NTSB · Safety Recommendation
Safety Recommendation A-22-017
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: 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 (ADS-B) 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.
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, although you continue to disagree with this recommendation, you have increased the number of aviation safety inspectors (ASIs) on staff at the Honolulu Flight Standards District Office (FSDO) to 15 and, to improve ASI retention at that FSDO, you are allowing ASIs to reside on other Hawaiian Islands.
We remain concerned that there may be a tendency among some companies or individual pilots (even those who fly for operators not otherwise identified as high-risk) to develop norms for accepting increasing weather-related risks—until they encounter a situation from which they cannot safely escape. We believe the FAA’s routine surveillance of air tour flight operations is critical to help counter such behavioral patterns because, without it, the FAA may be unaware that risky weather-related operating practices are occurring.
Although we believe the changes at the Honolulu FSDO that you reported are positive, we do not believe they satisfy the intent of this recommendation, which is to use available technology to conduct operational oversight of air tour operations from a distance.
We continue to believe that the FAA needs to develop innovative strategies for conducting operational oversight of air tour operations to reduce procedural drift toward risky weather-related operating practices. These strategies could include, for example, analysis of archived ADS-B data in conjunction with archived weather camera images, review of onboard video recordings from tour aircraft, or other as-yet unidentified methods. Pending the FAA taking the recommended action, Safety Recommendation A-22-17 remains classified OPEN-- UNACCEPTABLE RESPONSE.
August 31, 2023 · Recipient Response · FAA
-From Kathryn B. Thomson, Deputy Administrator: As previously stated, the FAA does not agree with this safety recommendation. The Board’s accident report and the subsequent FAA review did not observe a direct connection between this accident and the FAA’s safety oversight model. In response to the Board’s March 30, 2023, letter citing “staffing challenges and management priorities,”