Accident - Aviation NTSB Report

On September 24, 2004, about 16:42 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 Part 91 and visual flight rules with no flight plan filed. Instrument meteorological conditions prevailed near the accident site.

The National Transportation Safety Board determines that the probable cause of this accident was the pilot's decision to continue flight under visual flight rules into an area of turbulent, reduced visibility weather conditions, which resulted in the pilot's spatial disorientation and loss of control of the helicopter. Contributing to this accident was the pilot's inexperience in assessing local weather conditions, inadequate Federal Aviation Administration (FAA) surveillance of Special Federal Aviation Regulation 71 operating restrictions, and the operator's pilot-scheduling practices that likely had an adverse impact on pilot decision-making and performance.

The safety issues discussed in this report include the influence of pilot experience and operator scheduling on in-flight decision-making; the lack of FAA oversight of Part 91 air tour operators; the need for national air tour safety standards; and the lack of direct FAA surveillance of commercial air tour operators in Hawaii.

Nine safety recommendations are addressed to the FAA regarding local weather-training programs for newly hired Hawaii air tour pilots; evaluation of operational practices for commercial air tour helicopter pilots; Honolulu Flight Standards District Office control of the annual safety meetings, as required under approved certificates of waiver or authorization; evaluation of the safety impact of the altitude restrictions in the State of Hawaii; national air tour safety standards; and the potential benefits of automatic dependent surveillance-broadcast technology for Hawaii air tour operators.

1 Aircraft Accident Report

1 Aircraft Accident Report Factual Information 1.1 History of Flight On September 24, 2004, about 1642 Hawaiian standard time,1 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 (PAK) 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 912 and visual flight rules (VFR) with no flight plan filed.3 Instrument meteorological conditions (IMC) prevailed near the accident site.

The air tour flight was conducted under Special Federal Aviation Regulation (SFAR) 71, Special Operating Rules for Air Tour Operators in the State of Hawaii, and in accordance with a certificate of waiver or authorization approved for Bali Hai by the Federal Aviation Administration s (FAA) flight standards district office (FSDO) in Honolulu, Hawaii. The minimum altitude for tour flights specified in SFAR 71 is 1,500 feet above ground level (agl) and no closer than 1,500 feet to any person or property, unless otherwise authorized. Bali Hai s certificate of waiver or authorization allowed its pilots to deviate from the minimum altitude requirement and to fly transition segments4 at 1,000 feet agl, cross ridgelines at 500 feet agl, and cross razorback ridgelines5 at 200 feet agl.

The flight, which was the pilot s eighth and final tour flight for the day, was scheduled to depart PAK about 1600 and fly clockwise around the island of Kauai for a 45-minute sightseeing tour over a number of site-specific locations,6 including Waimea Canyon, the Na Pali Coast, Waialeale Crater, and Manawaipuna Falls (see figure 1).

1 Hawaiian standard time is coordinated universal time minus 10 hours. Unless otherwise indicated, all times are Hawaiian standard time based on a 24-hour clock.

2 According to Federal Aviation Regulations, 14 CFR Part 91 commercial air tour flights are authorized as long as they are conducted as nonstop sightseeing operations in non-common carriage in accordance with 14 CFR 119.1(e)(2) and 135.1(a)(5), which specify that the flights must begin and end at the same airport and must be conducted within a 25-statute-mile radius of that airport.

3 Personnel at the company office logged tour departure times and knew the usual tour routes, but they did not track the flights or perform flight-following services.

4 Bali Hai s FAA-approved transition segments were established with the Honolulu FSDO and were outlined in the certificate of waiver or authorization.

5 The certificate of waiver or authorization does not define razorback ridgeline. Generally, the description refers to a sharp, narrow ridge.

6 Bali Hai s site-specific locations were approved by the Honolulu FSDO, which maintained a master map that identified the locations for the operators. Bali Hai s certificate of waiver or authorization allowed its pilots to descend to 500 feet agl over site-specific locations.

Factual Information 2 Aircraft Accident Report Digital, time-stamped still images recovered from a passenger s camera showed that, when the helicopter departed, the weather near PAK appeared sunny with good visibility. Subsequent images taken during the tour showed low clouds and precipitation near some site-specific locations. Figure 1. Map of Kauai, showing accident site and some of Bali Hai s site-specific locations. A review of air traffic control (ATC) radar data from the FAA s air route traffic control center and radar approach control (CERAP) facility in Honolulu showed the helicopter s ground track entered the area north of Mount Waialeale about 1635;7 however, the helicopter s flight altitudes could not be determined.8 The radar data showed that, about 1641, the helicopter crossed a 2,000-foot ridge that extended east from Kahili Ridge (see figure 2), the main ridgeline 3,000 feet south of Waialeale Crater. Shortly 7 Radar coverage on the island of Kauai was limited due to the location of the radar station and the high terrain in the center of the island; the CERAP facility had no radar data for the helicopter before 1635. 8 The helicopter was equipped with a mode C transponder, which is designed to transmit the helicopter s identification code and altitude information in response to interrogation signals received from ground-based radar equipment. During the accident flight, however, the helicopter s transponder transmitted only a constant altitude of 1,000 feet mean sea level; thus, the helicopter s actual flight altitudes before the accident could not be determined. 0 3.75 7.5 15 Miles N 11.25 Lihue Airport Accident Site Port Allen Airport Kahili Ridge Hanapepe Valley Manawaipuna Falls Mount Waialeale Waimea Canyon Na Pali Coast Hanalei Valley Princeville Hanapepe Kalaheo Waialeale Crater Hanalei Factual Information 3 Aircraft Accident Report

Factual Information 3 Aircraft Accident Report 9

Figure 2. Radar data for the last 2 minutes of the accident flight plotted over a topographical map.

When the helicopter failed to return to PAK as scheduled, Bali Hai personnel notified the tower controllers at Lihue Airport (LIH) in Lihue, on the island of Kauai, and the U.S. Coast Guard that the flight was overdue. Bali Hai, other air tour companies, and the Coast Guard conducted visual aerial searches, but clouds obscured the location of the crash site. The Coast Guard located the wreckage about 1420 on September 25, 2004. Recovery of the victims and the wreckage took 10 days because of the terrain and weather conditions. According to recovery personnel, heavy downdraft wind conditions and low cloud cover affected the area.

9 The wreckage debris was scattered in a west-southwest direction. The duration and directions of the helicopter s ground track between the location of the last radar return and the accident site are not known. For more information about the wreckage debris path, see section 1.12.

Factual Information 4 Aircraft Accident Report

Factual Information 4 Aircraft Accident Report Injuries to Persons Table 1. Injury chart.

Injuries Flight Crew Cabin Crew Passengers Other Total Fatal 1 0 4 0 5 Serious 0 0 0 0 0 Minor 0 0 0 0 0 None 0 0 0 0 0 Total 1 0 4 0 5

1.3 Damage to Helicopter The helicopter was destroyed by impact forces and a postcrash fire.

1.4 Other Damage Trees and other vegetation at the accident site were damaged as a result of the accident.

1.5 Personnel Information 1.5.1 The Pilot The pilot, age 39, held a commercial pilot certificate with a rating for rotorcraft helicopter issued on May 6, 2004. His most recent FAA first-class airman medical certificate was issued on October 20, 2003, with no restrictions.

The pilot was a citizen of India and was retired from the Indian Air Force, in which he served from 1986 to 2003. He received his initial helicopter training at an Indian Air Force training school in Hyderabad, India. During his military career, he acquired a military helicopter pilot certificate with an instrument rating; was qualified as a rotorcraft instructor, instrument instructor, and pilot examiner in single- and twin-turbine helicopters; and was trained in military flying profiles, including nap-of-the-Earth (NOE) flight.10 In a résumé dated June 3, 2004, the pilot reported he had accumulated 4,005 total

10 NOE flight (sometimes also referred to as nape of the Earth) is low-level, military tactical flying that is intended to increase stealth and mission security. NOE flight requires the pilot to make continuous changes in the helicopter s speed, altitude, and heading to fly close to the ground and among obstacles.

Factual Information 5 Aircraft Accident Report

Factual Information 5 Aircraft Accident Report

The pilot moved to Michigan in November 2003. The FAA issued him a U.S. private pilot certificate with a rating for rotorcraft helicopter in February 2004 on the basis of his foreign pilot license.11 The pilot logged no flight time from February 2003 to March 2004. Between March and April 2004, the pilot accumulated 20 hours of civilian flight experience in Enstrom F28C2 helicopters while preparing for the FAA practical test for his commercial pilot certificate.

The pilot was hired by Bali Hai in July 2004, and he moved to Hawaii to begin work. It was his first civilian pilot job, and he had no previous Bell 206 helicopter experience. According to Bali Hai personnel, they provided the pilot 22 hours of ground instruction, 5 hours of flight instruction, and 1.7 hours of supervised PIC flight time between July 8 and July 31, 2004. Bali Hai s owner stated that the pilot demonstrated very good skills and controlled the helicopter well during training. The pilot passed an FAA SFAR 71 checkride12 on July 22, 2004. Company records indicated that the pilot accumulated 120 hours of flight experience in the company s helicopters between August 1, 2004, and the accident date.

A search of driver history records in Hawaii found no history of driver s license revocations or suspensions.

1.5.1.1 Flight Time and Duty Period Bali Hai did not maintain, and was not required to maintain, records of pilot flight time or duty periods.13 Bali Hai personnel stated that they kept records of only scheduled revenue flight hours. On the day of the accident, the pilot arrived at the company office about 0800, performed a preflight inspection of the helicopter, washed the turbine engine compressor, and helped the line service technician transport the helicopter to the airport. He was scheduled to fly eight tours consisting of five 45-minute tours and three 55-minute tours departing every hour, on the hour. During tours, the pilot s duties, in addition to flying, included narrating the tour for the passengers.

During the 5 to 15 minutes of ground time between the tours, the pilot sat in the cockpit and monitored the fuel gauge while the line service technician added fuel

11 According to 14 CFR 61.75, a person who holds a current foreign pilot license may apply for and be issued a U.S. private pilot certificate with the appropriate ratings on the basis of the foreign pilot license if the requirements of the regulation are met. Under this provision, a pilot who meets the requirements would not have to demonstrate proficiency to be issued the U.S. private pilot certificate.

12 The SFAR 71 checkride is administered by the FAA and is required for Hawaii air tour pilots who fly for an operator that holds a certificate of waiver or authorization to deviate from SFAR 71. The checkride was designed to evaluate the pilot s knowledge of SFAR 71 regulations and the company s approved deviations, among other criteria.

13 Part 91 air tour operators, unlike Part 135 and Part 121 operators, are not subject to any pilot flight time and duty period limitations or any pilot rest requirements.

Factual Information 6 Aircraft Accident Report

Factual Information 6 Aircraft Accident Report 14 Interviews with company personnel and an examination of company scheduling records indicated that, on the day of the accident, the pilot had been on duty about 8.7 hours, had been at the controls of the helicopter with the rotors turning for at least 7.7 consecutive hours, and had flown about 6.5 revenue flight hours15 by the time the accident occurred (see table 2).

Table 2. Revenue hours flown by the pilot on the day of the accident.

A Tour Number of Passengers Start Time Stop Time Duration (minutes) Turnaround (minutes) 1 3 0900 0955 0:55 0:05 2 4 1000 1045 0:45 0:15 3 4 1100 1155 0:55 0:05 4 4 1200 1245 0:45 0:15 5 4 1300 1345 0:45 0:15 6 4 1400 1455 0:55 0:05 7 3 1500 1545 0:45 0:15 8 4 1600 1642 0:42 ---Totals 30 ------ 6: 27 1:15

a All flight times are based on scheduled tour times, not actual tour times. The duration of the last flight is based on the estimated time of the accident.

With the exception of a continuous 9-day leave of absence from September 5 to September 13, 2004,16 company scheduling records indicated that the pilot was on duty each week for the 6 weeks from August 1, 2004, to the day of the accident.17 The pilot s average daily revenue flight time, recorded in a company spreadsheet, was 3.5 hours. According to the spreadsheet, the day before and the day of the accident were the pilot s longest days of flying, and the pilot was credited with 6.7 and 6.45 revenue flight hours, respectively.

14 For more information about Bali Hai s pilot-scheduling practices, see section 1.17.3.

15 Revenue flight hours include only the time that the helicopter was in use during tour flights. Additional flight time would have been required for the pilot to start the helicopter, maneuver it off the trailer, and land it nearby at the company s loading/unloading area.

16 During his leave, the pilot traveled to Michigan to visit his family and obtained a permanent resident card.

17 During that time, the pilot had three 6-day workweeks, two 5-day workweeks, and one 4-day workweek. In late August, the pilot worked 7 days in a row.

Factual Information 7 Aircraft Accident Report

Factual Information 7 Aircraft Accident Report 72-hour History The pilot lived alone, and little information was available regarding his nonwork activities in the 72 hours before the accident. The pilot s wife still resided in Michigan with their child but planned to join the pilot in Hawaii in October 2004. She last spoke with him by telephone about 1700 on September 21, 2004, 3 days before the accident. She stated that the pilot sounded normal and very happy. He told her that he had been going to bed early, getting up early, and going for morning walks. Based on the pilot s recent sleeping schedule, his wife estimated that he might have gone to bed between 2100 and 2130 that evening.

Two acquaintances of the pilot told investigators that they visited with the pilot for about an hour as he walked to his apartment after work 2 or 3 days before the crash. They reported that the pilot was very friendly during their discussion and told them he was looking forward to reuniting with his family.

The day of the accident was the pilot s fourth consecutive day of work after a 2-day weekend. According to the company s scheduling records and interviews, on September 22, 2004, the pilot flew two 45-minute tours and one 55-minute tour between 1300 and 1600.18 On September 23, 2004, the pilot flew four 45-minute tours, three 55-minute tours, and one 60-minute tour between 0900 and 1700.19

On the day of the accident, the pilot was the only pilot on duty at Bali Hai, and the customer service representative stated that the pilot appeared fine when he arrived at the office. The pilot s first tour began at 0900, and the line service technician stated that the pilot appeared fine between his tours. A passenger on the fourth tour stated that the pilot was very nice and professional and appeared relaxed as he narrated the tour. The passenger stated that he never saw the pilot get out of the helicopter and that he could not tell if the pilot was tired. The line service technician stated that, before departing on the sixth tour, the pilot asked how many tours he had left.

Passengers on the seventh tour stated that the pilot looked extremely tired before their flight and that he got out of the helicopter to stretch and walk around. When the line service technician boarded the four passengers for the eighth tour, he reminded the pilot that this was his last tour for the day. He stated that the pilot looked fine but was wearing sunglasses and that he couldn t see the pilot s eyes or determine if he looked tired.

18 Company records indicate that the pilot was credited with 2.37 hours of flight pay, rather than the

2.42 hours he was scheduled to fly. 19 Company records indicate that the pilot was credited with 6.7 hours of flight pay, rather than the 6.75 hours he was scheduled to fly.

Factual Information 8 Aircraft Accident Report

Factual Information 8 Aircraft Accident Report Helicopter Information 1.6.1 General The helicopter, serial number (S/N) 2355, was manufactured in 1978 and was equipped with a 420 shaft-horsepower Rolls-Royce 250-C20B engine, S/N CAE 832474. The helicopter s flight instruments included an airspeed indicator, attitude indicator, and heading indicator; the helicopter was not certificated for instrument flight rules (IFR) operations. The pilot s seat was positioned at the front right, a passenger seat was positioned at the front left, and a bench seat in the back accommodated three passengers. The pilot s seat was equipped with a four-point restraining system, and each passenger seat was equipped with a lapbelt restraining system. The helicopter s second set of cockpit flight controls, normally located at the front left seat, was removed, except for the antitorque pedals.20

1.6.2 Maintenance Information The helicopter was used only for Part 91 operations and was required to undergo annual and 100-hour inspections.21 Also, the operator was required to maintain records, in accordance with 14 CFR 91.417, and to adhere to the replacement times for life-limited parts, as specified in the helicopter s specifications, type certificate data sheets, or other documents approved by the FAA.22

According to the helicopter s airframe and engine maintenance logbooks, the helicopter s most recent 100-hour inspection was completed on September 16, 2004, at an airframe total time of 15,963.1 hours and an engine total time of 13,281.5 hours. According to the logbooks, the helicopter s most recent annual inspection was completed on March 2, 2004, at an airframe total time of 15,392.6 hours and an engine total time of 12,711.0 hours.

A review of Bali Hai s records revealed numerous discrepancies between the airframe total time and engine total time recorded in the respective logbooks and the times recorded in the airframe and engine component status reports.23 Other records, including component historical service records, also showed discrepancies. The discrepancies in various maintenance records included conflicting airframe and engine total times,

20 Antitorque pedals are foot-pedal controls for the tail rotor system.

21 A Part 91 operator must comply with 100-hour and annual inspections unless the operator elects to participate in a progressive inspection program, the manufacturer s approved maintenance/inspection program, or an FAA-approved continuous airworthiness inspection program.

22 Some records that the operator was required to maintain, according to 14 CFR 91.417, included records of maintenance, preventive maintenance, alteration, 100-hour inspection, annual inspection, progressive inspection, and other required or approved inspections for each aircraft, engine, rotor, and appliance; records of total time in service of the airframe, engine, and each rotor; records of the current status of life-limited parts of each airframe, engine, rotor, and appliance; records of the time since last overhaul for each installed item that is required to be overhauled on a specified basis; and copies of the forms required for each major alteration to the airframe, engine, rotors, and appliances.

Factual Information 9 Aircraft Accident Report

Factual Information 9 Aircraft Accident Report

Bali Hai s mechanic stated that the company did not use daily discrepancy records and that, instead, the pilots relayed airworthiness issues to him verbally at the end of each day. He stated that, if he noted any issues, he would fix them and would make a maintenance logbook endorsement only when he believed the repair to be a safety factor. Review of the maintenance records for the year before the accident revealed no record of any minor discrepancies having been reported or repaired.

The mechanic stated that he did not use the helicopter s Hobbs hour meter24 to track airframe and engine time because it was unreliable. He stated that he, instead, tracked these times by calling the sales office each day to obtain the total scheduled trip times for the tours flown that day.25 Review of various records revealed no evidence that time accumulated on the helicopter during nonrevenue operations, such as any flight before, between, and after tours, or during training and maintenance flights, were recorded at all for maintenance purposes as required.26

A review of historical correspondence between Bali Hai and the FAA revealed that, as far back as 1996, the accident helicopter was deemed unairworthy on at least two occasions because of improper maintenance practices and record-keeping.

1.7 Meteorological Information 1.7.1 Federal Aviation Administration Weather Radar Data The FAA s Weather Surveillance Radar-1988 Doppler (WSR-88D) located on the island of Kauai provides a three-dimensional volume scan of the atmosphere at varying degrees of elevation. Figures 3 through 5 display the WSR-88D images generated from data downloaded from Unidata and displayed using the Man computer Interactive Data Access System (McIDAS)27 and depict the base reflectivity images at 1634, 1639, and 1645.28 At the accident site, the radar beam center is about 2,800 feet above mean sea level

23 Bali Hai s airframe and engine component status report dated September 29, 2004, listed the airframe total time as 15,982.3 hours and the engine total time as 10,862.3 hours; this recorded engine time was about 2,000 hours less than what was recorded in the engine logbook for the annual and 100-hour inspection entries dated about 6 months and 2 weeks earlier, respectively.

24 A Hobbs hour meter is a time-recording device that activates by sensing such things as aircraft electrical power on, oil pressure, or other criteria. According to FAA Advisory Circular 43-9C, such a recording device can be helpful in determining time in service for maintenance purposes.

25 Sales office personnel did not record the helicopter s actual time in service; they logged how many 45- and 55-minute tours were flown each day and provided those totals to the mechanic.

26 For example, the accident pilot s training record showed he received 1.5 hours of flight instruction on July 13, 2004, and flew 1.5 hours with the owner on July 14, 2004, however, company flight schedules showed only revenue flights were logged, and there was no indication that the time accumulated on the helicopter during these training flights had been recorded at all for maintenance purposes.

Factual Information 10 Aircraft Accident Report

Factual Information 10 Aircraft Accident Report

Figure 3. Weather radar at 1634.

27 WSR-88D Doppler Weather Radar Level III products were acquired using tools made available to the research and education communities through the University Corporation for Atmospheric Research s Unidata Program, funded by the National Science Foundation. These data originated in the U.S. National Weather Service McIDAS. McIDAS is an interactive meteorological analysis and data management computer system and is administered by personnel at the Space Science and Engineering Center at the University of Wisconsin at Madison. Data are accessed and reviewed on a Hewlett-Packard 9000/C360 workstation running McIDAS-X software.

28 The weather radar product images display time in coordinated universal time, or Zulu, as denoted by the designator Z. The times in the figure captions have been converted to Hawaiian standard time.

Factual Information 11 Aircraft Accident Report

Factual Information 11 Aircraft Accident Report Figure 4. Weather radar at 1639.

Figure 5. Weather radar at 1645.

Factual Information 12 Aircraft Accident Report

Factual Information 12 Aircraft Accident Report Airmen s Advisories and Area Forecast At 120029 on the day of the accident, the National Weather Service (NWS) Forecast Office in Honolulu issued an airmen s meteorological information (AIRMET) advisory for turbulence. AIRMET Tango Update 3 was valid until 1800, and it reported, over and immediately south through west of mountains, all islands temporary moderate turbulence below 5,000 feet.

The area forecast, issued September 24, 2004, at 1140 and valid until midnight, contained the following information:

North through east coastal and mountain sections and adjacent waters of the remaining islands, including central Oahu (includes Kauai), scattered clouds at 2,500 feet, broken to overcast at 4,500 feet, tops to 8,000 feet, temporary 2,500 feet broken, isolated 1,500 feet broken, tops 12,000 to 15,000 feet, visibility 3 to 5 miles, and moderate rain showers.

1.7.3 Witness Weather Observations According to a tour pilot for another company conducting operations from PAK on the day of the accident, the weather was really nice in the morning but deteriorated later in the day. He also reported that he flew by Kahili Ridge about 1 hour after the accident and that the ridgeline was obscured by clouds.

A passenger on the accident pilot s fourth tour on the day of the accident stated that skies were clear when the tour departed the airport but that the flight encountered turbulence and rain along the Na Pali Coast and in Hanapepe Valley. Passengers from the accident pilot s tour before the accident tour stated that, when the helicopter crossed Kahili Ridge (near the accident site), it encountered strong winds and rain in that area. They also stated that the helicopter encountered rain, mist, and clouds inside Waialeale Crater and that clouds sometimes completely obscured ground references.

Time-stamped digital images recovered from a passenger s camera showed clouds and precipitation were at some locations along the accident tour, including areas along the Na Pali Coast, in the mountains south of Hanalei, and over the foothills east of Mount Waialeale. The last photograph recorded by the camera, which was taken about 5 minutes before the accident, showed a location about 4 miles from the accident site. The photograph showed that a broken layer of clouds appeared to be in front of the helicopter with some cloud bases below the horizon. The visibility below some clouds appeared to be degraded by mist and/or rain, and areas of coastline behind the line of clouds appeared to be brighter than the land in the foreground.

http://www.ntsb.gov/publictn/2007/AAR0703.htm

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