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Safety Recommendation Details

Safety Recommendation A-07-021
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: 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.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
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: 8/28/2018
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Air Tours,Oversight

Safety Recommendation History
From: NTSB
To: FAA
Date: 8/28/2018
Response: You reported that the Safety Performance Analysis System and the 135 Surveillance Priority Index (SPI) tool monitor and aggregate selected risk factor and safety performance data to provide a numerical basis by which to compare certificate holders and monitoring trends. We are aware that, in 2010, you revised Order 8900.1, “Flight Standards Information Management Systems,” to require FAA inspectors who oversee Part 135 certificate holders and commercial air tour operators to use the 135 SPI tool. We believe that these tools, which help inspectors identify operators at higher risk and prioritize their oversight activities accordingly, satisfy the intent of Safety Recommendation A-07-21, which is classified CLOSED--ACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 6/11/2018
Response: -From Daniel K. Elwell, Acting Administrator: As stated in our previous letter, dated January 2 1, 2014, the Federal Aviation Administration (FAA) uses the Safety Performance Analysis System (SPAS) and the Surveillance Priority index (SPI) tool to make information gathered as part of the FAA Modernization and Reform Act of 2012 available to field offices and inspectors to assist them in determining which air tour operators to prioritize. The FAA cannot disclose specific examples requested in the Board 's letter, dated April 23, 20 14, due to sensitive information contained in the system. However, this response illustrates examples of how the FAA utilizes the SPI tool and the SPAS to successfully identify operators whose activities justify the need to increase and redirect inspectors' surveillance resources. Both SPAS and SPI retain historical SPJ values for a year. These values are calculated and updated automatically using data from the following sources: • The Board; • The FAA 's Operations Safety System: • The FAA's Air Transportation Oversight System; • The FAA's Accident and Incident Database System; • The FAA's Air Traffic Quality Assurance System; • The FAA 's Enforcement Information System; • The FAA 's National Vital Information System; • Department of Defense data; and • The FAA's National Program Tracking and Reporting Subsystem (NPTRS). Data derived from NPTRS results are typically entered as observations by Principal Inspectors (PI) during inspections of the operators. The FAA' s Quick Reference Guide to the SPAS Risk Factor Analysis Tools explains how the SPI is utilized to assess operators' risk values as well as the details on associated data, including NPTRS. A copy of this document is enclosed. The display of SPI data available to each Pl allows the inspectors to evaluate the risk levels of each air carrier or operator to which the PI has assigned responsibility for conducting certificate management and surveillance. The FAA 's managers. in turn, use this information to allocate inspector resources. For example, a PI accessing the SPI data sheet for a part 135 certificate holder can view SPI values automatically updated by SPAS based on the NPTRS and other data contributors. In addition, the PI has the ability to adjust the SPI value based on factors they assess, including: • Known labor disputes; • Financial distress; and • Safety culture. Through the use of SPAS and SPI, PIs are able to review the underlying data used to calculate specific values, such as violations within the past 3 years or a single operator's trends of SPI data over a I -year period. PIs are also able to review the data for a group of certificate holders to compare operators· rankings, allowing the FAA to view a snapshot of a group of operators ' values during an evaluation of operators' risks levels. The number of inspections performed per operator is influenced by many factors. including size and scope of the operation, amount of different types of aircraft flown by the operators, total number of aircraft under the certificate holder, total number of employees, and number of satellite bases. However, SPY and SPAS allow the FAA to perform a yearly analysis of values identifying operators with higher risk, and subsequently assign additional inspections and surveillance resources. The FAA 's front line managers consider SPI data for each operator before determining where to assign additional inspections. I believe that the FAA has effectively addressed this safety recommendation and consider our actions complete.

From: NTSB
To: FAA
Date: 4/23/2014
Response: We note that, on August 4, 2010, you published a change to Order 8900.1, Flight Standards Information Management Systems, volume 6, chapter 2, section 1, which requires FAA inspectors with oversight responsibility for part 135 certificate holders and commercial air tour operators to use the Surveillance Priority Index (SPI). We also note that the SPI is one tool that inspectors use in their safety analysis to identify increased risk for a particular certificate holder or type of flight activity. We previously informed you that, although the SPI may allow the Honolulu Flight Standards District Office (FSDO) to better use its personnel and other resources, the tool did not address our concern that the Honolulu FSDO does not have sufficient resources to perform the needed level of air tour oversight to detect and correct risky flight practices. However, we believe that the mandated use of the SPI tool, in combination with the Safety Performance Analysis System and regular inspections, could constitute an acceptable alternate solution if you can show us, through the use of these tools, instances in which inspectors have identified operators whose activities have justified the need to increase and redirect inspectors’ surveillance resources. Pending our review of these data, Safety Recommendation A 07-21 is classified OPEN—ACCEPTABLE ALTERNATE RESPONSE.

From: FAA
To: NTSB
Date: 1/21/2014
Response: -From Michael P. Huerta, Administrator: In 2009, partly in response to this safety recommendation, the FAA issued guidance to inspectors with oversight responsibilities of air tour operators in the State of Hawaii to require the inspectors to: • Incorporate the SPAS risk assessment tool; • More efficiently use the limited inspector resources by prioritizing surveillance activities; • Use evaluation processes that identify weakness or potential safety risk in operator performance; and • Allow inspectors to apply the appropriate level of focus on any particular operator. As previously mentioned in our response to Recommendation A-07-20, we have also developed and implemented the Surveillance Priority Index (SPI) program. a data-driven work program in the SPAS. Inspectors can use the SP1 as part of a safety analysis to identify increased risk of a particular certificate holder or type of flight activity. In this way, inspectors can provide enhanced direct surveillance when warranted. However, it is important to note that the SPI is only one tool available to the inspector in his or her judgment of an operator's activities. The SPJ score is not an absolute measure of safety risk, and inspectors never use the SPI in a vacuum. It is only an indicator that helps the POI, in combination with other factors, detem1ine the need to increase and redirect his or her surveillance resources. In addition, POIs have a work schedule that includes regular inspections of each of their operators' bases and operations. Such regular site visits will alert them to issues through direct observation. The need for more frequent or enhanced surveillance is the POI's call. He or she will utilize a combination of all of the tools available, such as the SPI, SPAS, and regular inspections, to determine if an operators• activities justify the allocation of additional resources. On August 4, 201 0, the FAA published a change to FAA Order 8900.1, Flight Standards Information Management Systems, volume 6, chapter 2, section 1. This change required FAA aviation safety inspectors (ASIs) with oversight responsibility for part 135 certificate holders and commercial air tour operators to use the SPI. The change also includes a detailed summary of the factors that go into the SPI tool for risk analysis. On August 12, 2010, the FAA issued Notice 8900.132, Work Program Development for Title 14 Code of Federal Regulations (14 CFR) Part 135 Ce11ificate Holders, instructing these same ASIs to use the SPI when developing an annual work program or during reassessment of an existing work program. The contents of this notice were incorporated into Order 1800.56L, National Flight Standards Work Program Guidance. As stated in our response to Recommendation A-07-20, we believe that the mandated use of the SPT tool will allow us to quickly and efficiently identify those areas requiring enhanced surveillance. Therefore, we will be able to take appropriate and proportionate action to mitigate any risks identified. The Board's October 27, 2009, letter stated that FAA offices may not always be fully aware of the number of flights conducted by an air tour operator and implied that this absence of data may skew the allocation of surveillance resources. On February 14, 2012, the FAA Modernization and Reform Act of2012 was signed into law. This Act included title V, section 501, which amended 49 USC 40128, Overflights of National Parks, mandating all commercial air tour operators who conduct commercial air tour flights over or within ~ mile of the boundary of any unit of the National Park Service (NPS), and any abutting tribal lands, to submit detailed activity reports to the FAA and to the NPS. As a result of this statute, as of 2013, the FAA collects extensive and detailed flight operations data from air tour operators. The FAA and NPS jointly developed the air tour reporting requirements. Information requested for each tour includes the following: • Departure date and time; • Registration number, make, model, and series; and • Departure airport/helipad, detailed flight route, and park(s) overflown. For most park units, air tour operators must report infom1ation on a quarterly basis. For those parks that are exempt from the provisions of the Act by having 50 or fewer annual commercial air tours. operators must report on an annual basis and only need to report the number of flights conducted. The Act's provision affects the majority of air tour flights in Hawaii. Additionally, this provision of the Act is self-enacting and does not require the FAA to initiate rulemaking. The FAA will make this information available to field offices and inspectors to assist them in determining which air tour operators to prioritize. This infom1ation collection should alleviate the Board's concern that FAA offices may not be aware of the number of flights conducted by an air tour operator. While the FAA is providing information on the Act to address the concerns of the Board, we believe the issue off AA staffing levels is outside the scope of the original recommendation. The recommendation is to "develop a permanent mechanism to provide direct surveillance." The changes made to FAA Order 1800.56L, described above. establish a permanent mechanism for providing direct surveillance. The detailed flight route information collected via the FAA Modernization and Reform Act of2012 makes more information available to inspectors, enhancing the surveillance inspectors provide. Since we believe the implementation of the SPI is responsive to this recommendation. we plan no further action with regard to this recommendation.

From: NTSB
To: FAA
Date: 10/27/2009
Response: In response to Safety Recommendations A-07-89 and A-07-21, the FAA took several actions, including the development of the surveillance priority index (SPI), a risk-assessment tool based on the FAA’s safety performance analysis system. The SPI is used to identify safety risks in air tour operator performance and to increase FAA surveillance as necessary, based on the priority determined by the SPI. The FAA plans to issue guidance to the Honolulu FSDO to (1) use the 135 SPI and prioritize surveillance activities based on this tool, (2) use evaluation processes to identify safety risks in operator performance, and (3) allow inspectors to apply the appropriate level of focus on any particular operator. The FAA also plans to issue a notice that will require each principal operations inspector in Honolulu to conduct at least one en-route inspection annually for each Hawaii air tour operator. Finally, the FAA plans to generate a specific national use code for the Program Tracking and Reporting Subsystem (PTRS) to track the on-demand surveillance activities of its inspectors. In further response to both recommendations, the FAA stated that Order 1800.56, National Flight Standards Work Program Guidelines, section 7a, Special-Emphasis Inspections, advises principal inspectors to consider the NTSB’s recommendations when planning surveillance programs. Although both Safety Recommendations A-07-89 and A-07-21 address FAA oversight of air tour operators, Safety Recommendation A-07-21 is concerned with different issues. In the final report on the Bali Hai accident, the NTSB concluded that the FAA had not provided sufficient resources for the Honolulu FSDO to implement air tour surveillance. Such surveillance in the months before the accident might have detected and corrected the accident pilot’s risky flying practices, such as low-altitude, off-route ridge crossings, and flight into clouds and reduced visibility. Although the actions described by the FAA may allow the Honolulu FSDO to better use its personnel and other resources, they do not address the NTSB’s finding that the Honolulu FSDO does not have sufficient resources to perform the needed level of air tour oversight to detect and correct risky flight practices. Pending development of a permanent mechanism to provide direct surveillance of commercial air tour operations in Hawaii, Safety Recommendation A-07-21 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 The FAA concurs with the intent of this recommendation and will establish procedures similar to those addressed in our response previously provided for Safety Recommendation A-07-89. The FAA will issue guidance to inspectors with oversight responsibilities of air tour operators in the state of Hawaii to require the inspectors: To incorporate the Safety Performance Analysis System (SPAS) risk assessment tool; To more efficiently use the limited inspector resources by prioritizing surveillance activities; To use evaluation processes that identify weakness or potential safety risk in operator performance; and To allow inspectors to apply the appropriate level of focus on any particular operator. The 135 Surveillance Priority Index, a new SPAS module, is a tool that provides a ranked order of assessed safety risks that become the basis for action. The system assists inspectors in identifying the amount and prioritizing the timing of surveillance required for a particular operator. We will issue a notice to the Honolulu Flight Standards District Office (FSDO) requiring that they use the SPAS Surveillance Priority Index as a tool to identify increased safety risk in air tour operator performance and then to increase surveillance as necessary, based on priority. The Surveillance Priority Index tool allows the FAA to leverage resources smartly, focusing proper attention and surveillance where most needed. Additionally in the notice, the FAA will require each Honolulu FSDO operations inspector to conduct at least one enroute inspection annually for each of the Hawaii air tour operators. We will generate a specific national use code for the Program Tracking and Reporting Subsystem to track the progress of on-demand surveillance activities. I will provide you with a copy of the notice by March 2009. In addition, FAA Order 1800.56, National Flight Standards Work Program Guidelines, section 7a, titled Special-Emphasis Inspections, advises principal inspectors to consider the Board’s recommendations when planning surveillance programs. Specifically, appendix 1, paragraph 6c states, Trends affecting aviation safety are routinely identified through analysis. Recommendations from the National Transportation Safety Board (NTSB), Office of the Inspector General (OIG), and the Government Accountability Office (GAO) are also considered in identifying these trends. The special emphasis items should be actively included when planning the work programs for each field office. I will keep the Board informed of the FAA’s progress on this safety recommendation.

From: NTSB
To: FAA
Date: 12/4/2007
Response: The FAA replied that through its work program, it has a permanent mechanism for direct surveillance, consisting of baseline, required inspections for each air tour operator. The required inspections are prescribed by the national program office and may be supplemented by the local district office based on perceived potential risks. The Safety Board notes that the work plan that the FAA believes is responsive to this recommendation is the same work plan that was in effect at the time of the Bali Hai accident. This accident, as well as other air tour accidents in Hawaii investigated by the Safety Board, shows that the work plan was not effective for ensuring the direct surveillance needed. In the final report on the Bali Hai accident, the Board concluded that the FAA had not provided sufficient resources for the Honolulu flight standards district office (FSDO) to implement air tour surveillance. Such surveillance in the months before the accident may have detected and corrected the accident pilot’s risky flying practices, such as low-altitude, off-route ridge crossings, and flight into clouds and reduced visibility. Accordingly, pending development of a permanent mechanism to provide direct surveillance of commercial air tour operations in Hawaii, Safety Recommendation A-07-21 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 has a permanent mechanism for direct surveillance through the FAA work program. The work program consists of baseline, required inspections for each air tour operator. Required inspections are prescribed by the national program office and may be supplemented by the local district office based on perceived, potential risks. The work program is prioritized based on available resources. When noncompliance is detected, enforcement investigations are initiated.