MONDOR: The FAA’S latest Alaska aviation safety report harkens back to a whole lot of history

"Pea Soup" weather conditions in Southeast Alaska. (Photo by JLS Photography - Alaska/Flickr Creative Commons)

On December 7, 1999 a commuter flight enroute to Nightmute crashed about fifty miles from its departure point of Bethel. All five of the passengers, Henry and Theresa Tony, Matthew and Lucy Friend, and Isadore Therchik, were killed along with their pilot, Brenden Sullivan. The National Transportation and Safety Board (NTSB) would later determine the accident’s probable cause was due to the pilot’s continued visual flight into instrument meteorological conditions, also known as “VFR into IMC”. (In basic language, that means the pilot was operating under visual flight rules, and thus dependent upon certain visibility requirements, yet continued to fly in diminished weather conditions that warranted operation under the far more stringent instrument flight rules.)

When Flight 261 took off from Bethel, the local weather reported an overcast layer of clouds at 2,000 feet and ten miles visibility. Another pilot on a similar route who departed at almost the same time told investigators he encountered a “wall of weather” near the accident site, with fog and clouds rising up from the ground to about 1,500 feet. The closest available weather to the crash site was Bethel, and then Hooper Bay, about 90 miles northwest, and Mekoryuk, 80 miles south-southwest. There was no official weather for Nightmute, as that village did not have weather-reporting capability. It also had no instrument approach procedure.

Like many air taxis and commuters in Alaska of that era, which still fly under Part 135 of the Federal Aviation Regulations, Flight 261 was operated in a single-engine aircraft under visual flight rules. In 1999 there was a limited number of airports in the Y-K Delta that offered instrument approaches and certified weather. Without them, the safer option of instrument flight was unavailable for companies seeking to invest in aircraft approved to fly under instrument flight rules (IFR) with specially trained pilots. 

The NTSB and Federal Aviation Administration (FAA) were aware of the problem; by the time of the Nightmute accident the federal government had been studying it for decades. Based on the appearance of yet another report on Alaska air safety it is clear however, that while the problem is all too familiar, the solution remains stubbornly elusive. 

Everyone believes increased instrument flight is the route to safety in Alaska; the federal government just seems unwilling to pay for it.

Yet another study

Last month, the final report of the FAA’s Alaska Aviation Safety Initiative (FAASI) was released. A continuation of earlier Alaska Part 135 safety discussions, the report was put together with input from some 100 stakeholders that included pilots, operators and associations like the Alaska Airmen and Alaska Air Carriers. The 83-page report was buttressed with 40 pages of stakeholder comments that are bracing in both their honesty and frustration.  

This seems like it should be a prescient moment for aviation safety. As FAA Administrator Steve Dickson stressed in an Op-Ed about the FAASI to the Juneau Empire, “The FAA is committed to getting the work we’ve outlined done to make flying safer for everyone in Alaska.”

Before anyone basks too much in the accomplishment however, it is worthwhile to consider what the FAASI did not address, which is all the federal reports on Alaskan aviation safety that have come before it. This collection of studies, surveys and investigations, dating back more than forty years, provides remarkably similar conclusions and recommendations as those offered in the FAASI. This is particularly true when talking about the availability of routes and airports that accommodate instrument flight rules, and the prevalence of accidents that occur when pilots fly under VFR into IMC.

The Long Federal History of Studying Alaska Aviation

During World War II, to support the Lend Lease program, there was enormous federal investment in Alaska’s aviation infrastructure. Airports were built, existing runways were expanded and paved and navigational aids were installed. Similar work was done across the country but unlike the Lower 48, much of the investment in Alaska stalled after the war. With a low population and problems of weather, geography, and distance, the cost for modernizing such a large aviation environment was deemed excessive. 

The mythology of Alaska as a treacherous place to fly, already popular due to tales from the early bush pilot era, took over in this period with a prevalent narrative developing that accidents were an inherent part of Alaska aviation. In only a few years, as investment in air routes and weather reporting lagged further and further behind the Lower 48, the mythology became a fact. It truly was more dangerous to fly in Alaska, but as research into accidents was conducted it revealed a reason far more prosaic than mountains and snow. Pilots crash more frequently in Alaska because they do not have access to the infrastructure that is common in the Lower 48.

In 1980 the NTSB published a Special Study on Air Taxi Safety in Alaska. The report’s authors settled on three factors for the high commercial accident rate: “bush syndrome” (risk-taking behavior), inadequate airport facilities, and “inadequate weather observations, inadequate communications of weather information and insufficient navigation aids.” The report noted that references to “bush syndrome” were often emphasized by state and federal officials who “placed greater emphasis on operator and pilot attitude and less on physical infrastructure.” But the NTSB recognized that risky behavior did not develop on its own declaring, “bush syndrome is, in part, a manifestation of the deficiencies in the aviation system infrastructure…” The report then went on to note specifically that those deficiencies included “inadequate runways and insufficient aids to navigation and weather observation stations.” 

The board urged improvements in the areas of runway facilities, placing more Flight Service Stations and certified weather observers in villages, permanent placement of FAA inspectors in Bethel, Ketchikan, Nome and other regional hubs, and a higher degree of cooperation between the FAA, National Weather Service (NWS), the State of Alaska and aviation community for what was termed the “Alaskan aviation system.”

This densely packed and informative report should have been a revelation. 

Fifteen years later, after a host of devastating accidents, the NTSB revisited the subject to see how much had changed.

The 1995 NTSB safety study identified VFR into IMC—the familiar problem of relying on visual cues when flying in weather conditions that actually require the use of instruments and existence of an established instrument route structure—as the leading probable cause for commuter and air taxi accidents. It further noted that commercial operators were continuing to assume “higher-than-normal risks in response to demands for reliable air service in an operating environment and aviation infrastructure that are often inconsistent with these demands.” 

In other words, pilots were flying in areas that were dependent upon air service and presented weather conditions that required instrument flight, but instrument flight was not possible. The NTSB also found that while instrument approaches at airports would become more widely available with GPS, lack of necessary weather reporting facilities would prevent the use of those approaches. Perhaps most damning of all was that between 1980 and 1995, the number of aviation weather reporting sites in Alaska had not changed.  

(The acquisition of weather observing systems is complex. Some are owned by the NWS, some by the FAA and some by private entities. The most common manner of purchasing them for official use in aviation is with federal airport improvement funds, but there are multiple layers of state and federal decision-making involved. Private installation of systems is possible, but they can not be approved for “official weather” unless their deployment, use, and maintenance adheres to FAA guidelines.) 

Also in 1995, the FAA released a report focused on some single-engine Part 135 operations under IFR. The Alaska Air Carriers Association told the agency “it is believed that shifting…essential operations from the VFR environment to the IFR environment will have a great impact on safety.” The FAA agreed in the report, noting that increased IFR operations would benefit Alaska, where “a disproportionate share of accidents occur when aircraft continue flight under VFR into IMC.”

In 2001 the FAA published a report on Capstone, the federally funded program that tested ADS-B technology in Alaska before taking it nationwide. It drew on data from three other FAA reports previously published in 1982, 1998 and 1999, as well as the 1995 NTSB safety study. The Capstone report noted that earlier studies discussed the prevalence of VFR into IMC accidents, and the need for improved weather reporting services and expansion of the IFR route structure. 

The theme of IFR operations as increasing safety versus Alaska lacking the widespread infrastructure to support it, is the most familiar refrain in writing about Alaska aviation. In a 2006 Centers for Disease Control and National Institute of Occupational Safety and Health (NIOSH) survey, the report’s authors acknowledged they were on familiar ground and that “the FAA, NTSB and other agencies have investigated many aspects of the regional airline industry.” This report asked focus groups to share perceived “barriers” to aviation safety. The first two on the list were “inadequate weather reporting and a lack of weather-reporting equipment and trained weather observers” and “limited airport, airway and navigation infrastructure.” In seeking more answers, the CDC and NIOSH simply found echoes of all those that had been said before.

So, the FAASI report’s conclusion that “there are a variety of barriers, which, if eliminated or reduced would likely encourage…operators to operate in the IFR environment” has hardly arrived in a vacuum. This information has been known by everyone who asked for it over the forty years. In fact, in 1980 the NTSB noted that the FAA’s July 1979 update of the Ten Year Plan for Alaska recommended “major improvements to the aviation infrastructure, including the navaid system, weather observation and reporting system, and the airport system.” 

The FAA is thus finding out today what the FAA has known all along.

No Certified Weather = No Instrument Flying

One clear problem when it comes to IFR accessibility in 2021 is that, according to the FAASI, there are 112 airports in Alaska that do not have instrument approach procedures at all. For those destinations, only VFR flight is available. But for airports that do have instrument approaches, the FAASI does not document the frequency or degree of broken weather observation equipment, which was a stated concern for the pilots and operators who provided input during the drafting of that report.

Without certified weather reporting, or an FAA-approved exception to that requirement, air taxis and commuters are not permitted by the regulations to file a flight plan under IFR for that destination. According to the FAASI, there are 133 automated weather stations in Alaska (compared to about 1,800 in the lower 48). These stations, as well as specially trained human observers, provide the necessary weather reporting for an airport’s instrument approach procedure to be legally used. It is unclear how many of the state’s airports have instrument approaches with no certified weather available (the report uses the word “several”). Lack of weather reporting, the FAASI noted, is “a significant impediment to aviation operations”. 

Then there is the issue of broken navaids and weather stations, which can take months to be acknowledged and years to repair. The Galena VOR, (a navigation system), is perhaps a worst case scenario; it was destroyed in a 2013 flood and is set to finally return to service next year. The nine-year delay, according to the FAASI, was due to the FAA’s complex budgetary process and what was termed “remote and inhospitable terrain” plus Alaska’s shortened construction season. (Details on the condition of the longtime road to the Galena VOR, which should have been used by maintenance crews, were not included in the report.) 

When it comes to outages of Automated Weather Observing Systems (AWOSs), the situation is more pervasive. From a stakeholder comment in the FAASI:

The FAA needs to change their approach to AWOS outages…The FAA doesn’t consider an AWOS broke if it is a partial outage. Telecommunication issues aren’t reported by the FAA as a broken AWOS. From an operator standpoint if an AWOS has a partial outage or a telco [sic] issue then the operators can’t fly because they don’t have the information needed.”

Other stakeholders also complained about repeated telecommunication issues with AWOSs, and the failure of the FAA to properly designate them as broken. This raises a question concerning the reliable functionality of the AWOS system, because when a station is down, in terms of usability, it takes the entire instrument approach procedure down with it. But from comments in the FAASI, the FAA appears to continue to consider these approaches as available, when in truth no one can file an IFR flight plan to those destinations. 

The reasons why the definition of “broken” is elusive for the FAA when applied to a weather observing system is unclear. It could be due to lack of funds to fix it or an unwillingness to acknowledge chronic issues at certain sites or confusion over how debilitative and long term telecommunications issues can be in rural Alaska. Ultimately though, the reason is immaterial. When an AWOS is down, an instrument approach goes down with it and so does the level of safety for aircraft operations into that airport. And if an accident involving VFR into IMC occurs there, the probable cause finding is not likely to mention the AWOS. It will only say the pilot made a choice, and another crash will be added to the state’s statistics for federal agencies of the future to reference in their reports. 


In light of issues regarding both the number of weather stations and their maintenance, it is appropriate that the FAASI reviewed the solution that was proposed in 2018 with H.R. 302—the FAA Reauthorization Act. Under Section 322, the bill provided a process so Part 135 operators could fly IFR to airports with instrument approaches but no certified weather. Working with their assigned FAA principal operations inspectors, companies would develop FAA-approved procedures for specific airports. According to documents obtained via the Freedom of Information Act, multiple companies including Bering Air, Hageland Aviation, Warbelow’s, and Grant Aviation pursued the Section 322 process. The problem was that while the FAA had created an opportunity, its personnel were not in agreement about how to make it a reality. 

Frequent and frustrating email exchanges occurred in 2019 within the varied layers of FAA bureaucracy on Section 322. The FAA inspector handling Hageland Aviation’s application put a fine point on that frustration in a July email. 

“It defies logic to prevent a certificate holder from using H.R. 302,” he wrote, referencing the recent bill. “Operations under HR302 are without any doubt, immensely safer than their current method of operations. Denying their use of HR302, knowing they will continue to operate to those locations VFR, or back down to the lowest level of safety, would be a shame, when the FAA has the chance to use HR302 and increase safety.” 

Ultimately only Hageland’s procedures received approval. This gave one company the ability to operate both safer and more reliably than its competitors. There was no explanation from the FAA as to why Hageland, which was part of Ravn Air Group, obtained the permission, unlike Bering Air, Grant, Warbelow’s and others. For its part, the FAASI directs blame for the Section 322 failure at Alaska and its geography, writing that the “legislation direction has been extremely difficult to implement, as the rural nature of the communities served precludes reliable, trained weather observers or special weather equipment.” There is no mention of Hageland’s approval in the FAASI although it was discussed at length in the 2019 NTSB roundtable on Alaska Part 135 Flight Operations, entitled “Charting a Safer Course”, which was held in Anchorage..

Cost-Benefit Analysis

The FAASI does delve into several other issues including the ongoing project to map mountain passes, expanded deployment of weather cameras, and development of the visual weather observation system. There are some areas in which the report remains stubbornly obtuse, however. In the section discussing the further development of low altitude IFR routes, so-called “T-routes”, the FAASI includes a discussion of the Capstone program which ended in 2006. Capstone developed and utilized a low enroute IFR structure in Southeast, the “R-routes”, which are “essentially obsolete” as they are only approved for use with what is now outdated equipment. Operators brought up this issue in comments to the report, asking if approval could be granted to develop training programs and continue to use the routes with modified Garmin technology. The FAASI team provides no insight as to why these approvals have not been granted or if they are even under consideration. 

(The situation is reminiscent of the 1978 loss of the Wien Air Alaska system of nondirectional beacons which were installed and maintained by that airline. The equipment remained after Wien went out of business, but as recounted in the 1980 NTSB study, was deactivated and unusable to anyone else without FAA maintenance and approval.) 

Telling it like it is

More than anything else in the FASSI however, it is the lack of forthright discussion about funding issues that stands out. As comments from the 2019 NTSB roundtable transcript reveal, those participants were forthright when it came to discussing the battle for federal funds. In a conference room populated by federal employees, industry representatives, and management from several of Alaska’s larger air taxis and commuters, some individuals were compelled to extraordinarily honesty on the question of why instrument flight was so often recommended by the same agencies who were silent on failures to fund and maintain its necessary infrastructure.

“As long as the appropriations for Alaska and the FAA are made based on a cost-benefit analysis,” said Grant Aviation’s Dan Knesek, “putting an AWOS or an instrument approach in a tiny little village in western Alaska is never going to pass. So we can have all these meetings and do all we want, but we need to be able to come up with the money and investment on the federal side.”

The FAA’s Richard VanAllman, with the Planning and Requirements Group, proved Knesek’s point when he said “…there are some things that are just not going to happen because they’re just not economically feasible.” 

Jens Hennig of the General Aviation Manufacturers Association was the most darkly direct of all. 

“It sounds like money and federal money would be key here,” he said, “so Congress gets a role here. I mean, that’s not an easy nut to crack in D.C….if I go to a meeting about airspace today, we talk about one thing: New York. New York is choking the airspace for the United States. So look at getting into the priority station queue of New York being the focus.”

It’s hard to see how Alaska fits into any conversation that includes New York, or understand why two such vastly different states should ever have to be in competition over flight safety funds in the first place. The most obvious difference, as it always is when considering Alaskan transportation needs, is that one state has the luxury of a complex road system and the other does not. There will, in fact, never be a time when surface transportation compares to air travel for Alaskans, and there is no way in which Alaska’s unique aviation dependence can be compared to that of any other state. But all discussions about aviation in Alaska either officially, or covertly, include such comparisons. Like it or not, agree with it or not, this is the funding reality in which the FAASI, and all of its promises, has to be viewed through.

December 14, 1999 in Nightmute

So, with all this history of disappointment, what do we make of the FAA Alaska Aviation Safety Initiative?

In the Juneau Empire last month, FAA Administrator Dickson wrote that he is “…proud of what we achieved so far by working together” but sees the FAASI as a “starting point rather than an end.” If this is, again, a new beginning for the FAA’s approach to flight safety in Alaska then Mr. Dickson should familiarize himself with all the assurances offered by his predecessors, and thus minimize the agency’s habit of repetitive language, assertions, and promises. He also might want to review a few brief comments from the Oversight Hearing on Alaska Aviation Issues for the 21st Century, which was held in Anchorage on December 14, 1999. 

In that hearing before Senator Ted Stevens and Congressman Don Young, Patrick Poe, FAA Regional Administrator for the Alaska Region, made an all-too familiar mention of the “unique weather and terrain that poses great challenges to aviation” in the state. He then pointed out one accident in particular, that had occured just one week earlier, and resulted in six fatalities. This was the crash of Flight 261. In considering how the accident that weighed heavily on Poe’s mind back then could still resonate for aviation safety today, the current FAA Administrator could learn a lot by surveying present conditions at Nightmute.

Twenty-two years after the tragedy, that airport still does not have an instrument approach. Just as Flight 261 operated in 1999, the only way to fly into the village is under VFR.  

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1 Comment on "MONDOR: The FAA’S latest Alaska aviation safety report harkens back to a whole lot of history"

  1. Flying into Nightmute was always interesting. When the winds were “wrong”, sometimes the plane, a Twin Otter flown by ERA, would land on the frozen river immediately in front of the village rather than the runway outside of town.

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