NTSB · Safety Recommendation
Safety Recommendation A-21-007
Recommendation
TO ISLAND EXPRESS HELICOPTERS INC.: Participate in the Federal Aviation Administration’s Safety Management System Voluntary Program.
Safety Issue and Context
This report discusses the January 26, 2020, accident involving a Sikorsky S-76B helicopter, N72EX, being operated by Island Express Helicopters Inc. as a Title 14 Code of Federal Regulations (CFR) Part 135 on-demand flight, that crashed into terrain in Calabasas, California. The pilot and the eight passengers died.
Safety issues identified in this report include the pilot’s preflight weather and flight risk planning, the flight’s entry into instrument meteorological conditions and the pilot’s inadequate adverse weather avoidance, the pilot’s spatial disorientation, influences on the pilot’s decision to continue the flight into adverse weather, Island Express’ incomplete implementation of its safety management system (SMS), the benefits of a mandatory SMS, the benefits of flight simulation devices for pilot training in adverse weather avoidance, the benefits of a flight data monitoring program, and the value of crash-resistant flight recorder systems in preventing future accidents.
As a result of this investigation, the National Transportation Safety Board makes two new safety recommendations each to the Federal Aviation Administration and Island Express.
Response History
August 22, 2024 · NTSB Correspondence · Maverick Helicopters (formerly Island Express Helicopters, Inc.)
We note that the FAA’s final rule expands the applicability of Title 14 Code of Federal Regulations (CFR) Part 5, SMSs, beyond 14 CFR Part 121 operators to include Part 135 operators, such as Maverick Helicopters, without exceptions for the size of the operator.
We are aware that you have improved your SMS since this accident. We point out, however, that the intent of this recommendation is for Maverick Helicopters to participate in the FAA’s SMSVP, which would incorporate ongoing FAA oversight and compliance monitoring into your SMS to ensure it conforms with the safety policy, safety risk management, safety assurance, and safety promotion functions. Although we believe the intent of this recommendation will be met as result of the FAA’s final
rule, we are disappointed with your decision to not participate in the FAA’s SMSVP prior to the FAA’s mandate. Consequently, Safety Recommendation A-21-7 is classified CLOSED-- UNACCEPTABLE ACTION.
March 4, 2024 · NTSB Correspondence · Maverick Helicopters (formerly Island Express Helicopters, Inc.)
When we issued this recommendation, we were aware that IEX Helicopters had an SMS that was neither required by the FAA nor part of the company’s FAA-approved or -accepted programs. Although IEX Helicopters had informed us of improvements that it had made to its SMS since this accident, it had not indicated any plans to participate in the FAA’s SMS Voluntary Program, as recommended. The intent of this recommendation is for Maverick Helicopters to incorporate ongoing FAA oversight and compliance monitoring into its SMS to ensure it conforms with the safety policy, safety risk management, safety assurance, and safety promotion functions.
By participating in the FAA’s SMS Voluntary Program, Maverick’s SMS would be subject to FAA oversight that includes inspecting the SMS for alignment with FAA objectives and providing feedback to help you implement any needed improvements.