards Information Management System, also identifies the three failure modes of operational control and states in part:

1) Loss of operational control within the air carrier—hands-off management results in inadequate controls over its own operations.

2) Loss of operational control within the air carrier—exercise of operational control by an unapproved person.

3) Loss or surrender of operational control externally (e.g., an air carrier's illegal renting/franchising-out the use of its air carrier certificate to one or more uncertificated entities).

This document further summarizes operational control and states in part:

Only approved persons may exercise operational control on the certificate holder's behalf. The certificate holder must have adequate controls in place to ensure that officials in a position of authority over flights conducted under the certificate do so safely, and in compliance with the regulations, OpSpecs, GOM, as applicable, and accepted or approved procedures. Management of operations should never be inattentive, distracted, or careless. Hands-off management is not a legitimate excuse for failing to maintain operational control.

FAA Oversight and Surveillance

FAA Order 8900.1 Flight Standards Information Management System, discusses surveillance of operators, and states in part:

The Federal Aviation Administration (FAA) is empowered, by statutory requirement, "...to carry out the functions, powers, and duties of the Secretary relating to aviation safety." One of the most significant duties of the FAA is to conduct surveillance in all areas of air transportation safety. Surveillance is a continuing duty and responsibility of all aviation safety inspectors in the flight standards organization. The term "surveillance," as used in this handbook, relates to this ongoing duty and responsibility and related programs. Surveillance programs provide the FAA with a method for the continual evaluation of operator compliance with Title 14 of the Code of Federal Regulations (14 CFR) and safe operating practices. Information generated from the surveillance programs permits the FAA to act upon deficiencies, which affect or have a potential effect on aviation safety. For surveillance programs to be effective, they must be carefully planned and executed during the conduct of specific inspection activity. Inspections provide specific data, which can be further evaluated; therefore, they support and maintain ongoing surveillance programs.

Regal Air was managed by a certificate management team (CMT) based out of the Anchorage Flight Standards District Office. The CMT comprised one POI, one principal maintenance inspector, and one principal avionics inspector. Regal Air's FAA Operations Specifications were issued by the FAA. Regal Air's GOM was accepted by the FAA. Regal Air's training program was approved by the FAA.

During a postaccident interview, the POI stated that, at the time of the accident, he was responsible for surveilling a total of 50 certificates. He reported that this was the maximum number of certificates he had been assigned during his career. When asked if he felt he had adequate time to perform the duties associated with the 50 certificates, he responded that he did not, and that the workload was prioritized by risk for each certificate. A complete transcript of the interview is available in the public docket.

Review of FAA records for Regal Air, which included data from Program Tracking and Reporting System (PTRS) and the Safety Assurance System (SAS), indicated that the POI conducted a GOM inspection on June 29, 2016, and no issues were noted. Additionally, no issues of concern were found noted in the PTRS and SAS data regarding Regal Air's operational control, flight release, or training programs during the 3 years before the accident.