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NTSB Makes Recommendations Following Safari Aviation Inc. Accident Investigation
What happened
On Dec. 26, 2019, about 16:57 Hawaii Standard Time, a seven-seat helicopter operated by Safari Aviation Inc. as a commercial air tour flight encountered instrument meteorological conditions (IMC) 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.
The weather on Kauai had been favorable for tours for most of the day; however, just before the accident flight departed, low clouds and rain began moving onshore from the northwest (which was an atypical weather pattern for Kauai) and affecting locations on the tour route, including areas where the accident flight was headed. At least three other tour pilots saw the adverse weather and decided to divert their tours away from it. The accident pilot, however, decided to continue his
tour into deteriorating
weather, eventually losing adequate visual references before the helicopter struck terrain.
What we found
We determined that the probable cause of this accident was the pilot’s decision to continue flight under visual flight rules (VFR) into instrument meteorological
32 May/June 2022
conditions (IMC), which resulted in the collision into terrain. Contributing to the accident was Safari Aviation Inc.’s lack of safety management processes to identify hazards and mitigate the risks associated with factors that influence pilots to continue VFR flight into IMC. Also contributing to the accident was the Federal Aviation Administration’s (FAA) delayed implementation of a Hawaii aviation weather camera program, its lack of leadership in the development of a cue-based weather training program for Hawaii air tour pilots, and its ineffective monitoring and oversight of Hawaii air tour operators’ weather-related operating practices.
What we recommended
As a result of this investigation, we made safety recommendations to the FAA regarding infrastructure improvements in Hawaii that can enable continuous radio communications and flight position tracking, improvements to the FAA’s surveillance of Hawaii air tour operations, and requirements for Hawaii air tour operators to equip their fleets with flight tracking capabilities and to provide active flight monitoring by trained company flight support personnel.
We also made safety recommendations to the FAA to take actions that can help all air tour operators and pilots prevent a drift toward risky weather-related operating practices. These actions include developing and distributing guidance on how to scale an effective
safety management system (SMS) and encouraging operators to perform routine reviews of onboard video recordings and flight tracking data.
We also recommended that the FAA and helicopter industry and air tour safety groups encourage the voluntary adoption of helicopter safety technologies designed to help prevent accidents resulting from inadvertent encounters with IMC.
In addition, we reiterated our previously issued safety recommendations to the FAA related to installing aviation weather cameras in Hawaii, training ground support specialists to effectively use imagery from those cameras when providing weather briefings to pilots, developing and requiring cue-based training for Hawaii air tour pilots, and requiring operators to implement flight data monitoring programs and SMS.
We also reiterated our previously issued safety recommendations to the FAA related
to requiring the installation of
crash-resistant flight recorder systems in aircraft like the accident helicopter; requiring air tour operators to install onboard equipment that enables traffic-alerting, flight tracking, and other safety-related services; and developing and
requiring the use of simulation
technologies in pilot training programs to help prevent accidents involving inadvertent encounters with IMC.
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