Safety Recommendation A-07-018

On September 9, 2024, former FAA Administrator Michael G. Whitaker informed us that the agency is continuing the work described in its previous letter regarding Safety Recommendations A-07-18 and -19. We look forward to receiving your next update.

We note that your revisions to Operations Specifications (OpSpec) Paragraph B048, “Operations in the Vicinity of the Hawaiian Islands,” and Letter of Authorization (LOA) B548 continue to be delayed. We also note that, in 2023, you released a draft of Advisory Circular (AC) 136-B048, Supplemental Information for the Creation of Operating Procedures and Pilot Training Subjects Related to OpSpec/LOA B048, which proposed guidance for applicable certificate holders and operators on creating their specific operating procedures and pilot training subjects, as they pertain to meeting the conditions and limitations of OpSpec/LOA B048.

In addition, based on your review of Hawaii air tour operators’ proprietary training materials for the required cue-based, island-specific weather training, you believe the quality of this training material has improved and satisfies the need for training examples.

We remain concerned that, although OpSpec B048 and LOA B548 currently require “cue-based island-specific weather training,” and you intend to include this requirement in the updated policy documents, you have not yet developed a cue-based training program for commercial air tour pilots in Hawaii, as recommended. Instead, you have shifted responsibility for developing this training to operators.

We do not believe the guidance contained in draft AC 136-B048 is sufficient to ensure that operators’ training programs provide pilots with the type of training that the FAA’s cue-based training research determined was effective for improving pilots’ skills in accurately assessing and avoiding hazardous in-flight weather conditions.

Pending our review of a plan to develop the recommended training and completion of the recommended actions, Safety Recommendations A-07-18 and -19 remain classified OPEN-- UNACCEPTABLE RESPONSE.

-From Michael G. Whitaker, Administrator: The Federal Aviation Administration (FAA) continues to review Hawaii air tour operators’ proprietary training materials to ensure they include cue-based, island-specific weather training. The improved quality of available training materials reviewed so far has satisfied the need for training examples, which would have otherwise been provided by the FAA.

Advisory Circular (AC) 136-B048, Supplemental Information for the Creation of Operating Procedures and Pilot Training Subjects Related to Operations Specifications (OpSpec)/Letter of Authorization (LOA) B048, is in final coordination. The AC will provide guidance to air tour operators on training flight support personnel in the process of preflight risk analysis, providing pilots with weather briefings, monitoring the progress of active tour flights, and participating in two-way communications with pilots to alert them of any unanticipated weather hazards.

Additionally, the AC also has a specific inclusion for cue-based, island-specific weather training to enable pilots to evaluate weather patterns based on visual cues, and to determine from those cues if it is appropriate to continue the flight as planned or if an alternate route of flight is necessary.

An FAA notice is also in coordination to revise authorizations under the current OpSpec B048 and LOA B548, Air Tour Operations Below 1,500 feet AGL in the State of Hawaii. Operators will be required to archive previous versions of OpSpec B048 and LOA B548 and request approval of the new versions. This will be coordinated with and reviewed for approval by the Honolulu Flight Standards District Office and Certificate Management Team.

AC 136-B048 and the revisions to OpSpec B048 and LOA B548 are now anticipated to be published by December 31, 2024.

The FAA continues to expand weather camera services in Hawaii to enhance aviation safety and pilot decision-making with the completed installations of 21 of the 26 planned sites to date.

The following is the current list of sites available at https://weathercams.faa.gov/:

1. Hana (PHHN) 2. Holei Pali (POAA) 3. Kahakuloa (JHMA) 4. Kalaupapa (PHLU) 5. Kaneohe Bay (PHNG) 6. Kapalua (PHJH) 7. Laie (HI58) 8. Lanai (PLNY) 9. Laupahoehoe (PQHC) 10. Lihue (PHLI) 11. Loleau (PSOK) 12. Makaha Ridge (PHBK) 13. Manawainui Gulch (HMNB) 14. North Shore (PHDH) 15. Pahala (PQKL) 16. Powerline Trail (PQKK) 17. Princeville (PQQK) 18. Upolo (PHUP) 19. Wahiawa (PHHI) 20. Waimanalo (PCKH 21. Waimea (PMUE) 21. Waimea (PMUE)

-From Kathryn B. Thomson, Deputy Administrator: The Federal Aviation Administration (FAA) continues to expand weather camera services in Hawaii to enhance aviation safety and pilot decision-making with the installation of 15 of the 26 planned sites to date. The following 10 new sites, in addition to the 5 sites listed in our previous letter, include (available at https://weathercams.faa.gov/):

1. Holei Pali (POAA) 2. Kalaupapa (PHLU) 3. Kapalua (JHM) 4. Laie (HI58) 5. Laupahoehoe (QHC) 6. Lihue (PHLI) 7. Makaha Ridge (PHBK) 8. Upolo (PHUP) 9. Wahiawa (PHHI) 10. Waimanalo (CKH) The FAA also continues to develop an advisory circular (AC) providing guidance for all commercial air tour operators to implement an operator-specific flight monitoring system. This AC will include processes to train flight support personnel in the process of 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.

The FAA has initiated this draft AC with its anticipated publication by September 30, 2024.

Additionally, the FAA released draft AC 136-B048, Supplemental Information for the Creation of Operating Procedures and Pilot Training Subjects Related to OpSpec/LOA B048, for public comment, which can be found at the following website: https://www.faa.gov/aircraft/draft_docs/afs_ac/AC_136-B048_Coord_Copy.pdf

Finally, revisions to Operations Specifications (OPSPEC) Paragraph B048, Operations in the Vicinity of the Hawaiian Islands, and Letter of Authorization (LOA) B548 continue to be delayed due to the need for additional internal coordination. We are continuing to evaluate requirements for the use of ADS-B Out equipment in air tour operator aircraft as a requirement to obtain the revised OPSPEC B048/LOA B548. While the OPSPEC and LOA are being revised, the FAA continues to review Hawaii air tour operators’ proprietary training materials for the required cue-based, island-specific weather training.

On August 4, 2023, the Federal Aviation Administration (FAA) announced the publication of draft Advisory Circular (AC) 136-B048, Supplemental Information for the Creation of Operating Procedures and Pilot Training Subjects Related to OpSpec [operations specification]/LOA [letter of authorization] B048, and invited public comment on the document. The NTSB has a longstanding interest in air tour safety in the state of Hawaii, having investigated numerous Hawaii air tour accidents and issued many related safety recommendations and we offer our comments below.

We note that, based on the contents of the draft AC, it appears that the FAA’s intent is that it will replace FAA document AWP13-136, the Hawaii Air Tour Common Procedures Manual (HATCPM), which the FAA issued in 2008 for use by operators that obtained authorization (through OpSpec B048 or LOA B548) to deviate from the minimum altitude specified in 14 Code of Federal Regulations (CFR) Part 136, Appendix A. For those operators that obtained authorization through OpSpec B048/LOA B548, compliance with the provisions of the HATCPM was mandatory.

In our 2022 report on our investigation of the December 26, 2019, fatal air tour helicopter accident in Kekaha, Hawaii, we noted that the HATCPM had not been revised since it was issued and that the FAA informed us that it had been working on a replacement for about 7 years.

During our investigation, an air tour subject matter expert from the FAA’s Air Transportation Division, [14 CFR] Part 135 Air Carrier Operations Branch, informed us that the FAA’s vision for the new document was for it to be up to date; incorporate NTSB safety recommendations, congressional input, and National Park Service input; and be simpler, safer, and easier to manage. They also said that the document would likely address the use of Hawaii weather camera systems and operator implementation of safety management systems (SMSs).

We have examined the draft AC and are providing comments related to these issues and open NTSB recommendations related to air tour safety in Hawaii. We note that, although ACs, generally, are not regulatory documents, we presume that operators that obtain authorization through OpSpec/LOA B048 will be required to comply with the AC’s provisions (similar to the mandatory compliance with the HATCPM for those operators that held deviation authority).

We note that you are reviewing Part 136 as it relates to air tour operations in Hawaii and updating Operations Specifications (OPSPEC) Paragraph B048, Operations in the Vicinity of the Hawaiian Islands, and Letter of Authorization (LOA) B548, but that these updates have been delayed. We also note that OPSPEC B048 and LOA B548 currently—and will continue to—require initial ground training, recurrent ground training, and requalification training, which includes cue-based, island-specific weather training.

In our 2022 investigative report about the Safari Aviation accident, we found that the Honolulu Flight Standards District Office (FSDO) had imposed a cue-based training requirement on Hawaii air tour operators without the FAA having first developed any such training or information about what cue-based training should include or how it should be delivered.

Per its FAA-approved OPSPEC B048, the accident operator was required to comply with the procedures and limitations outlined in the Hawaii Air Tour Common Procedures Manual, which stated that operators must provide a “cue-based, island-specific weather” module during pilot initial and recurrent ground training and during requalification ground and flight training.

We concluded that, as a result of the lack of FAA guidance for air tour operators in Hawaii on developing cue-based weather training, the accident operator’s pilot training program, which was approved by the Honolulu FSDO, did not provide pilots with the type of training that the FAA’s cue-based training research determined was effective for improving pilots’ skills for accurately assessing and avoiding hazardous in-flight weather conditions. Consequently, Safety Recommendations A-07-18 and -19 were reiterated and classified Open—Unacceptable Response.

We remain concerned that, although OPSPEC B048 and LOA B548 require “cue-based island-specific weather training,” the FAA has not yet developed a cue-based training program for commercial air tour pilots in Hawaii, as recommended. Instead, the FAA has shifted responsibility for developing this training to operators without providing expert guidance that is based on cue-based training research.

From Billy Nolen, Acting Administrator, Federal Aviation Administration: The Federal Aviation Administration (FAA) met with staff from the National Transportation Safety Board (NTSB) on September 8, 2021, to discuss these safety recommendations. During this meeting, the FAA mentioned a new exemption process, which is still being developed and may help to address these safety recommendations. Once fully developed, the FAA will be able to answer questions that the NTSB may have about this new process.

The FAA continues to review the requirements of 14 CFR Part 136 as it relates to air tour operations in the state of Hawaii. Operations Specifications (OPSPEC) Paragraph B048, Operations in the Vicinity of the Hawaiian Islands, and Letter of Authorization (LOA) B548 continue to be updated, which is delayed due to the new exemption process. The OPSPEC and LOA are for air tour operations below 1,500 feet above ground level and require compliance with part 136. These special authorizations currently and will continue to include the requirement for initial ground training, recurrent ground training, and requalification training, which includes cue-based island-specific weather training.

Additionally, the FAA encourages all air tour operators, regardless if they have an OPSPEC or LOA, to include cue-based weather training in their operations where appropriate. Operators in Hawaii have provided examples of their cue-based weather training to the FAA, which include pages from their operation training manuals and a proprietary video-based training course.

Finally, the FAA is expanding weather camera services to Hawaii to enhance aviation safety and pilot decision-making. Cameras have been installed in Alaska and Colorado, among other locations, to provide pilots with real-time video of weather conditions at their destinations and along the intended flight routes. Surveys were started in March 2021 on Oahu and the Big Island, and engineering surveys and site selections on Kauai, Lanai, Maui, and Molokai have been completed. There are five completed camera sites (available at https://weathercams.faa.gov/

From Aviation Investigative Report AIR-22-05 “Collision into Terrain Safari Aviation, Inc. Airbus AS350 B2, N985SA Kekaha, Hawaii December 26, 2019” published on May 26, 2022:

2.3.2 Lack of Effective Cue-Based Weather Training

The NTSB has long advocated for the FAA to develop and require cue-based weather training for Hawaii air tour pilots to assist them in their ability to accurately assess hazardous local weather conditions and make appropriate in-flight weather-related decisions. Such training, if offered on a recurrent basis, may help prevent procedural drift and normalization of deviance among pilots by periodically recalibrating their perceptions of what constitutes acceptable weather.

We first expressed our interest in cue-based weather training in 2007 in our report on another helicopter air tour accident involving VFR flight into IMC on Kauai. Our report from that investigation discussed an FAA-sponsored project for developing and evaluating cue-based weather training, which at the time, was a new approach to training pilots to make accurate in-flight weather assessments (NTSB 2007).

As part of the FAA-sponsored project, researchers interviewed expert pilots to identify instances when they had made weather-related decisions they believed, in retrospect, to have been inappropriate and asked these pilots to describe cues in the environment that had indicated the need to change course. The researchers then used this information to develop training focused on the identified cues. Pilots who underwent this training received feedback on the accuracy of their own estimates of in-flight weather conditions, and they were familiarized with environmental cues that should prompt a decision about whether to divert.

These pilots demonstrated better decision-making during a simulated VFR flight in deteriorating weather compared to pilots who had not received this training (Wiggins and O’Hare 2003).

As a result of our investigation (and the relevance of the cue-based training research to our findings), in 2007, we recommended that the FAA do the following: In cooperation with Hawaii commercial air tour operators, aviation psychologists, and meteorologists, among others, develop a cue-based training program for commercial air tour pilots in Hawaii that specifically addresses hazardous aspects of local weather phenomena and in-flight decision-making (A-07-18).

A-07-18 was reiterated in the Aviation Investigative Report AIR-22-05 “Collision into Terrain Safari Aviation, Inc. Airbus AS350 B2, N985SA Kekaha, Hawaii December 26, 2019” published on May 26, 2022

We are pleased to learn that you are revising Operations Specifications (OPSS) paragraph B048 (issued to Part 135 operators) and Letter of Authorization (LOA) B548 (issued to Part 91 operators) to require cue-based weather training for commercial air tour operations below 1,500 feet above the surface in the state of Hawaii. We note that all newly hired pilots and transferred pilots flying air tours for the first time on any island will be required to receive training that includes examples of acceptable and unacceptable weather at critical points within routes and industry-recommended course reversal maneuvers for the specific island where they intend to operate.

We also note that, after completing the initial training, pilots will be required to undergo periodic checks (Part 135) or observations (Part 91).

Although these recommendations are almost 13 years old, we believe that your planned revisions to OPSS B048 and LOA B548, once finalized, will satisfy the intent of these recommendations. We urge you, however, not to delay issuing these much-needed policy changes. Pending our review of the revised OPSS and LOA, Safety Recommendations A-07-18 and -19 remain classified OPEN--ACCEPTABLE RESPONSE.

-From Steve Dickson, Administrator: Operations Specifications (OPSS) paragraph B048 and Letter of Authorization (LOA) 8548 authorize commercial air tour operations below 1,500 feet above the surface in the state of Hawaii. We are currently revising OPSS B048 issued to Part 135 commercial air tour operators and LOA B548 issued to Part 91 commercial air tour operators to require cue-based weather training. This is in addition to all other current training requirements which include hazardous aspects of local weather phenomena and in-flight adverse weather avoidance decision-making.

The cue-based weather training required by the revised OPSS 8048 and LOA 8548 may be provided via pictorial description, actual video, or power point presentations of each commercial air tour site specific area showing examples of acceptable and unacceptable weather at each critical point within the route along with industry-recommended course reversal maneuvers.

The Hawaii air tour industry participants will have location-specific training products for each island where air tour operations are conducted. The Honolulu Flight Standards District Office will review, approve, and accept all initial and revised adverse weather training material as an inclusion if applicable in each air tour operator's training program. The anticipated implementation date is December 2019.

All newly hired pilots and transferred pilots flying air tours for the first time on any island will be required to receive the cue-based weather training for the pertinent island/site prior to initiating flight operations on each island. Following completion of the training, part 135.293 initial and recurrent checks will include verification of the part 135

We are pleased to learn that you have implemented a cue-based training program for air tour operators in Southeast Alaska and that all operators in that region have incorporated the training into their individual programs. We note that, although you haven’t finished developing a similar program for air tour operators in Hawaii, the only component still to be developed is the digitization of aerial photography. Once the product becomes available, the training will be required for 14 Code of Federal Regulations Part 91 and Part 135 commercial air tour operators, to satisfy requirements specified in the Hawaii Air Tour Common Procedures Manual.

Accordingly, pending completion of the recommended actions, Safety Recommendations A-07-18 and -19 remain classified OPEN—ACCEPTABLE RESPONSE.

The Federal Aviation Administration (FAA) has developed and implemented a cue-based weather training program for operators in Southeast Alaska. This program was developed by working with a variety of organizations from the local aviation community, such as the Medallion Foundation, and national organizations, such as the National Institute for Occupational Safety and Health. Additional expertise was sought out as needed, which included utilizing a third party to provide the photo-realistic terrain modeling of the air tour environment involved. The State meteorology departments of Alaska and Hawaii also participated.

As of the 2011 Alaska air tour season, all air tour operators in Southeast Alaska had added materials and concepts developed as part of the cue-based training project to their training programs. These include, but are not limited to, training videos, use of basic airplane training devices with wide screen outside view, and photo-realistic instrument panels for each type of tour airplane. These devices include programmable visibility restrictions and deterioration rates, visibility targets, and photo-realistic terrain.

The FAA plans on using the Alaska cue-based weather training program as a hardware and software basis for Hawaii based operators. The only remaining component that remains to be developed for the Hawaii based operators is the digitization of the aerial photography to provide three-dimensional terrain mapping. Completion of this component is contingent on receiving additional funding.

I will keep the Board informed of the FAA's progress on these safety recommendations and provide an update by July 2014.

The NTSB notes that the FAA has established a project management team to develop and produce high quality, comprehensive, expert-vetted, cue-based weather and in-flight decision-making visual training aids for commercial air tour operators in both Alaska and Hawaii. The FAA indicated that the product developed for use in Hawaii is scheduled to be completed in March 2012. Once the product is available, the training will be required for 14 Code of Federal Regulations Part 91 and Part 135 commercial air tour operators, to satisfy requirements specified in the Hawaii Air Tour Common Procedures Manual.

The FAA’s efforts are responsive to both of these recommendations. Pending completion of the cue-based training, which will be required for all newly hired commercial air tour pilots in Hawaii, Safety Recommendations A-07-18 and -19 are classified OPEN—ACCEPTABLE RESPONSE. We commend your efforts to ensure the same level of safety for air tour operators in Alaska, as well.

CC# 201100102: - From J. Randolph Babbitt, Administrator: We have established a cue-based weather training project management team to develop and produce high quality, comprehensive, expert-vetted, cue-based weather and in-flight decision-making visual training aids for commercial air tour operators in both Alaska and Hawaii. The team includes representatives from the Federal Aviation Administration Safety Team, commercial air tour operators, the Civil Aerospace Medical Institute, the National Institute of Occupational Safety and Health, and State meteorology departments of Alaska and Hawaii.

Each cue-based training product would consist of high resolution, photo-realistic terrain depictions overlaid with a range of low ceilings, restricted visibilities, and motion speeds. The pilot would be able to select from various speeds, flight altitudes, routes, and conditions to simulate flight into actual indigenous weather conditions along actual tour routes. The training systems would permit pilots to view the full range of weather conditions they could experience in the localities in which they would operate.

Pilots would be educated on which conditions could indicate rapid deterioration, existing below minimum visibility conditions, and cloud clearance margins beyond the current sight limit. The high-definition video clips along with knowledge of local weather phenomena would foster development of strong weather awareness and avoidance judgment. The cue-based weather training product for Hawaii was initiated in March 2010 and is scheduled for completion in March 2012.

On May 17, 2007, the FAA responded, stating that Operations Specification (OpSpec) B048 requires operators to have a training program that includes the recommended elements. On December 4, 2007, the NTSB replied, stating that the OpSpec applies only to Part 135 operators and that it was not clear how these restrictions would be applied to Part 91 operators like Bali Hai. However, the most serious shortcoming in the FAA’s response was that the recommendation asked the FAA to develop a cue-based training program for comprehensiveness and consistency among operators with respect to the components of the training programs.

The FAA response requires that the operators develop a training program, thereby shifting the responsibility to the operators without providing any FAA leadership or guidance; also, there was no indication that this training would be cue based. Safety Recommendation A-07-18 specifically asks that the program be developed in cooperation with Hawaii commercial air tour operators, aviation psychologists, and meteorologists, yet it appeared from the FAA’s response that only air tour operators would be involved.

The recommendation also asks for the creation of a set of audio-visual aids that would show pilots actual weather conditions as they appear in flight and that would train pilots about when certain in flight decisions (such as whether to deviate from the usual flightpath) should be made. The OpSpec did not adequately address these concerns. Therefore, on December 4, 2007, the NTSB classified Safety Recommendations A-07-18 and -19 Open Unacceptable Response.

In its current letter, the FAA indicated that Part 91 operators will now be covered by Letter of Authorization (LOA) B548 1. An LOA serves a similar purpose for a Part 91

Letter Mail Controlled 12/29/2008 11:35:13 AM MC# 2080751: - From Robert A. Sturgell, Acting Administrator: 12/2/08 With the August 15, 2008 issuance of the revised Operations Specification (OpSpec) B048-1 (enclosure 1) and Letter of Authorization (LOA) B548-1 (enclosure 2), both titled, Air Tour Operations Below 1,500' AGL in the State of Hawaii, the Federal Aviation Administration now requires both 14 CFR part 91 and part 135 operators to develop a cue-based weather training module for incorporation into their approved pilot training curriculum and to provide such training to pilots conducting commercial air tour operations, applicable to their approved area of operations.

These requirements are listed in the training grid contained on page 4 of the Hawaii Air Tour Common Procedures Manual (FAA Document Number AWP13-136A) (enclosure 3). Because this manual is referenced in both the LOA and OpSpec, it becomes mandatory pilot training for these operators. Additionally, the following link provides public access to the Hawaii Air Tour Common Procedures Manual: http://www.faa.gov/about/office_org/field_offices/fsdo/hnl/local_more/media/hawaii_air_tour_common_proc.pdf. I believe that the FAA has effectively addressed these safety recommendations, and I consider our actions complete.

The FAA indicated its belief that Operations Specifications (OpSpec) paragraph B048 (b) (4) fully addresses this recommendation. The Safety Board disagrees. OpSpec B048(b)(4) specifies that Part 135 air tour operators are responsible for including in their new-hire training program the issues addressed in this recommendation. The Board notes that OpSpecs apply only to Part 135 operators and that the operator involved in the accident that prompted this recommendation, Bali Hair Air Tours, was a Part 91 operator.

Although the FAA has initiated the use of Letters of Authorization (LOA) for Part 91 air tour operators, the FAA has not indicated that the provisions of OpSpec B048 can or will be applied to Part 91 operations.

However, issuance of OpSpec B048 is not responsive to this recommendation because the recommendation asks for the development, in cooperation with Hawaiian commercial air tour operators, aviation psychologists, and meteorologists, among others, of a cue-based training program (emphasis added). Issuance of the OpSpec does not necessarily lead to the development of the cue-based program recommended, nor does it necessarily involve anyone other than the individual air tour operator. The Safety Board believes that an acceptable response to this

recommendation will create a set of audio-visual aids that would show pilots actual weather conditions, as they would appear in flight, and train them in consensus opinions about when certain in-flight decisions (for example, whether or not to deviate from the usual flight path) should be made. The Board does not believe that OpSpec B048 (b) (4) will develop such a program. Pending the FAA’s taking the recommended action, Safety Recommendation A-07-18 is classified OPEN -- UNACCEPTABLE RESPONSE.

Letter Mail Controlled 5/31/2007 8:30:30 AM MC# 2070237: - From Marion C. Blakey, Administrator: 5/17/07 The Federal Aviation Administration believes that recently published Operations Specifications paragraph B048 dated March 9, 2007, addresses these recommendations. Below is the specific paragraph that addresses the respective safety recommendations and a copy of the Operations Specifications is enclosed. Paragraph B048(b)(4) addresses A-07-18 This paragraph covers the subjects that a training program must address: ·Mountain flying techniques; ·High density altitude flying techniques; ·Use of performance plan information;

·Island-specific weather and weather avoidance procedures; ·Criteria for making a pre-departure go-no-go weather decision; ·Route knowledge, including en route and site-specific hazards; ·Ditching procedures; ·A review of Hawaii air tour accidents during the past 10 years; and ·A review of in-flight island-specific weather pilot cues to determine deteriorating weather conditions. I believe that the FAA has satisfactorily responded to these safety recommendations, and I look forward to your response.