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NTSB Cites Poor Decision-making and Spatial Disorientation as Cause of Hawaiian Air Tour Accident
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 NTSB Cites Poor Decision-making and Spatial Disorientation as Cause of Hawaiian Air Tour Accident

In a report adopted today, the National Transportation Safety Board determined that the probable cause of a fatal crash of an air tour helicopter in Hawaii was "the pilot's decision to continue flight into an area of turbulent, reduced visibility weather conditions, which resulted in the pilot's spatial disorientation and loss of control of the helicopter."

The accident occurred on September 24, 2004, when the Bell 206B helicopter, operated by Bali Hai Helicopter Tours, Inc., conducting an air tour flight on the island of Kauai, encountered adverse weather conditions and crashed into mountainous terrain. The pilot and all four passengers were killed in the crash.

"The air tour industry in Hawaii serves hundreds of thousands of paying passengers each year and the public deserves an appropriate level of safety when they embark on an air tour," said NTSB Chairman Mark V. Rosenker. " It is my fervent hope that the FAA will move quickly on our recommendations."

The Board's report examined local weather training for newly hired Hawaii air tour pilots, air tour operational practices, Federal Aviation Administration (FAA) surveillance of air tour operators, and flight tracking and on-board weather technology for Hawaii air tour aircraft.

Experienced local pilots interviewed for the investigation noted that helicopter operations on Kauai can be challenging due to the terrain, mountain winds, and rapidly changing cloud conditions. A review of the eight weather-related accidents that have occurred in Hawaii since 1994 found that four involved pilots who were relatively new to air tour operations in Hawaii, three of whom, including the accident pilot, had been operating for less than two months. The Board cited the pilot's inexperience in assessing local weather conditions as a contributing factor and recommended that the FAA develop and require a cue-based training program for pilots that specifically addresses local weather phenomena and in-flight decision-making.

Bali Hai's helicopter tours departed from Port Allen Airport (PAK), a general aviation airport with no buildings or shelters, and Bali Hai did not provide any airport shelter or restroom facilities for their employees or customers. Further, a review of scheduling practices discovered that pilots typically flew between seven or eight hours a day without lunch or bathroom breaks. Between tours, pilots would remain in the helicopter with rotors turning, to reduce wear on the engine. The Board concluded that these operational practices, although permitted under Federal regulations, likely had an adverse impact on pilot decision-making and performance. Bali Hai's operational practices were cited as a contributing cause and the Board recommended that the FAA establish best scheduling practices to ensure acceptable pilot performance and safety and require commercial air tour operators to adhere to these practices.

In addition to challenging scheduling practices, the review of Bali Hai's operations found significant discrepancies with aircraft maintenance procedures and logbooks. Although under the jurisdiction of the Honolulu Flight Standards District Office (FSDO), because Bali Hai operated under the less stringent 14 CFR Part 91 operating rules, there are no requirements for FAA inspection of operations. In fact, prior to this accident, Bali Hai had never received an FAA operations inspection. The Board concluded that the public would benefit from air tour regulations that provide increased oversight and additional safety requirements for Part 91 air tour operators. The lack of FAA surveillance was cited as a contributing cause and the Board recommended that the FAA develop and enforce safety standards for all commercial air tour operators that include at a minimum, pilot training programs, special airspace restrictions, maintenance policies, and flight scheduling procedures. The Board also noted that these recommended safety standards are not required by the FAA's recently released 14 CFR Part 136 air tour rules.

Finally the NTSB noted that Hawaii's mountainous landscape, limited air traffic control coverage, challenging weather, and high-density air traffic make it a prime candidate for the National Automatic Dependent Surveillance- Broadcast (ADS-B) program and recommended that the FAA accelerate the implementation of ADS-B infrastructure capable of providing services to the aircraft flying air tour routes in Hawaii. The Board further recommended that the FAA require Hawaii air tour operators to equip their aircraft with ADS-B technology within one year of the installation of a functional national ADS-B program.

A synopsis of the Board's report, including the probable cause and safety recommendations, is available on the Board's website, The Board's full report will be available on the website in several weeks.

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Contact: NTSB Media Relations
490 L'Enfant Plaza, SW
Washington, DC 20594