NTSB · Safety Recommendation
Safety Recommendation A-22-016
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: 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 (ADS-B) 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.
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
July 3, 2024 · NTSB Correspondence · FAA
We note that you continue to believe the recommended SAFO is unnecessary because the FAA already routinely discusses safety assurance processes, including reviewing ADS-B data, during initial and recurrent operator training, annual commercial air tour safety meetings, and annual FAA surveillance.
We point out that the intent of this recommendation is for the FAA to encourage air tour operators to review recorded ADS-B data to identify and track occurrences, such as a flight’s descent below a required minimum altitude, and discuss the circumstances of the event with the pilot in a nonpunitive fashion. Despite your efforts to discuss safety assurance processes with operators, the accident operator did not have adequate safety assurance processes to assess if company strategies to reduce pilots’ risk of inadvertent encounters with instrument meteorological conditions were effective.
In addition, you have not responded to the part of this recommendation that asks you to ensure that operators establish safety assurance processes to routinely review recorded onboard videos.
We believe that air tour operators could systematically review onboard videos in conjunction with weather data and other information to identify and track risky trends in weather-related operating practices and review them in a nonpunitive fashion with their pilots. The accident operator in this case could have identified and mitigated some of the risks for continuing flight under visual flight rules into reduced-visibility conditions by periodically reviewing videos from the accident pilot’s flights prior to the accident. We also believe periodic reviews could reinforce continuous good decision-making.
Therefore, we continue to believe that issuing a SAFO on these topics is appropriate and needed. Pending the recommended action, Safety Recommendation A-22-16 remains classified OPEN-- UNACCEPTABLE 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.