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Safety Recommendation Details

Safety Recommendation A-11-048
Synopsis: On August 9, 2010, about 1442 Alaska daylight time, a single-engine, turbine-powered, amphibious float-equipped de Havilland DHC-3T airplane, N455A, impacted mountainous, tree-covered terrain about 10 nautical miles (nm) northeast of Aleknagik, Alaska.1 The airline transport pilot and four passengers received fatal injuries, and four passengers received serious injuries. The airplane sustained substantial damage, including deformation and breaching of the fuselage. The flight was operated by GCI Communication Corp. (GCI), of Anchorage, Alaska, under the provisions of 14 Code of Federal Regulations (CFR) Part 91. About the time of the accident, meteorological conditions that met the criteria for marginal visual flight rules (MVFR)2 were reported at Dillingham Airport, Dillingham, Alaska, about 18 nm south of the accident site. No flight plan was filed. The flight departed about 1427 from a GCI-owned private lodge on the shore of Lake Nerka and was en route to a remote sport fishing camp about 52 nm southeast on the Nushagak River. The National Transportation Safety Board (NTSB) determined that the probable cause of this accident was the pilot’s temporary unresponsiveness for reasons that could not be established from the available information. Contributing to the investigation’s inability to determine exactly what occurred in the final minutes of the flight was the lack of a cockpit recorder system with the ability to capture audio, images, and parametric data.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Consult with appropriate specialists and revise the current internal Federal Aviation Administration guidance on issuance of medical certification subsequent to ischemic stroke or intracerebral hemorrhage to ensure that it is clear and that it includes specific requirements for a neuropsychological evaluation and the appropriate assessment of the risk of recurrence or other adverse consequences subsequent to such events.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Aleknagik, AK, United States
Is Reiterated: No
Is Hazmat: No
Accident #: ANC10MA068
Accident Reports: Collision into Mountainous Terrain, GCI Communication Corp. de Havilland DHC-3T, N455A
Report #: AAR-11-03
Accident Date: 8/9/2010
Issue Date: 6/9/2011
Date Closed: 12/3/2013
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Medical

Safety Recommendation History
From: NTSB
Date: 12/3/2013
Response: In its August 19, 2011, letter, the FAA stated that, on June 3, 2011, it had revised the Aeromedical Certification Reference Manual (ACRM) to improve guidance regarding cerebrovascular accidents, including specific requirements for neurocognitive testing. Unfortunately, the July 2010 version of the ACRM guidance enclosed with the letter did not include the revisions made on June 3, 2011. This recommendation was issued because of the shortcomings of the earlier version of the guidance. In our December 16, 2011, letter, we indicated that, before we could close this recommendation, we would need to review the revisions to the ACRM. We are grateful that the FAA subsequently supplied a copy of the revised sections of the ACRM, which we reviewed, and for the October 23, 2013, meeting between members of our staffs to discuss those revisions. Because the revised document satisfies Safety Recommendation A 11 48, the recommendation is classified CLOSED—ACCEPTABLE ACTION.

From: NTSB
Date: 12/16/2011
Response: On June 3, 2011, the FAA revised the Aeromedical Certification Reference Manual (ACRM) to improve guidance regarding cerebrovascular accidents, including specific requirements for neurocognitive testing. The FAA’s August 19, 2011, letter included a copy of the July 2010 version of the ACRM guidance on these accidents but not the revisions made on June 3, 2011. We point out that this recommendation was issued because of the shortcomings of the July 2010 version of the guidance; however, we are not able to evaluate—without examining a copy of the revised ACRM—whether the recent revisions fully address the issues raised in this recommendation. On September 15, 2011, NTSB staff requested a copy of the June 3, 2011, revisions, but, as of the date of this letter, we have not received that information. Although the FAA regards its actions in response to this recommendation to be complete, we need to review the revisions to the ACRM before we can close Safety Recommendation A-11-48. Accordingly, pending our receipt and review of the current version of the ACRM guidance regarding cerebrovascular accidents, and our determination that it adequately addresses the issues in this recommendation, Safety Recommendation A-11-48 is classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
Date: 8/19/2011
Response: CC# 201100331: - From J. Randolph Babbitt, Administrator: The Federal Aviation Administration (FAA) agrees that portions of the neurology section of the Aeromedical Certification Reference Manual (enclosed), which is an internal reference guide to be used in the evaluation of airmen and air traffic controllers for medical certification or medical clearance, are confusing and not well organized. The Aeromedical Certification Reference Manual was revised on June 3, 2011. The revision provides guidance for cerebrovascular accidents, which include a completed stroke, either ischemic or hemorrhagic. The guidance also includes specific requirements for neurocognitive testing. Consultation with "appropriate specialists" and review of current medical scientific peer reviewed literature is the usual and standard process for the review of any medical standard set by the FAA's Office of Aerospace Medicine (AAM). In April 2010, the FAA Federal Air Surgeon (FAS) convened a Neurology Summit that brought together prominent neurologists familiar with aviation medical standards to review FAA policy in a number of important neurologic areas. This group made recommendations to the FAS for changes in some portions of neurologic policy and reaffirmed other existing neurologic policy. The FAS continues to incorporate recommendations from the Neurology Summit into current medical policy. Guidance regarding mandated neuropsychological testing was initiated verbally shortly after the completion of the Neurology Summit and was added to the Aeromedical Certification Reference Manual on June 3, 2011. The assessment of aeromedical risk and the risk of recurrence of any medical condition is the hallmark of any aerospace medicine evaluation. In every evaluation, whether performed directly by an Aviation Medical Examiner (AME), or indirectly by a complete review of the medical records, the AAM is assessing risk. This basic concept is taught as part of all basic and recurrent AME training, and is inherent in the thinking of all AAM physicians. It is not necessary to state this repeatedly in internal guidance documents, and therefore we do not intend to make this change. I believe the FAA has effectively addressed this safety recommendation, and I consider our actions complete.