NTSB IMAGE
Again, this is an area where there are known methods of mitigating the risk of spatial disori- entation. Simulators or perhaps virtual-reality headgear that could be worn in an actual aircraft present more realistic training. Stability aug- mentation systems and basic autopilots would also improve the safety of VFR air tour helicop- ters. Economics is ever the driver of safety deci- sions for regulators and operators across all modes of transportation. But if you think preven- tion is expensive, do the math on the real cost of crashes.
While both the NTSB and FAA proclaim the benefits
of a systemic approach to managing safety, the FAA has ignored its own guidance. In an area where rapidly changing weather conditions are well known, real-time weather observa- tions for VFR air tours are essential. Again, cameras pro- vide a relatively inex- pensive technology to accomplish that. Likewise, having ADS-B and radio coverage in the area would allow for both collision avoid- ance and pilot reports that would enhance safety tre- mendously. An antenna is all that’s needed. All these items have been recommended to the FAA for years. The accident flight was in clear violation of the Hawaii Air Tour Common Procedures Manual (HATCPM), a doc- ument published by the FAA’s Honolulu Flight Standards District Office (FSDO) that details standard procedures for air tours in that state. Updating the HATCPM and developing cue-based weather training are safety initia- tives the FAA has said it would undertake. Despite years of delay, neither has been completed. Part of a systemic approach to safety is looking at
how management failures contributed to the accident chain. During our investigation, the NTSB determined
The NTSB gets no satisfaction about being proven right once again. Instead, we want the FAA and operators to address the problem and end these types of accidents.
that the tour company’s lack of safety management pro- cesses contributed to the accident. Going even further up the chain, we identified as a factor the FAA’s ineffec- tive monitoring of Hawaii air tour operators. The agency’s Honolulu FSDO was set up to fail
because upper man- agement didn’t pro- vide it with the personnel or funding to allow for training, travel, and proper
oversight of air tour operations in the state. These are performance activities, as is piloting, that require the same attention to personnel qualifications and detail, along with a willingness to constantly self-evaluate. The FAA has failed to address the safety issues in
Hawaii that have been brought forward over the decades. But we can’t let that agency’s inaction limit our attempts to improve aviation safety. Why not have indus- try update the HATCPM and develop cue-based weather training, and then let the FAA sanction it? Tour passen- gers deserve that much! The NTSB report on the Kekaha accident made
11 recommendations to the FAA—all of which had been made previously. But we get no satisfaction from saying, “We told you so.” It’s time to do better.
JUNE 2022 ROTOR 9
In addition to showing the weather conditions encountered by the accident aircraft, this image and similar ones from tour videos taken by helicopters operating nearby demonstrate the normalization of deviance by local tour companies and their pilots.
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