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NTSB PRESS RELEASE
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National Transportation Safety Board
Washington, DC 20594
FOR IMMEDIATE RELEASE: February 13, 2007
SB-07-07
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NTSB CITES POOR DECISIONMAKING AND SPATIAL DISORIENTATION AS
CAUSE OF HAWAIIAN AIR TOUR ACCIDENT
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Washington, D.C. - 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, www.ntsb.gov. The Board's full report
will be available on the website in several weeks.
-30-
NTSB Media Contact: Keith Holloway (202) 314-6100
hollowk@xxxxxxxx or Lauren Peduzzi (202) 314-6100
peduzzi@xxxxxxxx
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