NTSB · Safety Recommendation
Safety Recommendation A-21-008
Recommendation
TO ISLAND EXPRESS HELICOPTERS, INC.: Install flight data recording devices capable of supporting a flight data monitoring (FDM) program on each helicopter in your fleet and establish an FDM program that reviews all available data sources to identify deviations from established norms and procedures as well as other potential safety issues.
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
March 4, 2024 · NTSB Correspondence · Maverick Helicopters (formerly Island Express Helicopters, Inc.)
IEX Helicopters had informed us that, as part of its SMS, it planned to install FDR devices on its S76 helicopters and establish an FDM program to review the captured data. We told IEX Helicopters that its planned actions were positive, but pointed out that the intent of this recommendation is to install FDR devices on all its helicopters—not just S76 helicopters.
We urge Maverick Helicopters to address this concern and look forward to receiving updates as you progress towards this goal. In the meantime, pending completion of the recommended actions, Safety Recommendation A-21-8 remains classified OPEN-- ACCEPTABLE RESPONSE.
January 10, 2024 · Recipient Response · Maverick Helicopters (formerly Island Express Helicopters, Inc.)
-From Garrett Dalton, Maverick Helicopters: Island Express Inc, has been purchased by Maverick Helicopters. We have gone through a thorough review and upgrade of our company including but not limited to, Management, Fleet, facilities, training, policies and procedures etc.
One of the reviews was of our SMS program and it has been determined that in its current state it is well above our industry standards and is incorporated into every aspect of our day-to-day operations. We believe that we have 100% buy in from all employees in our SMS Program and they use it in a constructive way every day. At this time, we have taken the decision not to participate in the FAA’s SMS Voluntary Program.
Please feel free to contact me anytime with any questions or concerns.
September 28, 2022 · NTSB Correspondence · Maverick Helicopters (formerly Island Express Helicopters, Inc.)
We note that, as part of your SMS, you plan to install FDR devices on your S76 helicopters and establish an FDM program to review the captured data. Although we believe your planned actions are responsive to this recommendation, we point out that this recommendation asks IEX Helicopters to install FDR devices on all its helicopters—not just S76 helicopters. Pending updates on your progress and completion of the recommended actions, Safety Recommendation A-21-8 is classified OPEN--ACCEPTABLE RESPONSE.