Aircraft Accident Report - Weather Encounter and Subsequent Collision into Terrain,Bali Hai Helicopter Tours, Inc., Bell 206B, N16849

Kalaheo, Hawaii
September 24, 2004

NTSB Number: AAR-07-03
NTIS Number: PB2007-910404
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Executive Summary

On September 24, 2004, about 1642 Hawaiian standard time, a Bell 206B helicopter, N16849, registered to and operated by Bali Hai Helicopter Tours, Inc., of Hanapepe, Hawaii, impacted mountainous terrain in Kalaheo, Hawaii, on the island of Kauai, 8.4 miles northeast of Port Allen Airport, in Hanapepe. The commercial pilot and the four passengers were killed, and the helicopter was destroyed by impact forces and postimpact fire. The nonstop sightseeing air tour flight was operated under the provisions of 14 Code of Federal Regulations Part 91 and visual flight rules with no flight plan filed. Instrument meteorological conditions prevailed near the accident site.

The National Transportation Safety Board determines that the probable cause of this accident was the pilot's decision to continue flight under visual flight rules into an area of turbulent, reduced visibility weather conditions, which resulted in the pilot's spatial disorientation and loss of control of the helicopter. Contributing to this accident was the pilot's inexperience in assessing local weather conditions, inadequate Federal Aviation Administration (FAA) surveillance of Special Federal Aviation Regulation 71 operating restrictions, and the operator's pilot-scheduling practices that likely had an adverse impact on pilot decision-making and performance.

The safety issues discussed in this report include the influence of pilot experience and operator scheduling on in-flight decision-making; the lack of FAA oversight of Part 91 air tour operators; the need for national air tour safety standards; and the lack of direct FAA surveillance of commercial air tour operators in Hawaii.

Nine safety recommendations are addressed to the FAA regarding local weather-training programs for newly hired Hawaii air tour pilots; evaluation of operational practices for commercial air tour helicopter pilots; Honolulu Flight Standards District Office control of the annual safety meetings, as required under approved certificates of waiver or authorization; evaluation of the safety impact of the altitude restrictions in the State of Hawaii; national air tour safety standards; and the potential benefits of automatic dependent surveillance-broadcast technology for Hawaii air tour operators.

Safety Recommendations

As a result of the investigation of this accident, the National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration:

In cooperation with Hawaii commercial air tour operators, aviation psychologists, and meteorologists, among others, develop a cue-based training program for commercial air tour pilots in Hawaii that specifically addresses hazardous aspects of local weather phenomena and in-flight decision-making. (A-07-18)

Once a cue-based training program that specifically addresses hazardous aspects of local weather phenomena and weather-related, decision-making issues is developed, as requested in Safety Recommendation A-07-18, require all commercial air tour operators in Hawaii to provide this training to newly hired pilots. (A-07-19)

Establish operational practices for commercial air tour helicopter pilots that include rest breaks and that will ensure acceptable pilot performance and safety, and require commercial air tour helicopter operators to adhere to these practices. (A-07-20)

Develop a permanent mechanism to provide direct surveillance of commercial air tour operations in the State of Hawaii and to enforce commercial air tour regulations. (A-07-21)

Direct the Honolulu Flight Standards District Office to ensure that the annual safety meetings, as required under approved certificates of waiver or authorization, focus on pertinent and timely commercial air tour safety issues, including, but not limited to, reviews of Hawaii air tour accidents, local weather phenomena, and SFAR 71 procedures. (A-07-22)

Reevaluate the altitude restrictions in the State of Hawaii to determine if they may have resulted in any unintended degradation of safety with regard to weather-related accidents and fatalities. (A-07-23)

Develop and enforce safety standards for all commercial air tour operations that include, at a minimum, initial and recurrent pilot training programs that address local geography and meteorological hazards and special airspace restrictions; maintenance policies and procedures; flight scheduling that fosters adequate breaks and flight periods, as established by the implementation of Safety Recommendation A-07-20; and operations specifications that address management, procedures, route specifications, and altitude restrictions, as necessary. (A-07-24)

Accelerate the implementation of automatic dependent surveillance-broadcast (ADS-B) infrastructure in the State of Hawaii to include high-quality ADS-B services to low-flying aircraft along heavily traveled commercial air tour routes. (A-07-25)

Require that Hawaii air tour operators equip tour aircraft with compatible automatic dependent surveillance-broadcast (ADS-B) technology within 1 year of the installation of a functional National ADS-B Program infrastructure in Hawaii. (A-07-26)