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NTSB · Safety Recommendation

Safety Recommendation A-22-011

Recommendation

TO 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.

Safety Issue and Context

This report discusses the December 26, 2019, accident involving a seven-seat helicopter operated by Safari Aviation Inc. as a commercial air tour flight that encountered instrument meteorological conditions and collided into terrain in a remote, wooded area near Kekaha, Hawaii, on the island of Kauai. The pilot and the six passengers were fatally injured, and the helicopter was destroyed.

Safety issues identified in this report include limited ability of existing infrastructure to fully support some aviation safety-related functions needed for the safe operation of low-flying air tour flights, resulting in air tour pilots having to rely on their own in-flight visual weather assessments; absence of safety assurance processes to guide pilot decision-making; and ineffective monitoring and oversight of Hawaii air tour operators by the Federal Aviation Administration (FAA).

As a result of this investigation, the National Transportation Safety Board (NTSB) makes eight new safety recommendations to the FAA, one new safety recommendation to the Vertical Aviation Safety Team, and one new safety recommendation to tour flight operators. NTSB also reiterates nine previously issued recommendations and two previously issued classified recommendations to the FAA.

Response History

April 18, 2025 · Recipient Response · FAA

-From Christopher J. Rocheleau, Acting Administrator: The Federal Aviation Administration (FAA) completed its assessments of the six Hawaiian Islands that have weather camera sites for radio coverage at 500 feet and above using physical site surveys and predictive radio propagation software.

Four of the six Hawaiian Islands, Hawaii, Lanai, Oahu, and Molokai, have radio coverage from existing FAA Remote Communication Outlets (RCO). Kauai and Maui currently lack coverage in the northwest portion of their islands, and planned RCO coverage will be added to the FAA’s Corporate Work Plan for Fiscal Year 2025.

Additionally, the FAA received $1.6 million above the budget request for fiscal year 2023 to enable continuous radio communication between the pilots of low-flying tour flights and ground support personnel and to make infrastructure improvements needed to improve coverage in mountainous terrain. We will continue to address this safety recommendation through our planned activities and provide future updates on the progress of our work.

July 3, 2024 · NTSB Correspondence · FAA

We note that, due to the high cost of a standalone air/ground communications site, you are assessing six of the existing operational weather camera sites in Hawaii to determine if they can support the infrastructure needed to enable radio communications between air tour pilots and flight service station specialists. Pending our review of your findings and a plan for completing the recommended action, Safety Recommendation A-22-11 remains classified OPEN-- ACCEPTABLE RESPONSE.

September 6, 2023 · NTSB Correspondence · FAA

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.

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Recommendation Facts

Status
Open - Acceptable Response
Issued
May 26, 2022
Priority
CLASS II
Recipient
FAA
Adopted
May 10, 2022
Related Investigation
ANC20MA010
Related Report
AIR-22-05

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).

Additional Recommendations Not Addressed in the AC

In addition to the recommendations discussed above, we have identified the following NTSB safety recommendations to the FAA that are relevant to Hawaii air tour safety but whose subject matter is not discussed in the draft AC:

• Safety Recommendation A-22-11: 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. (Open—Acceptable Response)

August 31, 2023 · Recipient Response · FAA

-From Kathryn B. Thomson, Deputy Administrator: The Federal Aviation Administration’s (FAA) Weather Camera Program studied the most heavily trafficked air tour routes to determine which weather camera sites could support air/ground communications infrastructure. Of the 15 operational weather camera sites in Hawaii, 6 have been preliminarily identified as possible locations for this infrastructure.

These six sites were added to the FAA’s Corporate Work Plan to conduct additional site surveys to determine if they can support air/ground communications infrastructure. The FAA rationale for co-locating with the weather camera sites is cost, and the communications provided would be to flight service station specialists, not company flight support personnel. To implement a standalone air/ground communications site is approximately $1 million per site. Congressional funding has provided $1.6 million above the budget request for infrastructure and improvements needed to enhance coverage in mountainous terrain.

March 30, 2023 · NTSB Correspondence · FAA

We note that you plan to assess the feasibility of installing the necessary infrastructure for providing continuous radio communication between low-flying tour flights and ground support personnel and of expanding ADS-B coverage along the most heavily trafficked air tour routes. Pending our review of your findings and a plan for completing the recommended actions, Safety Recommendations A-22-11 and -12 are classified OPEN-- ACCEPTABLE RESPONSE.

August 3, 2022 · Recipient Response · FAA

-From Billy Nolen, Acting Administrator: The Federal Aviation Administration (FAA) will begin assessing the feasibility of installing the infrastructure necessary to provide continuous radio communication between low-flying tour flights and ground support personnel. The FAA will also evaluate expanding ADS-B coverage along the most heavily trafficked air tour routes.

May 26, 2022 · NTSB Correspondence · FAA

The attached letter from the NTSB Chair provides information about the NTSB’s May 10, 2022, report, Collision into Terrain, Safari Aviation Inc., Airbus AS350 B2, N985SA, Kekaha, Hawaii, December 26, 2019, NTSB AIR-22-05. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov.

The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (for example, new Safety Recommendations A-22-11 through -18, Reiterated Recommendations A 13 13, A-13-25, A-13-27, A-16-34 through -36, A 21 5, A-21-6, and A-21-15)

We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply exceeds 20 megabytes, including attachments, please e mail us at the same address for instructions on how to send larger documents. Please do not submit both an electronic copy and a hard copy of the same response.

This letter provides information about the National Transportation Safety Board’s (NTSB) May 10, 2022, report, Collision into Terrain, Safari Aviation Inc., Airbus AS350 B2, N985SA, Kekaha, Hawaii, December 26, 2019, NTSB AIR-22-05. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. As a result of this investigation, we identified the following safety issues:

• Aviation safety infrastructure limitations in Hawaii, including the need for aviation weather cameras, improved air-to-ground radio communications, and improved automatic dependent surveillance-broadcast (ADS-B) capabilities to enable flight tracking and other safety services for low-flying air tour flights.

• Lack of effective cue-based weather training for air tour pilots in Hawaii.

• Need for trained company flight support personnel with operational control authority to support pilots’ en route, weather-related decision making.

• Need for safety management systems and flight data monitoring programs for Part 135 operators and the incorporation of recorded onboard videos and ADS B flight tracking data into safety assurance reviews.

• Need for improved Federal Aviation Administration (FAA) surveillance of air tour operations in Hawaii.

• Value of crash-resistant flight recorder systems in providing information critical for enabling the identification of the most effective measures to prevent similar accidents. • Emerging technologies to help prevent accidents resulting from inadvertent encounters with instrument meteorological conditions, including helicopter safety technologies and simulation devices used in pilot training. Accordingly, the NTSB makes the following safety recommendations to the FAA. Additional information regarding these recommendations can be found in the noted sections of the report.

• 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. (A-22-11) (See section 2.4.2.1)

• 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. (A-22-12) (See section 2.4.2.2)

• As an interim measure until completion of the action to satisfy Safety Recommendation A 21-15 [previously issued on May 13, 2021], require Hawaii air tour operators to install Automatic Dependent Surveillance-Broadcast Out equipment in their aircraft to enable real time flight position tracking. (A-22-13) (See section 2.4.2.2)

• 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. (A-22-14) (See section 2.5.1)

• 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. (A 22 15) (See section 2.5.2)

• 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 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. (A-22-16) (See section 2.5.4)

• 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 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. (A 22 17) (See section 2.6)

• 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. (A-22-18) (See section 2.8.1)

In addition, the NTSB reiterates the following recommendations to the FAA:

• Require all existing turbine-powered, nonexperimental, nonrestricted-category aircraft that are not equipped with a flight data recorder or cockpit voice recorder and are operating under 14 Code of Federal Regulations Parts 91, 121, or 135 to be retrofitted with a crash-resistant flight recorder system. The crash resistant flight recorder system should record cockpit audio and images with a view of the cockpit environment to include as much of the outside view as possible, and parametric data per aircraft and system installation, all as specified in Technical Standard Order C197, “Information Collection and Monitoring Systems.” (A-13-13) (See section 2.7)

• Initiate an aviation weather camera program in Hawaii that includes the installation and maintenance of aviation weather cameras at critical locations in Hawaii. Establish public access to these aviation weather cameras’ real-time imagery. (A-13-25) (See section 2.4.1) • Equip flight service station specialists responsible for Hawaii and the continental United States with the technical capabilities and training to provide verbal preflight and en route briefings using aviation weather camera imagery. (A-13-27) (See section 2.4.1) • Require all 14 Code of Federal Regulations Part 135 operators to install flight data recording devices capable of supporting a flight data monitoring program.

(A-16-34) (See section 2.5.3) • After the action in Safety Recommendation A-16-34 is completed, require all 14 Code of Federal Regulations Part 135 operators to establish a structured flight data monitoring program that re