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Safety Recommendation Details

Safety Recommendation A-14-109
Details
Synopsis: On March 30, 2013, at 2320 Alaska daylight time, a Eurocopter AS350 B3 helicopter, N911AA, impacted terrain while maneuvering during a search and rescue (SAR) flight near Talkeetna, Alaska. The airline transport pilot, an Alaska state trooper serving as a flight observer for the pilot, and a stranded snowmobiler who had requested rescue were killed, and the helicopter was destroyed by impact and postcrash fire. The helicopter was registered to and operated by the Alaska Department of Public Safety (DPS) as a public aircraft operations flight under 14 Code of Federal Regulations Part 91. Instrument meteorological conditions (IMC) prevailed in the area at the time of the accident. The flight originated at 2313 from a frozen pond near the snowmobiler’s rescue location and was destined for an off-airport location about 16 mi south.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Revise the Pilot’s Handbook of Aeronautical Knowledge to clarify the information it contains on attitude indicator pitch and bank limitations to explain that attitude indicators have pitch and bank indication limits, that the pitch indicating range is required to be at least ± 25°, and that, if an aircraft operates at a pitch that exceeds the indicating limits, the pitch indicator may stop and remain at the limit until the pitch no longer exceeds the limitation, or the pitch indicator may tumble.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Aviation
Location: Talkeetna, AK, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: ANC13GA036
Accident Reports: ​Crash Following Encounter with Instrument Meteorological Conditions After Departure from Remote Landing Site Alaska Department of Public Safety Eurocopter AS350 B3, N911AA
Report #: AAR-14-03
Accident Date: 3/30/2013
Issue Date: 11/24/2014
Date Closed:
Addressee(s) and Addressee Status: FAA (Open - Acceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 7/22/2019
Response: We note that the next revision of the PHAK will include guidance on current glass cockpit technology improvements and on the contents of Safety Alert for Operators 17008, “Attitude Indicator Pitch Indication Limitations,” and is expected to be published in December 2020. Pending our review of the revised handbook, Safety Recommendation A-14-109 remains classified OPEN--ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 4/24/2019
Response: -From Daniel K. Elwell, Acting Administrator: The Board's September 18, 2018, letter mentions updating information in the Pilot 's Handbook of Aeronautical Knowledge concerning improvements to attitude indicators used in glass cockpit technology. The anticipated publication date for the next revision of the Pilot's Handbook of Aeronautical Knowledge is December 2020 and will contain the recommended language from Safety Alert for Operators 17008 concerning the limitations of some attitude indicators. We anticipate providing an updated response by April 2020.

From: NTSB
To: FAA
Date: 9/18/2018
Response: We note that, in 2016, you updated the PHAK with guidance on angle-of-attack indicators, and, during the next revision cycle, you intend to update the PHAK to include guidance on current glass cockpit technology improvements and on the contents of Safety Alert for Operators 17008, “Attitude Indicator Pitch Indication Limitations.” Pending our review of the revised handbook, Safety Recommendation A-14-109 remains classified OPEN--ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/29/2018
Response: -From Daniel K. Elwell, Acting Administrator: The FAA plans to add language aligning Section 8-18 of the Pilot's Handbook of Aeronautical Knowledge with current glass cockpit technology improvements and Safety Alert for Operators (SAFO) 17008, Attitude Indicator Pitch Indication Limitations. Taking into account publication schedules, we expect to implement the changes by 2020. This SAFO is available at the following website: https://www.faa.gov/other_visit/aviation_industry/airline_operators/airline_safety/safo/all_safos/media/2017/SAFO17008.pdf. Additionally, we updated section 5-26 of the Pilot's Handbook of Aeronautical Knowledge in 2016 with new guidance describing the function and use of angle of attack indicators in aircraft, as well as reducing stall and loss of control events. This update addresses the topic "Prevent Loss of Control in Flight in General Aviation:· noted by the Board as a critical aviation accident reduction area in the 2017-2018 Most Wanted List. I believe that the FAA has effectively addressed Safety Recommendation A-14-l07 and consider our actions complete. I will keep the Board informed or the FAA’s progress on Safety Recommendation A-14-109 and provide an update by April 2019.

From: NTSB
To: FAA
Date: 4/8/2015
Response: We note that you plan to integrate the recommended information into the Pilot’s Handbook of Aeronautical Knowledge the next time you revise the handbook. Pending our review of the revised handbook, Safety Recommendation A-14-109 is classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 1/30/2015
Response: -From Michael P. Huerta, Administrator: The Pilot's Handbook of Aeronautical Knowledge briefly discusses the pitch and bank limitations of most attitude indicators. The Instrument Flying Handbook also gives information regarding gyroscopically-driven attitude indicators, as well as limited detail about the caging mechanism contained on some older units. However, the FAA agrees that additional clarification of instrument limitations would be useful. The FAA plans to integrate this information into the Pilot's Handbook of Aeronautical Knowledge during the next revision cycle. This revision would also include the appropriate revisions developed in response to recommendation A-14-108. I will keep the Board informed of the FAA's progress on these recommendations and provide an update by February 2016.