The NTSB written report on this accident was finally Published:


"4.1 New Safety Recommendations
To the Federal Aviation Administration:

Analyze automatic dependent surveillance-broadcast data from Ketchikan air tour operations on an ongoing basis and meet annually with Ketchikan air tour operators to engage in a nonpunitive discussion of any operational hazards reflected in the data and collaborate on mitigation strategies for any hazards identified. (A-17-42)

Develop and implement special operating rules for the Ketchikan air tour industry that include en route visual flight rules weather minimums that are tailored to the industry’s unique requirements and are more conservative than those specified in 14 Code of Federal Regulations Part 135. (A-17-43)

To Cruise Lines International Association:
Encourage your members that sell air tours as shore excursions to review the circumstances of this accident and to consider ways to mitigate associated risks. (A-17-44)"

Board Member Statement

Member Christopher A. Hart filed the following concurring statement on May 1, 2017:------

"Nonetheless, by analogy here, the big picture would suggest that two other participants that are involved in this situation – the cruise ship operators and the Medallion Foundation – should work with the carriers in an effort to create a sightseeing program that eliminates financial incentives to carriers to take more risk. The cruise ship operators make the flight services available to the passengers, and the Medallion Foundation was created to help improve the safety of the carriers in Alaska, so they, in addition to the carriers, have a vested interest improving the safety of the sightseeing carriers by eliminating these adverse incentives.

Time Pressure. Another issue in this accident was the time pressure that was created by the agreement between the cruise ship operator and the sightseeing carrier that if the carrier returned passengers too late to catch the ship, the carrier would be responsible, at its expense, for timely delivery of the passengers to the cruise ship’s next port of call, which might be several hundred miles away. In this accident the pressure to return the passengers to the ship in time clearly played a key role in the pilot’s decision to take a shorter but obviously more dangerous route back to the ship.

As with the adverse safety incentives, the cruise ship operators and the Medallion Foundation should work with the carriers to develop agreements that eliminate this time pressure because they all have a vested interest in improving safety. The program would need to be more comprehensive than simply enlarging the time window because the problem, although it might be less frequent, could still occur."

Acting Chairman Sumwalt and Members Weener and Dinh-Zarr joined in this statement.