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NTSB · Safety Recommendation

Safety Recommendation A-22-019

Recommendation

TO THE VERTICAL AVIATION SAFETY TEAM: Include, in your proposed helicopter safety rating system, helicopter safety features for preventing accidents resulting from inadvertent encounters with instrument meteorological conditions.

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

September 26, 2025 · NTSB Correspondence · Vertical Aviation Safety Team

We note that, on November 26, 2024, the VAST Rotorcraft Safety Rating Concept Special Working Group published a white paper titled, “Investigation of a Rotorcraft Safety Rating Concept,” which includes a proof-of-concept system for assessing and rating safety-enhancing technologies, including those capable of reducing the probability or severity of accidents linked to inadvertent or unintended flight into IMC. The paper includes recommendations to the vertical aviation industry and points out that completing those actions is critical to ensuring widespread adoption of your proposed helicopter safety rating system.

We believe the VAST working group’s paper includes research, analysis, and conclusions that are responsive to this recommendation and will enable industry to complete the additional work needed to successfully implement a helicopter safety rating system. Consequently, Safety Recommendation A-22-19 is classified CLOSED-- ACCEPTABLE ACTION.

December 11, 2024 · Recipient Response · Vertical Aviation Safety Team

-From Chris Hill, Industry Co-Chair, Safety Promotion Working Group, Vertical Aviation Safety Team (VAST): On November 26, 2024, the Vertical Aviation Safety Team (VAST) published a white paper titled “Investigation of a Rotorcraft Safety Rating Concept,” introducing an innovative proof-of-concept system aimed at elevating safety standards for vertical aircraft worldwide.

The VAST also submits the white paper in direct response to NTSB safety recommendation A-22-19. The safety rating concept detailed in the white paper assesses and rates several safety-enhancing technologies, including those capable of reducing the probability or severity of accidents linked to inadvertent or unintended flight into instrument meteorological conditions (IIMC/UIMC).

Rigorous testing, validation, and feedback from industry stakeholders will refine the system to maximize its potential. While the VAST supports all subsequent refinement efforts, the team does not currently possess the resources required to perform validation activities and seeks support from the NTSB to communicate the need for the industry to pick up and address ownership of the next steps – to make this concept a working reality. As such, the VAST requests that NTSB safety recommendation A-22-19 directed to the VAST be amended to a Closed – Acceptable status.

If you have any questions, our Safety Promotion Working Group Co-Chair, Chris Hill, is prepared to facilitate any further discussions.

August 26, 2022 · NTSB Correspondence · Vertical Aviation Safety Team

We note that you support this recommendation and that the VAST Safety Rating working group is considering safety technologies designed to reduce the likelihood and severity of rotorcraft accidents—including systems for preventing inadvertent encounters with IMC. Pending our review of the working group’s findings, and completion of the recommended action, Safety Recommendation A-22-19 is classified OPEN-- ACCEPTABLE RESPONSE.

June 15, 2022 · Recipient Response · Vertical Aviation Safety Team

-From James Viola, President and CEO, Helicopter Association International (HAI) and Industry Advisor, Vertical Aviation Safety Team and Miguel Marin, Authorities Advisor, Vertical Aviation Safety Team nominated by the International Civil Aviation Organization (ICAO): The Vertical Aviation Safety Team (VAST) unequivocally supports the National Transportation Safety Board’s (NTSB) goals to enhance global aviation safety. The VAST submits the following response to referenced safety recommendation A-22-19:

The VAST Safety Rating Concept working group was established on June 2, 2021 and consists of rotorcraft industry and safety professionals as well as representation from the FAA and EASA. The objective of the working group is to investigate the feasibility of a safety rating concept that would incentivizing innovation and implementation of enhancing technologies into the new and current fleet of helicopters.

The current focus of the working group is to develop a concept and an implementation plan for a world-wide voluntary safety rating scheme that is reflective of the helicopter in its operational context. The working group is considering safety technologies designed to reduce the likelihood or severity of rotorcraft accidents. Systems that can prevent accidents related to inadvertent or unintended flight into instrument meteorological conditions (UIMC) and related accident occurrence categories (e.g., spatial disorientation, loss of control inflight, controlled flight into terrain, etc.) will be considered.

We would be happy to discuss further should you have any questions, concerns, or require any additional details. Our communications lead for VAST matters is Mr. Dan Sweet.

May 26, 2022 · NTSB Correspondence · Vertical Aviation Safety Team

The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters.

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 recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary.

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 recommendation by number (for example, Safety Recommendation A-22-19). 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.

All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov.

The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters.

Read Recommendation

Recommendation Facts

Status
Closed - Acceptable Action
Issued
May 26, 2022
Priority
CLASS II
Recipient
Vertical Aviation Safety Team
Adopted
May 10, 2022
Closed
September 26, 2025
Related Investigation
ANC20MA010
Related Report
AIR-22-05

We are providing the following information to urge the Vertical Aviation Safety Team (VAST) to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents.

This letter also includes information about our 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 issue relevant to your organization’s interest in helicopter safety:

• Helicopter safety technologies to help prevent accidents resulting from inadvertent encounters with instrument meteorological conditions.

Accordingly, the NTSB makes the following safety recommendation to VAST. Additional information regarding this recommendation can be found in the noted section of the report.

Include, in your proposed helicopter safety rating system, helicopter safety features for preventing accidents resulting from inadvertent encounters with instrument meteorological conditions. (A-22-19) (See section 2.8.1)

The NTSB is vitally interested in this recommendation because it is 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 this recommendation. When replying, please refer to the safety recommendation by number (Safety Recommendation A-22-19). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply, including attachments, exceeds 20 megabytes, 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.

All communications regarding safety recommendations are stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this/these recommendation(s). Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. In the likely event that your company uses auto generated and/or preformatted confidentiality statements on letterhead or outgoing e-mails, please include a statement in your letter indicating that the information can be publicly released. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov.