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