AIRBUS AS350B2Safari Aviation Inc.
Kekaha, HI, USA · 2019-12-27·N985SA
What happened
NTSB summary, verbatimOn December 26, 2019, about 1657 Hawaii standard time, an Airbus AS350 B2 helicopter, N985SA, was destroyed when it collided into terrain in a remote, wooded area about 11 miles north of Kekaha, Hawaii, on the island of Kauai. The pilot and the six passengers were fatally injured. Safari Aviation Inc. (Safari), doing business as Safari Helicopters, operated the flight as a Title 14 Code of Federal Regulations (CFR) Part 135 on-demand air tour under visual flight rules (VFR).
Photographs
9the aircraft, and what the investigators foundPhotographs are NTSB docket attachments — works of the US government, in the public domain. Captions are the Board’s own.
Probable cause
the Board's determinationThe pilot’s decision to continue flight under visual flight rules (VFR) into instrument meteorological conditions (IMC), which resulted in the collision into terrain. Contributing to the accident was Safari Aviation Inc.’s lack of safety management processes to identify hazards and mitigate the risks associated with factors that influence pilots to continue VFR flight into IMC. Also contributing to the accident was the Federal Aviation Administration’s delayed implementation of a Hawaii aviation weather camera program, its lack of leadership in the development of a cue-based weather training program for Hawaii air tour pilots, and its ineffective monitoring and oversight of Hawaii air tour operators’ weather-related operating practices.
Occurrence sequence
2 stepsNTSB coding · CICTT taxonomy- 1 · Enroute-cruiseVFR encounter with IMCdefining event
- 2 · Enroute-cruiseUnknown or undetermined
Findings
6 causal · 0 contributing- CAUSEPersonnel issues › Action/decision › Info processing/decision › Decision making/judgment — Pilot
- CAUSEEnvironmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip › Below VFR minima — Effect on operation
- CAUSEOrganizational issues › Support/oversight/monitoring › Safety programs › Adequacy of safety program — Operator
- CAUSEOrganizational issues › Management › Resources › Availability of equipment — FAA/Regulator
- CAUSEOrganizational issues › Support/oversight/monitoring › Oversight › Oversight of reg compliance — FAA/Regulator
- CAUSEOrganizational issues › Support/oversight/monitoring › Training › Emergency proc training — FAA/Regulator
Safety recommendations
10 issuedwhat changed because of this accidentTO THE FEDERAL AVIATION ADMINISTRATION: Install the necessary infrastructure in Hawaii to enable continuous radio communication between the pilots of low-flying tour flights and ground support personnel, such as flight service station specialists and company flight support personnel, along the most heavily trafficked air tour routes.
TO THE FEDERAL AVIATION ADMINISTRATION: Implement automatic dependent surveillance-broadcast (ADS-B) infrastructure improvements in Hawaii, such as additional ADS-B ground stations, that provide adequate coverage to enable real-time flight tracking and traffic advisory services for ADS-B Out- and In-equipped, low-flying air tour aircraft throughout their entire tour routes.
TO THE FEDERAL AVIATION ADMINISTRATION: As an interim measure until completion of the action to satisfy Safety Recommendation A-21-15, require Hawaii air tour operators to install Automatic Dependent Surveillance-Broadcast Out (ADS-B) equipment in their aircraft to enable real-time flight position tracking.
TO THE FEDERAL AVIATION ADMINISTRATION: Require air tour operators to have flight support personnel who are trained to exercise operational control authority, participate in preflight risk analysis, provide pilots with weather briefings, monitor the progress of the flights, and participate in two-way communications with pilots to alert them of any weather hazards.
TO THE FEDERAL AVIATION ADMINISTRATION: Develop guidance for small operators for scaling a safety management system that includes methods and techniques for implementation and specific examples applicable to several operational sectors, including air tours.
TO THE FEDERAL AVIATION ADMINISTRATION: Issue a safety alert for operators to encourage air tour operators to establish safety assurance processes to routinely review recorded onboard videos and automatic dependent surveillance-broadcast (ADS-B) flight tracking data, ideally as part of a safety management system with an integrated flight data monitoring program, for the purpose of identifying and addressing risky trends in weather-related operating practices, such as encounters or near encounters with instrument meteorological conditions-related hazards.
TO THE FEDERAL AVIATION ADMINISTRATION: Improve the surveillance of air tour operations in Hawaii through the use of technologies and innovative approaches, including but not limited to comparing automatic dependent surveillance-broadcast (ADS-B) flight position data from air tour flights with weather camera imagery for the route and periodically reviewing onboard video recordings, to detect and correct operating practices that may lead to unacceptable weather-related risky behavior.
TO THE FEDERAL AVIATION ADMINISTRATION: Issue and periodically update a special airworthiness information bulletin that lists newly manufactured helicopters that are equipped with features likely to reduce accidents resulting from inadvertent encounters with instrument meteorological conditions, describes retrofit options for helicopters that do not have such equipment, and encourages the voluntary integration of these safety features.
TO THE VERTICAL AVIATION SAFETY TEAM: Include, in your proposed helicopter safety rating system, helicopter safety features for preventing accidents resulting from inadvertent encounters with instrument meteorological conditions.
TO THE TOUR OPERATORS PROGRAM OF SAFETY: Inform your members and make information available to the broader air tour community about the circumstances of this accident, provide information about available helicopter safety technologies for reducing the risk of accidents related to inadvertent encounters with instrument meteorological conditions, and encourage air tour operators to voluntarily incorporate such features into their helicopter fleets.