Board Meeting Closing Statement: Collision into Terrain Safari Aviation Inc. Airbus AS350 B2, N985SA

​​Our deliberations have now concluded.

I thank my fellow Board members for their preparation and participation in today’s meeting. We discussed important topics that will benefit the final report and inform our safety recommendations.

This tragedy should never have occurred. It was preventable.

Since 1997, the NTSB has investigated 282 air tour accidents nationwide, 61 of which were fatal. We’ve investigated 41 air tour accidents in Hawaii (including this one), 15 of which were fatal. Of those 41 accidents, 9 involved a pilot’s decision to continue a visual flight rules (VFR) flight into deteriorating weather. Those 9 accidents resulted in 51 deaths; 51 deaths that were preventable.

Some watching might feel this was all on the pilot. It was, after all, his decision to continue flight under VFR into instrument meteorological conditions (IMC) and pilots operating under VFR must take appropriate action to avoid weather hazards, including knowing when not to fly, when to divert, or when to land.

But I want to draw attention to something Safari’s president said which I think is telling: pilots are the only ones who can assess whether to continue, divert, return, or cancel a flight” because the pilot is the only one who sees what the weather is like.

But others should be able to help the pilot. There are infrastructure, equipment, safety technologies, and training that can assist pilots to help ensure safe flights. And that’s where the operator, Safari Aviation, and the regulator, the Federal Aviation Administration (FAA), come in.

I’m pleased that Safari took action to implement ADSB Out and In equipment on all three of its helicopters but it also needs to take immediate action to develop and implement a comprehensive safety management system to identify hazards (such as weather) and mitigate the risk to their pilots and their passengers and a flight data monitoring (FDM) program to help pilots, instructors, and operators improve performance and safety.

Most concerning to me is the lack of leadership, safety action, and oversight provided by the regulator which is charged by law with “assigning and maintaining safety as the highest priority in air commerce.”

The NTSB has issued recommendation after recommendation to the FAA following accident after accident which would have, if implemented, prevented the deaths of the four adults and three children (the youngest of whom was just 10 years old) who died in this tragedy.

In fact, in this report, we reiterated 11 recommendations that we have made to FAA before. Eleven!

We recommended crash resistant flight data recorders and cockpit voice recorders in 2013, 2014, two times in 2017, 2018, 2020, 2021, and now again in 2022.

In 2016, we asked the FAA to require Part 135 operations to establish a safety management system. We asked them again in 2017, 2018, 2019, 2020, and two times in 2021.

Starting in 2009, twelve years ago, we recommended that the FAA require helicopter air amblance operators to establish a structured FDM program and install recording devices capable of supporting it. In response, the FAA required such operators to equip their fleet with recording devices but did not require them to establish an FDM program. In 2016, we expanded our FDM recommendation to FAA to all Part 135 operators and reiterated it in 2018, 2019, 2020, and 2021. FAA’s response has been disconcerting, at best. Their regulatory evaluation for the helicopter air ambulance final rule showed FDM costs of approximately $20.4 million over a 10-year period and benefits of $0. Zero! Explain that to the families and friends who’ve lost loved ones in numerous tragedies we’ve investigated.

The recommendation is now classified as “Open – Unacceptable Response” and SMS, crash-resistant recorders, and flight data monitoring continues to be among our Most Wanted List of Transportation Safety Improvements.

In 2007, we recommended that the FAA develop cue-based training programs for Hawaii pilots so that they can address hazardous local weather phenomena and make informed in-flight decisions. 

In 2008 and again in 2019, the FAA informed us that it was shifting responsibility for developing cue-based weather training to Hawaii air tour operators without providing leadership or expert guidance on what the training should include or how it should be delivered.

As a result, and as stated in the report, the accident pilot did not receive the type of training that FAA’s own research has shown can improve the accuracy of pilots’ in-flight weather assessments and increase the likelihood of a prompt diversion in deteriorating weather conditions. Had the accident pilot made a timely decision to divert, this accident may have been avoided.

We have also continually suggested actions that the FAA can take to improve safety in air tour operations. This includes implementing ADS-B equipment in Hawaii. We made a recommendation in 2007 to the FAA to require air tours to install ADS-B Out and In on their aircraft. But the FAA decided to try and encourage voluntary installation rather than require operators to install this important safety equipment. Since that time, we have conducted a number of investigations that have shown the benefits of ADS-B. So we are again making a recommendation to the FAA about having air tour operations in Hawaii install and utilize ADS-B.

The same can be said for weather cameras. In 2013, we called on the FAA to develop a weather camera program in Hawaii – which has had tremendous success in Alaska. I understand that the FAA has made some progress in this area, installing cameras in two locations on Kauai (but not the accident location) but they have got a long way to go.

Locally, there was minimal FAA oversight of the safety of air tour operations in Hawaii, particularly with respect to the kinds of decisions pilots were actually making during tour flights.

The FSDO was understaffed and, as described by inspectors, had an extremely high workload. There were six inspector positions available; only two were filled with fully trained inspectors at the time of the accident despite the presence of 17 helicopter air tour operators in Hawaii. At the same time, the FAA had transitioned to more of a risk-based approach to oversight versus an enforcement program, which according to the GAO the FAA has not evaluated to determine whether it supports the FAA’s mission.

Our investigation also found that the Hawaii Air Tour Common Procedures Manual has not been updated since 2008. As stated in the Board Meeting, this manual provides operators in Hawaii with island specific and site-specific FAA requirements, such as minimum altitudes at which tours should enter and exit the sites, the reporting points where pilots must transmit over the radio the aircraft’s call sign and location, and certain altitude limitations. The FAA started to revise the manual, but around 2018 they transitioned the authority for the revisions to the very industry they were charged with regulating: the air tour industry.

Additionally, the safety meetings that brought the industry and the FAA together had been organized by the FAA, but over time, they began to decrease their involvement and began to shift responsibility of these meetings to the air tour operators.

The fact is the FAA should be leading safety, not ceding their responsibility to the industry that they are charged with regulating and overseeing.

We know that the FAA is not providing the necessary leadership because accidents like this continue to happen. We at the NTSB have made safety recommendations to address the issues that continue to contribute to these accidents.

The FAA needs to act on our safety recommendations now to ensure the safety of pilots and their passengers.

In closing, I’d like to extend the Board’s gratitude to our colleagues in the Office of Aviation Safety, the Office of Research and Engineering, and the Office of General Counsel for their work over the course of this investigation and in the development of an excellent report.

The Board extends its appreciation to our colleagues in the Office of Administration, the Office of the Chief Information Officer, and the Digital Services Division for their vital support of this meeting. As I mentioned earlier, this is the first in-person meeting of the Board since February 2020. I can’t tell you how much I value getting to see my NTSB colleagues in person, and I appreciate all the work it took to make this meeting a success.

Finally, I’d like to thank the Office of Safety Recommendations and Communications for its diligent work and advocacy to improve safety. When acted upon, the recommendations we’ve issued and reiterated today will save lives.

The NTSB looks forward to working with the Federal Aviation Administration, the Vertical Aviation Safety Team, and the Tour Operators Program of Safety to implement our recommendations.

At the same time, NTSB will not stop working to create a safe transportation system where there’s no longer a need for our recommendations.

Thank you. We stand adjourned.​


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