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Safety Recommendation Details

Safety Recommendation A-07-018
Details
Synopsis: 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 (CFR) Part 91 and visual flight rules (VFR) with no flight plan filed. Instrument meteorological conditions (IMC) prevailed near the accident site.
Recommendation: 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.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Aviation
Location: Kalaheo, HI, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: LAX04FA329
Accident Reports: Weather Encounter and Subsequent Collision into Terrain, Bali Hai Helicopter Tours, Inc., Bell 206B, N16849
Report #: AAR-07-03
Accident Date: 9/24/2004
Issue Date: 2/27/2007
Date Closed:
Addressee(s) and Addressee Status: FAA (Open - Acceptable Response)
Keyword(s): Air Tours,Decision Making,Training and Education,Weather

Safety Recommendation History
From: FAA
To: NTSB
Date: 8/23/2019
Response: -From Steve Dickson, Administrator: Operations Specifications (OPSS) paragraph B048 and Letter of Authorization (LOA) 8548 authorize commercial air tour operations below 1,500 feet above the surface in the state of Hawaii. We are currently revising OPSS B048 issued to Part 135 commercial air tour operators and LOA B548 issued to Part 91 commercial air tour operators to require cue-based weather training. This is in addition to all other current training requirements which include hazardous aspects of local weather phenomena and in-flight adverse weather avoidance decision-making. The cue-based weather training required by the revised OPSS 8048 and LOA 8548 may be provided via pictorial description, actual video, or power point presentations of each commercial air tour site specific area showing examples of acceptable and unacceptable weather at each critical point within the route along with industry-recommended course reversal maneuvers. The Hawaii air tour industry participants will have location-specific training products for each island where air tour operations are conducted. The Honolulu Flight Standards District Office will review, approve, and accept all initial and revised adverse weather training material as an inclusion if applicable in each air tour operator's training program. The anticipated implementation date is December 2019. All newly hired pilots and transferred pilots flying air tours for the first time on any island will be required to receive the cue-based weather training for the pertinent island/site prior to initiating flight operations on each island. Following completion of the training, part 135.293 initial and recurrent checks will include verification of the part 135 pilot's knowledge of weather-related decision making pertinent to the pilot's assigned area of operation. For 14 CFR 91.147 LOA pilots, a Honolulu FSDO Inspector or FAA Designated Pilot Examiner will conduct a 91.147 LOA pilot flight observation on an annual basis. We anticipate providing an update to the Board on the FAA's progress for these safety recommendations by February 2020.

From: NTSB
To: FAA
Date: 4/23/2014
Response: We are pleased to learn that you have implemented a cue-based training program for air tour operators in Southeast Alaska and that all operators in that region have incorporated the training into their individual programs. We note that, although you haven’t finished developing a similar program for air tour operators in Hawaii, the only component still to be developed is the digitization of aerial photography. Once the product becomes available, the training will be required for 14 Code of Federal Regulations Part 91 and Part 135 commercial air tour operators, to satisfy requirements specified in the Hawaii Air Tour Common Procedures Manual. Accordingly, pending completion of the recommended actions, Safety Recommendations A-07-18 and -19 remain classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 12/13/2013
Response: The Federal Aviation Administration (FAA) has developed and implemented a cue-based weather training program for operators in Southeast Alaska. This program was developed by working with a variety of organizations from the local aviation community, such as the Medallion Foundation, and national organizations, such as the National Institute for Occupational Safety and Health. Additional expertise was sought out as needed, which included utilizing a third party to provide the photo-realistic terrain modeling of the air tour environment involved. The State meteorology departments of Alaska and Hawaii also participated. As of the 2011 Alaska air tour season, all air tour operators in Southeast Alaska had added materials and concepts developed as part of the cue-based training project to their training programs. These include, but are not limited to, training videos, use of basic airplane training devices with wide screen outside view, and photo-realistic instrument panels for each type of tour airplane. These devices include programmable visibility restrictions and deterioration rates, visibility targets, and photo-realistic terrain. The FAA plans on using the Alaska cue-based weather training program as a hardware and software basis for Hawaii based operators. The only remaining component that remains to be developed for the Hawaii based operators is the digitization of the aerial photography to provide three-dimensional terrain mapping. Completion of this component is contingent on receiving additional funding. I will keep the Board informed of the FAA's progress on these safety recommendations and provide an update by July 2014.

From: NTSB
To: FAA
Date: 7/12/2011
Response: The NTSB notes that the FAA has established a project management team to develop and produce high quality, comprehensive, expert-vetted, cue-based weather and in-flight decision-making visual training aids for commercial air tour operators in both Alaska and Hawaii. The FAA indicated that the product developed for use in Hawaii is scheduled to be completed in March 2012. Once the product is available, the training will be required for 14 Code of Federal Regulations Part 91 and Part 135 commercial air tour operators, to satisfy requirements specified in the Hawaii Air Tour Common Procedures Manual. The FAA’s efforts are responsive to both of these recommendations. Pending completion of the cue-based training, which will be required for all newly hired commercial air tour pilots in Hawaii, Safety Recommendations A-07-18 and -19 are classified OPEN—ACCEPTABLE RESPONSE. We commend your efforts to ensure the same level of safety for air tour operators in Alaska, as well.

From: FAA
To: NTSB
Date: 3/8/2011
Response: CC# 201100102: - From J. Randolph Babbitt, Administrator: We have established a cue-based weather training project management team to develop and produce high quality, comprehensive, expert-vetted, cue-based weather and in-flight decision-making visual training aids for commercial air tour operators in both Alaska and Hawaii. The team includes representatives from the Federal Aviation Administration Safety Team, commercial air tour operators, the Civil Aerospace Medical Institute, the National Institute of Occupational Safety and Health, and State meteorology departments of Alaska and Hawaii. Each cue-based training product would consist of high resolution, photo-realistic terrain depictions overlaid with a range of low ceilings, restricted visibilities, and motion speeds. The pilot would be able to select from various speeds, flight altitudes, routes, and conditions to simulate flight into actual indigenous weather conditions along actual tour routes. The training systems would permit pilots to view the full range of weather conditions they could experience in the localities in which they would operate. Pilots would be educated on which conditions could indicate rapid deterioration, existing below minimum visibility conditions, and cloud clearance margins beyond the current sight limit. The high-definition video clips along with knowledge of local weather phenomena would foster development of strong weather awareness and avoidance judgment. The cue-based weather training product for Hawaii was initiated in March 2010 and is scheduled for completion in March 2012.

From: NTSB
To: FAA
Date: 10/27/2009
Response: On May 17, 2007, the FAA responded, stating that Operations Specification (OpSpec) B048 requires operators to have a training program that includes the recommended elements. On December 4, 2007, the NTSB replied, stating that the OpSpec applies only to Part 135 operators and that it was not clear how these restrictions would be applied to Part 91 operators like Bali Hai. However, the most serious shortcoming in the FAA’s response was that the recommendation asked the FAA to develop a cue-based training program for comprehensiveness and consistency among operators with respect to the components of the training programs. The FAA response requires that the operators develop a training program, thereby shifting the responsibility to the operators without providing any FAA leadership or guidance; also, there was no indication that this training would be cue based. Safety Recommendation A-07-18 specifically asks that the program be developed in cooperation with Hawaii commercial air tour operators, aviation psychologists, and meteorologists, yet it appeared from the FAA’s response that only air tour operators would be involved. The recommendation also asks for the creation of a set of audio-visual aids that would show pilots actual weather conditions as they appear in flight and that would train pilots about when certain in flight decisions (such as whether to deviate from the usual flightpath) should be made. The OpSpec did not adequately address these concerns. Therefore, on December 4, 2007, the NTSB classified Safety Recommendations A-07-18 and -19 Open Unacceptable Response. In its current letter, the FAA indicated that Part 91 operators will now be covered by Letter of Authorization (LOA) B548 1. An LOA serves a similar purpose for a Part 91 operator as an OpSpec does for a Part 135 operator. Both LOA B548-1 and OpSpec B048-1 require the operators to develop a cue-based weather training module for incorporation into their approved pilot training curriculum and to provide such training to pilots conducting commercial air tour operations. The NTSB acknowledges that issuance of an LOA for Part 91 operators addresses the concern that Part 91 air tour operators were not covered by the OpSpec. However, the more important issue of who develops the training has not changed, and the FAA continues to place this responsibility on the operators. On December 4, 2007, the NTSB indicated this was not an acceptable response. The individual operators in Hawaii do not have the resources or expertise to develop appropriate training materials, particularly a cue-based program, on their own. In contrast, the FAA has appropriate human factors staff who could organize such an effort; however, the FAA staff must work with Hawaiian meteorologists and tour operators to identify key weather phenomena and key geographic areas on each island where heavy air tour activity occurs. The air tour operators need to provide photos and/or video of these weather conditions and areas. These materials should be shown to new pilots operating on the island to help them recognize when weather conditions are deteriorating to unsafe levels and when it is appropriate to deviate from standard tour routes. The general strategy and rationale for cue-based training is found in an article describing an FAA-sponsored research project (see Weatherwise: Evaluation of a Cue-based Training Approach for the Recognition of Deteriorating Weather Conditions During Flight, Wiggins, M. and O’Hare, D. [2003] Human Factors Vol. 45 (2): 337-345). The requirements stated in the OpSpec and LOA do not adequately respond to the need for the recommended cue based training. The Bali Hai accident pilot received 22 hours of ground training and 5 hours of flight training, including area familiarization flight training; all of this training was at the owner/operator’s discretion based on his assessment of what the pilot needed. This training included the owner’s counseling on go/no-go decisions about flying in marginal weather. The owner stated that he personally believed that common sense, not instrument training under the hood, was more practical. Because weather phenomena develop daily on the island where Bali Hai operated, it is likely that some of the training flights included weather avoidance and could therefore be construed as cue based. Thus, the NTSB is concerned about whether the training program developed by Bali Hai, which did not adequately prepare the accident pilot to avoid dangerous weather, would meet the current requirements outlined in LOA B548-1. Pending the development, in cooperation with Hawaii commercial air tour operators, aviation psychologists, and meteorologists, among others, of a cue-based training program, Safety Recommendation A-07-18 remains classified OPEN -- UNACCEPTABLE RESPONSE. Pending the FAA’s instituting a requirement that Hawaii commercial air tour operators provide the training developed in response to Safety Recommendation A-07-18 to all newly hired pilots, Safety Recommendation A-07-19 also remains classified Open Unacceptable Response.

From: FAA
To: NTSB
Date: 12/2/2008
Response: Letter Mail Controlled 12/29/2008 11:35:13 AM MC# 2080751: - From Robert A. Sturgell, Acting Administrator: 12/2/08 With the August 15, 2008 issuance of the revised Operations Specification (OpSpec) B048-1 (enclosure 1) and Letter of Authorization (LOA) B548-1 (enclosure 2), both titled, Air Tour Operations Below 1,500' AGL in the State of Hawaii, the Federal Aviation Administration now requires both 14 CFR part 91 and part 135 operators to develop a cue-based weather training module for incorporation into their approved pilot training curriculum and to provide such training to pilots conducting commercial air tour operations, applicable to their approved area of operations. These requirements are listed in the training grid contained on page 4 of the Hawaii Air Tour Common Procedures Manual (FAA Document Number AWP13-136A) (enclosure 3). Because this manual is referenced in both the LOA and OpSpec, it becomes mandatory pilot training for these operators. Additionally, the following link provides public access to the Hawaii Air Tour Common Procedures Manual: http://www.faa.gov/about/office_org/field_offices/fsdo/hnl/local_more/media/hawaii_air_tour_common_proc.pdf. I believe that the FAA has effectively addressed these safety recommendations, and I consider our actions complete.

From: NTSB
To: FAA
Date: 12/4/2007
Response: The FAA indicated its belief that Operations Specifications (OpSpec) paragraph B048 (b) (4) fully addresses this recommendation. The Safety Board disagrees. OpSpec B048(b)(4) specifies that Part 135 air tour operators are responsible for including in their new-hire training program the issues addressed in this recommendation. The Board notes that OpSpecs apply only to Part 135 operators and that the operator involved in the accident that prompted this recommendation, Bali Hair Air Tours, was a Part 91 operator. Although the FAA has initiated the use of Letters of Authorization (LOA) for Part 91 air tour operators, the FAA has not indicated that the provisions of OpSpec B048 can or will be applied to Part 91 operations. However, issuance of OpSpec B048 is not responsive to this recommendation because the recommendation asks for the development, in cooperation with Hawaiian commercial air tour operators, aviation psychologists, and meteorologists, among others, of a cue-based training program (emphasis added). Issuance of the OpSpec does not necessarily lead to the development of the cue-based program recommended, nor does it necessarily involve anyone other than the individual air tour operator. The Safety Board believes that an acceptable response to this recommendation will create a set of audio-visual aids that would show pilots actual weather conditions, as they would appear in flight, and train them in consensus opinions about when certain in-flight decisions (for example, whether or not to deviate from the usual flight path) should be made. The Board does not believe that OpSpec B048 (b) (4) will develop such a program. Pending the FAA’s taking the recommended action, Safety Recommendation A-07-18 is classified OPEN -- UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 5/17/2007
Response: Letter Mail Controlled 5/31/2007 8:30:30 AM MC# 2070237: - From Marion C. Blakey, Administrator: 5/17/07 The Federal Aviation Administration believes that recently published Operations Specifications paragraph B048 dated March 9, 2007, addresses these recommendations. Below is the specific paragraph that addresses the respective safety recommendations and a copy of the Operations Specifications is enclosed. Paragraph B048(b)(4) addresses A-07-18 This paragraph covers the subjects that a training program must address: ·Mountain flying techniques; ·High density altitude flying techniques; ·Use of performance plan information; ·Island-specific weather and weather avoidance procedures; ·Criteria for making a pre-departure go-no-go weather decision; ·Route knowledge, including en route and site-specific hazards; ·Ditching procedures; ·A review of Hawaii air tour accidents during the past 10 years; and ·A review of in-flight island-specific weather pilot cues to determine deteriorating weather conditions. I believe that the FAA has satisfactorily responded to these safety recommendations, and I look forward to your response.