E PLURIBUS UNUM

NATIONAL TRA SPORTATIO

N

B OARD

SAFE T Y

N

National Transportation Safety Board 

Washington, D.C. 20594 

Aviation Accident Brief

Accident Number: SEA05MA199 

Operator: Heli-USA Airways, Inc. 

Aircraft and Registration: Aerospatiale AS350BA, N355NT 

Location: Haena, Hawaii 

Date: September 23, 2005 

Adopted On: March 5, 2007 

HISTORY OF THE FLIGHT 

On September 23, 2005, about 1415 Hawaiian standard time,1 an Aerospatiale AS350BA 

helicopter, N355NT, registered to Jan Leasing, LLC, and operated by Heli-USA Airways, Inc., 

of Las Vegas, Nevada, encountered adverse weather and crashed into the Pacific Ocean several 

hundred feet off the coast of Kailiu Point, near Haena, Hawaii, on the island of Kauai. The 

sightseeing air tour flight was operated under the provisions of 14 Code of Federal Regulations

(CFR) Part 135 and visual flight rules (VFR) with a company flight plan in effect. Localized 

instrument meteorological conditions (IMC) prevailed in the vicinity of the accident site. Three 

passengers were killed, and the commercial pilot and two other passengers received minor 

injuries. The flight departed from Lihue Airport (LIH), Lihue, Hawaii, on the island of Kauai, at 

1354 for the intended 45-minute tour. 

The flight was operated under Special Federal Aviation Regulation (SFAR) 71, “Special 

Operating Rules for Air Tour Operators in the State of Hawaii,”2

 and in accordance with a 

certificate of waiver or authorization approved for Heli-USA by the Federal Aviation 

Administration (FAA) Honolulu Flight Standards District Office (FSDO) in Honolulu, Hawaii.3

The flight proceeded westbound from LIH, which is on the southeastern part of the island, on the 

operator’s standard clockwise tour route around the island (see figure 1).4

 

 1

 All subsequent times are reported in Hawaiian standard time based on a 24-hour clock, unless noted 

otherwise. Hawaiian standard time is coordinated universal time minus 10 hours. 

2

 SFAR 71 prescribes the operating rules for airplane and helicopter air tours conducted in Hawaii. It includes 

requirements for helicopter flotation equipment, performance plans, and operating limitations; minimum flight 

altitudes; and passenger briefings. 

3

 Under SFAR 71, the minimum altitude for tour flights is 1,500 feet above ground level (agl) and no closer than 

1,500 feet to any person or property, unless otherwise authorized. Heli-USA’s certificate of waiver or authorization 

allows its pilots to deviate from the minimum altitude requirement and to descend as low as 500 feet agl over FAAapproved site-specific locations and traverse FAA-approved transition segments as low as 1,000 feet agl. 

4

 The operator reported that the intended tour route was to depart from LIH and proceed west, which is the 

standard harbor departure, to the first tour site, Hanapepe Valley. From there, the tour was to proceed northwest to 

Waimea Canyon, then north to the Na Pali Coast, then northeast along the coastline to the northern end of the island 

to Kailiu Point. The tour was then to proceed south to Hanalei Valley and then to Waialeale Crater before returning 

to LIH. 
NTSB/AAB-07/01 

2

Figure 1. Map of Kauai. 

The pilot reported that the weather and visibility were good during the initial part of the 

tour. The pilot stated that he flew the helicopter over the Na Pali Coast on the northern part of the 

island at 2,000 feet above ground level (agl) and that the weather along the coastline was clear 

and without rain. The pilot stated that he saw rain showers offshore as the flight approached 

Kee Beach and Kailiu Point on the northern part of the island. 

The pilot reported that, as the flight came around Kailiu Point, he “suddenly saw [a 

McDonnell Douglas (MD)-500 helicopter] coming straight for [his helicopter]” and that he made 

a left turn to avoid it. He stated that, when he leveled his helicopter out of the turn, it was 

“already inside the storm,” and it encountered heavy rain. Two passengers reported that they saw 

another helicopter flying in the opposite direction but that it was far below them, and one 

passenger stated that it was far enough below them that she thought it was a bird. Both of these 

passengers said that their helicopter made no evasive maneuver, or any maneuver, before 

entering what they described as “a wall of pure rain and thick clouds.” 

The pilot stated that, while the helicopter was in the heavy rain, he could still see down 

and to the right to the coastline and that he reduced the helicopter’s airspeed and initiated a 

descent to maintain visual reference to the beach. One passenger reported that he could not see 

anything in the heavy rain and that he was about to say something about this to the pilot when 

the pilot announced that they were turning back. The pilot said that he started a right turn over 

the beach and that, during the turn, the helicopter’s airspeed dropped to zero and the helicopter 

started to rapidly descend. 
NTSB/AAB-07/01 

3

The pilot said that his control inputs were not effective and that he realized that the 

helicopter was going to hit the beach at a high rate of descent. The pilot stated that he applied full 

power and that the helicopter’s rate of descent suddenly stopped. He stated that the helicopter 

went back up in the air momentarily and entered an immediate hard spin to the left, which took 

the flight over the water. 

The pilot stated that he instructed the passengers to open the doors to get ready for the 

water impact and that the helicopter hit the water, bounced back into the air, and continued to 

spin. The pilot said that he transmitted a mayday call on the radio and that the helicopter 

impacted the water again and remained on the surface spinning. The pilot stated that the 

helicopter was submerged to the belly panel when it stopped spinning, then it rolled to the right 

and immediately began to sink. 

A pilot flying a tour for another operator said that he heard the mayday call over the 

common traffic advisory frequency (CTAF)5

 and twice attempted to fly his helicopter in the 

Kee Beach area to try to locate the downed helicopter but was unable to do so because of poor 

visibility. While returning to the airport to alert rescue authorities, he saw another Heli-USA 

helicopter in flight and used the CTAF to inform that pilot of the mayday call. That Heli-USA 

pilot then conducted a brief search and spotted an oil slick on the water extending toward the 

area of poor weather. He made an unscheduled landing on a beach to let out his passengers6 then 

searched the area near the oil slick. He said that the visibility was low but usable and that he saw 

debris and people in the water. He used his radio to direct U.S. Navy aircraft into the area. 

PERSONNEL INFORMATION

The pilot, age 43, held a commercial pilot certificate with a rating for rotorcraft helicopter 

and a private pilot certificate with a rating for airplane single-engine land; he did not hold an 

instrument rating. His most recent FAA second-class airman medical certificate was issued on 

October 29, 2004, with the limitation that he “shall possess glasses for near and intermediate 

vision.” 

A review of the pilot’s logbook indicated that, on the date of the accident, he had 

accumulated about 2,814 hours total flight time, which included about 29 hours simulated 

instrument experience, 939 hours night flight, and 334 hours in AS350-series helicopters. The 

pilot reported that, during the 90 days, 30 days, and 24 hours before the accident, he had flown 

about 176 hours, 115 hours, and 6 hours, respectively. He reported that he had conducted about 

233 tours around Kauai and that those tour routes were similar to the route of the accident flight. 

The pilot was hired by Heli-USA on July 29, 2005, about 2 months before the accident, 

and he completed his initial training and received 4.5 hours of flight instruction at the Heli-USA 

base in Las Vegas. The initial training included 40 hours of ground instruction, in accordance 

 5

 Pilots can use CTAFs to carry out advisory practices while operating in airspace that lacks an operating air 

traffic control tower. 

6

 The pilot made the unscheduled landing to let out the passengers so that he could use his helicopter to assist 

with the emergency. Two of the passengers volunteered to remain on board to help search for the downed helicopter. 
NTSB/AAB-07/01 

4

with Heli-USA’s FAA-approved Part 135 training program. On August 1, 2005, the pilot passed 

the 14 CFR 135.293 (a) and (b) and 14 CFR 135.299 airman competency checkrides in 

Las Vegas in the AS350-series helicopter. The pilot subsequently completed his SFAR 71 

training and an additional 3.5 hours of flight instruction in Kauai. The pilot completed his 

SFAR 71 checkride in Kauai on August 7, 2005, with a company check airman, and he 

conducted his first tour flight on August 8, 2005. His logbook revealed that he had flown about 

177 hours while employed with Heli-USA. 

AIRCRAFT INFORMATION 

The helicopter was manufactured in 1987 as an AS350B model and was converted to an 

AS350BA model in 1997.7 It was powered by a Turbomeca Arriel 1B turboshaft engine. It was 

configured with three seats in the front row and four seats in the second row, and the pilot 

position was the front right seat. Each passenger seat was equipped with a lap belt, and the pilot 

seat was equipped with a lap belt and shoulder harness. The helicopter was not equipped, and 

was not required to be equipped, with flotation equipment.8

A review of the maintenance records indicated that the helicopter had accumulated about 

11,483 total hours and that the engine’s total time was about 13,560 hours. The helicopter’s most 

recent continuous airworthiness inspection, a 100-hour inspection, was completed on 

September 16, 2005. At the time of the accident, the helicopter had accumulated about 39 hours 

since the inspection. 

METEOROLOGICAL INFORMATION 

The only official National Weather Service (NWS) reporting facility on the island of 

Kauai was located at LIH, about 20 miles southeast of the accident site, at an elevation of 

153 feet above mean sea level. The airport was equipped with an automated surface observing 

system augmented by certified NWS observers as necessary. At 1353,9

 the meteorological 

aerodrome report (METAR) included winds from 090° at 9 knots, visibility unrestricted at 

10 miles, and few clouds at 2,400 feet. The METAR for 1453 included the same wind and 

visibility conditions but with few clouds at 1,500 feet. 

The Hawaii Area Forecast (FA) issued at 1140 on September 23, 2005, and valid until 

midnight, indicated that a tropical storm was about 300 miles northeast of Hilo, Hawaii, and was 

 7

 The conversion, performed in accordance with the manufacturer’s Service Bulletin 1.35, included the 

replacement of the main and tail rotor blades and other retrofits to increase the helicopter’s useful load and other 

performance parameters. 

8

 According to SFAR 71, a single-engine helicopter may be used to conduct air tours in Hawaii without 

helicopter flotation equipment, provided that the flight either does not go beyond the shore or that each person on 

board the helicopter is wearing approved flotation gear. Per Heli-USA’s operations specifications, each person on 

board the helicopter was wearing a quick-donning life vest in a pouch around his/her waist. Following the accident, 

Heli-USA voluntarily began to equip its Hawaii-based helicopters with flotation equipment. By December 2006, 

Heli-USA had five Hawaii-based helicopters, and all were equipped with floats. 

9

 FAA and NWS weather information products are reported in coordinated universal time. The times in this 

section have been converted to Hawaiian standard time. 
NTSB/AAB-07/01 

5

moving northwest and weakening.10 The FA indicated that, for Kauai and adjacent waters, 

conditions were forecasted to include scattered clouds at 2,000 feet, ceilings broken to overcast 

at 3,500 feet with tops to 12,000 feet, temporary ceilings below 3,000 feet in cumulonimbus 

clouds with tops to 40,000 feet, and visibility below 3 miles in thunderstorms and heavy rain. 

The outlook was for VFR conditions to prevail. 

An in-flight weather advisory,11 airmen’s meteorological information (AIRMET) Sierra 

update 8 for instrument flight rules conditions, was issued at 1355 and was valid until 1800. The 

AIRMET warned of mountain obscuration over the islands of Oahu and Kauai and indicated that 

the mountains would be temporarily obscured above 1,500 feet because of clouds, 

thunderstorms, and rain. The conditions were expected to continue beyond 1800. 

The terminal aerodrome forecast (TAF) closest to the accident site was for LIH and was 

issued at 0744 and was valid at 0800 for a 24-hour period. From 0800, the forecast was for winds 

from 080° at 8 knots, visibility better than 6 miles, and scattered clouds at 2,500 feet. From 1400, 

the forecast was for winds from 100° at 12 knots, visibility better than 6 miles with rain showers 

in the vicinity, scattered clouds at 2,500 feet, and ceiling broken at 3,500 feet, and, temporarily 

between 1400 and 1800, visibility 5 miles in moderate rain showers, scattered clouds at 

2,500 feet, and overcast at 3,500 feet. 

Meteorological Study of Weather Data 

The closest NWS Weather Surveillance Radar-1988 Doppler (WSR-88D) was located in 

Numila, Hawaii, on the island of Kauai, about 21 miles south of the accident site. The WSR-88D 

is a computer-controlled radar system that automatically creates a complete series of scans in a 

specific sequence. The scan completed at 1403 depicted areas of reflectivities of 15 to 

25 decibels (dBZ) in the immediate vicinity of the accident site. Echoes in the 25-dBZ intensity 

range are typically associated with rain showers or developing cumulonimbus or other towering 

cumulus clouds.12 The echo intensity images derived from WSR-88D, however, do not represent 

the true reflectivity and/or intensity of the activity encountered by the accident helicopter; high 

terrain between the WSR-88D system and the accident site resulted in significant beam blockage 

below 5,000 feet over the accident site.13

A review of satellite imagery data14 indicated that, at 1400, low- to mid-level clouds 

obscured most of the island of Kauai with several areas of towering cumulus to cumulus 

 10 A forecast discussion bulletin issued by the NWS weather forecast office in Honolulu at 0955 indicated that 

the tropical storm would not directly affect the islands; however, indirect impacts, such as light trade winds and high 

surf, were expected. 

11 In-flight advisories are forecasts to notify en route aircraft of the possibility of encountering hazardous 

weather conditions. The NWS weather forecast office in Honolulu issues advisories for the Hawaiian Islands. 

12 Echoes of this intensity correspond with the video integrator and processor (VIP) intensity “Level 1” or “very 

light.” According to FAA Advisory Circular 00-24B, “Thunderstorms,” light to moderate turbulence with lightning 

is possible in VIP Level 1 weather. 

13 A Safety Board meteorology specialist performed a beam-height calculation for the accident site. 

14 Geostationary Operations Environmental Satellite number 10 data was obtained from the National Climatic 

Data Center and displayed on the Safety Board’s Man-computer Interactive Data Access System workstation. Both 
NTSB/AAB-07/01 

6

congestus clouds; the radiative cloud top temperatures in the vicinity of the accident site 

corresponded to cloud tops from 17,000 to 24,000 feet. The 1430 infrared image depicted 

developing cumulonimbus clouds over the northern shore of Kauai and in the vicinity of the 

accident site; the radiative cloud top temperatures in the vicinity of the accident site 

corresponded to cloud tops from 19,000 to 30,000 feet. Images from 1330 to 1430 depicted 

broken to overcast layers of stratocumulus and towering cumulus clouds extending over the 

interior sections and the northwest and north shores of Kauai. The images showed several 

towering cumulus clouds capable of producing rain showers embedded within the cloud layers; 

the accident site was located under one such band of towering cumulus clouds at 1400. By 1430, 

an elongated area of cumulus congestus to cumulonimbus clouds extended from the accident site 

northeastward. 

A study was performed using the upper air sounding for 1400 and the observed and 

derived stability parameters. The data indicated an unstable, moist, low-level environment with a 

relative humidity of 75 percent or more from the surface to approximately 5,000 feet. The 

sounding supported a moderate to high risk of thunderstorms, with the K-index15 indicating an 

approximate 80 percent chance of thunderstorms. The study determined that the maximum 

vertical velocity of the potential convective updrafts in thunderstorms was 160 knots, the wind 

gust or potential outflow winds from thunderstorms were about 41 knots, and the sounding was 

favorable for microburst development with outflow winds of 55 knots. 

Microbursts are small-scale intense downdrafts, which, upon reaching the surface, spread 

outward in all directions from the downdraft center. This causes both vertical and horizontal 

windshears that can be extremely hazardous to all types and categories of aircraft, especially at 

altitudes below 1,000 feet, because the conditions can produce a situation in which it is difficult 

to control the aircraft. A typical microburst lasts about 15 minutes and occurs in a space of less 

than 1 mile horizontally and within 1,000 feet vertically. Due to their short life span, small size, 

and the fact that they can occur over areas without surface precipitation, microbursts are not 

easily detectable using conventional weather radar or windshear alert systems. 

Weather Information Sources Available to the Pilot 

According to company personnel, pilots usually obtain their weather information from a 

combination of sources, including the FAA Flight Service Station (FSS) in Honolulu, local 

television reports, various Internet sites, and the LIH automatic terminal information service 

(ATIS). 

According to the pilot, he arrived for work on the day of the accident about 0615, 

obtained a printout of FAA and NWS weather information from the direct user access terminal 

system (DUATS)16 and noted nothing unusual about the information. The accident flight was his 

 visible and infrared imagery was obtained surrounding the time of the accident. 

15 The K-index is a measure of thunderstorm potential based on the vertical temperature lapse rate and the 

amount and vertical extent of low-level moisture in the atmosphere. 

16 DUATS provides pilots access to FAA and NWS alphanumeric preflight weather information, such as FAs, 

TAFs, METARs, and AIRMETs, via personal computer. 
NTSB/AAB-07/01 

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seventh tour flight of the day, and he had just finished his lunch break. In preparation for the 

flight, he spoke with a representative located at the company base in Princeville, Hawaii, on the 

northern part of Kauai, to see if there were any schedule changes. The pilot did not ask the 

representative about the weather conditions in that area. The pilot stated that, before departure on 

the accident flight, he listened to the LIH ATIS, which reported no adverse weather. 

For in-flight weather information, tour pilots also use the CTAF to exchange brief, 

informal statements regarding their weather observations;17 however, the high terrain in the 

middle of the island can limit the effective range of these transmissions. 

Weather Conditions Observed by Pilot Witnesses 

Three other tour pilots were conducting helicopter flights in the area of Kailiu Point 

within minutes before and after the accident. One pilot, who flew along the Na Pali Coast about 

15 minutes before the accident flight, stated that the conditions at that time were clear with rain 

showers just off the point at Kee Beach. The pilot stated that he maintained an altitude of about 

1,500 to 2,000 feet agl and that his flight entered heavy rain conditions when he passed 

Kailiu Point about 1400. He stated that he initiated a gradual descent to about 300 feet agl to 

maintain visual contact with the shoreline and that he did not encounter any turbulence, 

downdrafts, lightning, or windshear while maneuvering through the rain. He stated that his 

helicopter emerged from the storm abeam Haena and that he announced over CTAF that “Haena 

is clear, blue, and twenty-two”18 and advised other flights to avoid the showers. He stated that 

unknown pilots made two inquiries over the CTAF about the intensity of the showers and that he 

responded “intense” and “heavy duty.” 

Another tour pilot stated that he heard the report over the CTAF of “heavy duty rain 

showers” at Kee Beach. He stated that he asked about the visibility over the CTAF but received 

no reply. He stated that, when his flight reached the Kee Beach area, he saw a “super dark misty 

rain shower” and decided to turn his helicopter around rather than enter the weather.19 He 

estimated that the visibility associated with the storm at that time was about 1/8 mile or less. He 

stated that the air was smooth with no thunder or lightning and that the water was smooth with 

no white caps. He stated that he discontinued his tour and was on his way back to base when he 

heard the mayday calls over the CTAF. 

A third tour pilot stated that he was flying his helicopter about 1,500 feet agl headed 

northeast along the Na Pali Coast when he heard the mayday calls. Shortly thereafter, he saw the 

 17 These informal air-to-air communications differ from pilot reports (PIREPs), in which pilots provide weather 

observation reports in a standard format to FAA ground facilities that serve as collection points for the exchange of 

PIREP information with other pilots and en route aircraft. According to the FAA Aeronautical Information Manual, among other uses, air traffic control facilities can use PIREPs for air traffic weather-avoidance procedures; FSS can 

use the information to brief other pilots or to provide in-flight advisories and weather-avoidance information to en 

route aircraft; and the NWS can use the information to verify or amend conditions contained in aviation forecasts 

and advisories. 

18 The pilot’s statement was slang for visibility unlimited, or clear. 

19 This helicopter was an MD-500, and its direction of flight was consistent with the helicopter that the accident 

survivors reported seeing flying below their helicopter before it entered the storm. 
NTSB/AAB-07/01 

8

helicopter that had turned around and was returning to base, and he discussed the mayday calls 

with that pilot. He stated that he continued his flight northeast, and, after passing Kailiu Point, 

his flight entered the rain. He stated that he initiated a gradual descent to about 500 feet agl to 

maintain visual reference with the coastline but that the weather was getting worse and he did not 

think he could continue and maintain VFR. He chose to turn back, and, while reversing course, 

he had to descend the helicopter to 100 feet agl to maintain visual contact with the shoreline until 

he exited the storm. He stated that the conditions inside the storm were smooth with no 

turbulence or windshear. 

WRECKAGE AND IMPACT INFORMATION 

The wreckage was located several hundred feet off the shoreline near Kee Beach in about 

60 feet of water. The wreckage was recovered on September 25, 2005, and transported to LIH 

for examination. 

Examination revealed that control continuity could be established throughout the 

fuselage, and evidence of rotational signatures and component system continuity was noted. The 

tail boom, horizontal and vertical stabilizers, and the tail rotor system showed no evidence of 

preimpact anomalies. All main rotor blade root sections remained attached to the main rotor hub. 

The engine remained attached to the airframe and was removed for examination. The 

compressor blades turned freely when manually rotated and showed no evidence of foreign 

object damage or anomalies. The main rotor transmission was removed for examination, and 

rotation occurred when the main rotor head was turned. No evidence of any preimpact 

mechanical malfunction of the helicopter’s airframe, engine, or systems components was 

observed. 

MEDICAL AND PATHOLOGICAL INFORMATION 

Postmortem examinations revealed that the cause of death for the passengers from the 

front left and center seats was “drowning.” The cause of death for the passenger from the rear 

right center seat was reported as “cardiac arrest due to near drowning.” The coroner noted no 

serious injuries on any of the passengers. 

SURVIVAL ASPECTS 

During the tour flight, two passengers were seated in the two front seats to the left of the 

pilot, and the other three passengers were seated in rear seats.20 The two surviving passengers, 

who had been seated in rear seats, reported that they received a safety briefing before departure 

and that each passenger was wearing a personal flotation device (PFD) in a pouch attached 

around the waist. 

 20 The passengers occupied the rear right seat, rear right center seat, and the rear left seat; the rear left center 

seat was empty. 
NTSB/AAB-07/01 

9

The passenger who was seated in the right rear seat stated that, after the helicopter rolled, 

the right side of the cabin was engulfed in water within about 3 seconds. He stated that he 

remembered the pretakeoff safety briefing and took off his headset and donned his PFD vest; 

however, he noted that the vest interfered with his ability to find and unlatch his seat belt and 

that it took him “precious seconds” to open the waist pouch to remove and don the vest. He 

stated that he exited the helicopter out the right side door but that he could not recall opening it. 

He stated that he pushed and kicked hard to make it to the water’s surface, where he observed 

heavy rain, thunder, and lightning. 

The passenger from the left rear seat stated that she did not know how to swim and was 

panicked. She stated that she donned her PFD vest but had trouble remembering the safety 

briefing and tried to inflate it while inside the helicopter but could not figure out how to do it.21

She stated that she attempted to assist the passenger in the rear right center seat, who was having 

difficulty because he was tangled with his headset. After she exited the helicopter out the left 

side and reached the surface, she still could not figure out how to inflate her PFD. The passenger 

from the right rear seat assisted her by pulling at least one of the inflation handles to inflate her 

vest for her. 

The passenger from the right rear seat stated that he then dove back down to the 

helicopter to attempt to extricate the passenger from the rear right center seat. When he 

resurfaced with that passenger, who was having difficulties breathing, he put that passenger’s 

PFD vest over the passenger’s head and inflated it for him.22

The pilot stated that he was already completely under water when he released his seatbelt. 

He stated that, as he made his way out the helicopter’s left side, he tried to see or feel for 

passengers as he exited, but he did not find anyone. He stated that he made his way to the surface 

then tried to dive back down to the helicopter, but he could not find its door. He then returned to 

the surface and found one passenger being supported by two others. He stated that he helped one 

of the passengers don and inflate a life vest and that he donned and inflated his own vest. 

Recovery personnel found the body of the passenger in the front center seat still secured 

in the seat by the lap belt and wearing an uninflated PFD vest. The body of the passenger from 

the front left seat was found floating facedown in the water and wearing a PFD vest. First 

responders recalled that the passenger’s PFD vest appeared inflated, but they did not know if 

only one or both chambers appeared inflated. At some point during recovery of the victim, the 

PFD was removed from the body and misplaced; therefore, it was not available for examination 

to determine its actual inflation configuration. 

 21 The safety briefing video instructed the passengers to remove their headsets before donning the PFD vests. 

The video also showed how to use the PFD’s inflation handles and the manual inflation tubes, and it instructed the 

passengers not to inflate their vests until after exiting the helicopter. 

22 The survivors attempted to assist the passenger by providing aided breathing and chest compressions before 

rescue arrived, but the passenger died later that day. 
NTSB/AAB-07/01 

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TESTS AND RESEARCH 

Examination and Functional Testing of Recovered Personal Flotation Devices 

Four of the six PFDs from the accident were recovered for examination;23 all of the 

recovered PFDs were Hoover Industries model FV-35E, manufactured in accordance with 

Technical Standard Order (TSO)-C13e. This model PFD features two separate inflation 

chambers that a user must inflate separately by pulling each chamber’s plastic handle. According 

to the PFD’s design, each chamber is equipped with a pressurized, 16-gram, carbon dioxide 

cylinder that punctures when the handle is pulled, releasing the pressurized gas into the chamber 

to inflate it fully within 2 seconds. Each chamber is also equipped with an oral inflation tube into 

which the user can blow to inflate the chamber. 

One of the recovered PFDs belonged to the passenger in the front center seat. 

Examination revealed that neither chamber was inflated and that the plastic inflation handles 

were not pulled. Testing revealed both chambers inflated when the handles were pulled. The 

three other recovered PFDs were, on the basis of passenger interviews, those that were used by 

the pilot and the two surviving passengers, though it was not known which PFD belonged to 

which occupant. Examination of these vests revealed one had both chambers inflated, and the 

other two vests each had only one chamber inflated. Examination and testing of one PFD that 

had only one chamber inflated revealed the other chamber inflated when the handle was pulled. 

Examination of the other PFD that had only one chamber inflated revealed that the 

inflation cylinder for the uninflated section was dimpled in the discharge area but was not 

punctured. Testing revealed that, after the dimpled cylinder was reinstalled in the PFD, pulling 

the inflation handle punctured the cylinder, and the chamber inflated. 

Water-Immersion Performance Demonstration of Personal Flotation Devices 

Heli-USA provided the investigative team with two PFDs: one was a Hoover Industries 

model FV-35E, and the other was an Eastern Aero Marine model KSE-35HC2L8.24 Heli-USA 

had recently retired both PFDs from service after about 12 months of use in accordance with the 

manufacturers’ recommended inspection interval.25 These PFDs were used for water-immersion 

demonstrations to examine donning procedures and to compare vest performance with one and 

both chambers inflated. 

 23 According to interviews with the survivors, of the two PFDs that were not located, one belonged to the 

passenger from the rear right center seat, and the other belonged to the passenger whose body was found floating 

facedown in the water. 

24 The Eastern Aero Marine model KSE-35HC2L8 is also manufactured in accordance with TSO-C13e. 

25 Each PFD manufacturer recommends that the PFDs be returned for inspection at specified intervals. On the 

recommended annual inspection dates, Heli-USA retired the PFDs from service and replaced them with new ones. 

The Honolulu FSDO requires its air tour operators to maintain the PFDs in accordance with the manufacturer’s 

instructions (the requirement is included in Section D104 of each operator’s approved operations specifications). 

Although Heli-USA’s operations specifications were approved by the Las Vegas FSDO, and Section D104 did not 

specifically reference PFD maintenance, Heli-USA followed the manufacturer’s recommended inspection intervals. 
NTSB/AAB-07/01 

11

Two test subjects26 entered the water before donning the PFD vests, and each described 

that the vests were “relatively easy” to put on but that two hands were required to place the vest 

over the head while in the water. The subjects found that, with only one vest chamber inflated, 

each PFD provided flotation for the wearer, and they were able to remain at the surface with their 

heads above the water. The subjects also found that, with only one chamber inflated, if they 

simulated unconsciousness and made no attempts to right themselves, it was possible for them to 

float facedown. With both vest chambers inflated, it was not possible for either subject to float 

facedown; the PFDs rolled them to a faceup position within seconds. According to TSO-C13e, 

which specifies that the PFD must right a wearer who is in a facedown position, the buoyant 

force needed to meet the TSO is determined with both chambers inflated. 

During the demonstration, when the subjects first attempted to pull the inflation handles 

one at a time, the investigator found that one chamber on the Eastern Aero Marine PFD failed to 

inflate when the handle was pulled. Examination revealed that the threaded cylinder for that 

chamber was not screwed securely into its housing. When the investigator properly seated the 

cylinder and then pulled the inflation handle, the chamber inflated. 

Following these demonstrations, another Hawaii air tour operator voluntarily examined 

13 PFD vests that had been recently retired from service after about 1 year of use.27 Each PFD 

had 2 inflation cylinders, and the operator reported that 18 of the 26 cylinders were loose in their 

housings. 

ORGANIZATIONAL AND MANAGEMENT INFORMATION 

Heli-USA is based in Las Vegas and conducts Part 135 air tours in Las Vegas and on the 

islands of Kauai and Oahu, Hawaii. At the time of the accident, the company operated 

9 helicopters, including the accident helicopter, and employed 20 pilots and 13 mechanics; 

3 helicopters, 6 pilots, and 4 mechanics were used for the company’s operations in Hawaii. 

 26 One test subject was 5-feet 5-inches tall and weighed 128 pounds, and the other was 6-feet 3-inches tall and 

weighed 195 pounds. 

27 Such a voluntary inspection by the operator is only feasible for retired-from-service PFDs because in-service 

PFDs must remain unopened within their waist pouches to meet FAA airworthiness requirements. The operator had 

to open the pouches on the retired PFDs to examine the security of the cylinders. 
NTSB/AAB-07/01 

12

In 1997, Heli-USA began sightseeing operations in Las Vegas under the provisions of 

14 CFR Part 91. The company obtained a Part 135 air carrier certificate in March 1999 to 

conduct on-demand air taxi operations in the contiguous United States and the District of 

Columbia, and, in 2000, the FAA amended the company’s Part 135 operations specifications to 

allow for operations in Hawaii. 

The Las Vegas FSDO issued Heli-USA’s Part 135 operating certificate and, as the 

certificate holding district office, was responsible for all FAA reporting requirements, technical 

administration requirements, and regulatory oversight of Heli-USA. The Honolulu FSDO was 

responsible for surveillance of air tour activities within its geographic area; this surveillance 

included enforcing SFAR 71 rules and Honolulu FSDO-approved SFAR 71 procedures 

throughout the Hawaiian Islands. 

Company Procedures for Weather Information and Adverse Weather 

According to Heli-USA’s operations specifications, in class G airspace,28 no flight may 

be conducted on overland transition segments where the flight visibility is less than 3 statute 

miles, no flight may be conducted on overwater transition segments where the flight visibility is 

less than 1 statute mile, and no flight may be conducted closer than 300 feet above, below, or 

horizontally from any cloud. The operations specifications also require that en route helicopter 

operations be conducted a minimum of 500 feet above raw terrain and no closer than 1,500 feet 

from any person, structure, vehicle, or vessel. 

According to Heli-USA’s general operations manual, pilots are required to obtain valid 

aeronautical weather information from FAA- or NWS-approved sources. The manual also states 

that, for VFR operations, the pilot may “use weather information based on your own 

observations or on those of other acceptable sources29 to supply appropriate observations” if no 

reports are available from the approved sources. 

The general operations manual also provides procedures for encounters with adverse 

weather and states that pilots should “avoid flight through or near thunderstorms” and should 

“not trust the visual appearance to be a reliable indicator of the turbulence inside a 

thunderstorm.” The manual states that, when flying a helicopter under VFR, a pilot must 

maintain visual surface reference sufficient to safely control the helicopter. 

Special Federal Aviation Regulation 71 Procedures Regarding Adverse Weather 

Heli-USA’s Honolulu FSDO-approved SFAR 71 procedures manual contains adverseweather provisions that enable pilots to deviate from the SFAR 71 minimum altitude requirement 

to avoid poor weather, if necessary. According to the manual: 

 28 The accident occurred in class G airspace, which, according to the FAA Aeronautical Information Manual, 

chapter 3-3-1, is “uncontrolled” airspace that “has not been designated as” class A, B, C, D, or E airspace. 

29 These sources include television news reports and radio reports. 
NTSB/AAB-07/01 

13

In the event that unforecasted weather conditions are encountered, so as to 

prevent flight along the planned flight path, the pilot in command must use his/her 

judgment in order to safely circumnavigate the weather. In doing so, the following 

must be accomplished, [among others]: A radio report transmitted to another 

company or non-company aircraft, air traffic control agency or FSS of your 

intended route and the extent of the weather conditions encountered. ... Should 

weather conditions deteriorate to a condition that would disallow the tour to 

continue in compliance with SFAR 71, the pilot will declare the air tour 

terminated and return to base. In this event the flight will be conducted in 

accordance with the regulations of ... Part 135. 

According to 14 CFR 135.205, the daytime VFR minimum visibility requirement for 

helicopter operations at or below 1,200 feet agl in class G airspace is 1/2 mile. The requirements 

of 14 CFR 135.207 state, “No person may operate a helicopter under VFR unless that person has 

visual surface reference ... sufficient to safely control the helicopter.” 

ADDITIONAL INFORMATION 

Preflight Safety Briefing 

According to Heli-USA personnel, the passengers were shown an approximate 4-minute 

safety video before they boarded the helicopter.30 A review of the video showed that the safety 

topics included a briefing that demonstrated various aspects of the vest-type PFD, including how 

to remove it from the waist pouch and place it over the head. The video instructed the passengers 

to remove their headsets before donning the vests. The video also identified the two red handles 

to be pulled to inflate the vest and the two oral tubes to blow into in case the vest does not 

inflate. In addition to the safety video, the passengers received verbal instructions from ground 

personnel and the pilot when they boarded the helicopter and were asked if they had any 

questions. 

Previous Weather-Related Air Tour Accident on Kauai 

During the National Transportation Safety Board’s investigation of the 

September 24, 2004, accident on Kauai involving a Bali Hai Helicopter Tours, Inc., air tour 

flight that encountered reduced visibility and crashed into a ridgeline, killing the pilot and the 

four passengers,31 the Safety Board found evidence that the pilot of that helicopter had flown into 

clouds on previous tours and that he had previously performed ridgeline crossings at low 

altitudes in areas where the minimum flight altitude, per SFAR 71, was 1,500 feet agl. In 

addition, some Hawaii air tour pilots interviewed did not fully understand the minimum altitude 

requirements established by their FAA-approved SFAR 71 deviation authorizations. 

 30 SFAR 71 requires that, before takeoff, passengers on air tour flights that include any segment beyond the 

shore must receive a briefing on water ditching procedures, use of required flotation equipment, and emergency 

egress from the aircraft in the event of a water landing. 

31 National Transportation Safety Board, Weather Encounter and Subsequent Collision into Terrain, Bali Hai 

Helicopter Tours, Inc., Bell 206B, N16849, Kalaheo, Hawaii, September 24, 2004, Aviation Accident Report 

NTSB/AAR-07/03 (Washington, D.C.: NTSB, 2007). 
NTSB/AAB-07/01 

14

During that investigation, Safety Board investigators also met with Honolulu FSDO 

personnel in February 2005 to discuss air tour oversight and surveillance issues. FSDO personnel 

reported that, from October 1995 to 2003, the FSDO had a dedicated geographic surveillance 

unit (GSU) that provided direct oversight of all air tour operators in Hawaii and was responsible 

for ensuring compliance with SFAR 71. The GSU was equipped with surveillance cameras, 

binoculars, video cameras, and other equipment that the inspectors used to monitor tour 

operations and ensure that the pilots were complying with cloud and terrain clearance 

requirements. The GSU also used a number of innovative surveillance methods, such as 

monitoring air tour activity from remote locations and sending inspectors posing as tourists on 

revenue flights. According to FSDO personnel, the GSU was highly successful. 

That investigation found that, however, by late 2003, the Honolulu FSDO needed to fill 

operations and airworthiness inspector positions and that the GSU inspectors were reallocated. 

After the GSU was officially disbanded in May 2004, there were no inspectors dedicated to 

providing direct surveillance of air tour flights in Hawaii. By the time of the Heli-USA accident, 

the Honolulu FSDO still did not have a GSU or other means of providing direct surveillance of 

commercial air tour operations. 
NTSB/AAB-07/01 

15

ANALYSIS 

Accident Sequence 

The air tour flight departed LIH, on the southeastern part of the island, and headed west 

to begin a clockwise tour around the island. Weather forecasts for the afternoon included VFR 

conditions with the possibility of reduced visibility in thunderstorms and heavy rain. The pilot 

stated that, while flying the helicopter along the island’s northern coastline, he maneuvered the 

helicopter to avoid traffic, and it entered a storm with heavy rain and reduced visibility. The 

passengers reported that the helicopter made no evasive maneuvers before entering the adverse 

weather. 

The pilot stated that, while in the heavy rain, he descended the helicopter to maintain 

visual reference to the beach. The pilot then decided to turn back, and, while doing so, the 

helicopter’s airspeed went to zero, and the helicopter rapidly descended. The pilot added full 

power and control inputs, but the helicopter continued to descend, and it crashed into the water 

several hundred feet off shore. Survivors reported they observed heavy rain, thunder, and 

lightning while they were in the water. 

Microburst Phenomena 

A weather study found that satellite infrared imagery for the location and timeframe of 

the accident indicated the rapid development of cumulus clouds capable of producing heavy rain 

showers, and stability and energy indices indicated potentially strong updrafts and downdrafts. 

The heavy rain showers and building thunderstorm activity reported by witnesses and the 

sounding profile supported the presence of embedded wet-type microburst activity. Statements 

from the pilot and passengers regarding the helicopter’s rapid descent in torrential rain are 

consistent with an encounter with a microburst event. 

Weather-Reporting Facility Limitations 

No weather reporting facility is located on the north end of the island where the accident 

occurred, and the weather facility on the south end of the island is unable to observe the weather 

on the north end reliably because of interference from high terrain in the middle of the island. 

The WSR-88D radar’s depiction of the convective area showed only light showers in the 

immediate vicinity of the accident site; however, the actual weather conditions were likely much 

stronger than what was depicted. Although a radar system capable of accurately observing the 

north end of the island could not have detected the presence of a microburst, the characteristics 

of the storm encountered by the accident helicopter (and two of three other tour helicopters in the 

area) would have produced strong reflectivity returns. 

In the absence of reliable and timely official weather information, Kauai air tour pilots 

typically use their own judgment on the basis of the appearance of the weather to determine 

whether to proceed. Because the island’s unique weather patterns involve daily, brief, localized 

rain showers, it is not unusual for Kauai air tour pilots to encounter and briefly penetrate areas of 

precipitation during tours. For example, of the three other tour pilots who approached the storm 
NTSB/AAB-07/01 

16

associated with the accident, one elected to turn back without entering the conditions and two 

chose to fly through it. Because of the rapidly changing characteristics of the storm, each pilot 

likely encountered different conditions. The three pilots (including the accident pilot) who 

entered the storm found that they did not quickly break out of the weather as expected. 

Federal Aviation Administration Surveillance of Air Tours in Hawaii 

One year before this accident, an air tour accident involving Bali Hai Helicopter Tours, 

Inc., occurred on the island of Kauai on September 24, 2004, after the pilot decided to continue 

the flight into deteriorating weather rather than deviate from his tour route; the helicopter entered 

IMC and crashed into mountainous terrain, killing the pilot and the four passengers. During the 

Safety Board’s investigation of that accident, the Board noted that, for a number of reasons, the 

Honolulu FSDO has not been able to enforce the SFAR 71 regulations and deviation 

authorizations adequately. This situation and other factors led the Board to conclude in the Bali 

Hai accident report that, “because the Honolulu FSDO is not providing direct surveillance of and 

enforcement of SFAR 71, pilots continue to violate SFAR 71 and the certificate of waiver or 

authorization requirements, either intentionally or unintentionally, thus, placing themselves and 

their passengers at unnecessary risk for accidents, particularly in marginal weather conditions.” 

The Board determined that a contributing factor in the Bali Hai accident was “inadequate FAA 

surveillance of SFAR 71 operation restrictions” and issued a safety recommendation in the report 

to address the issue.32

At the time of the Heli-USA accident, the Honolulu FSDO still did not have a means to 

provide direct surveillance of air tour activities. Although some operators had FAA-approved 

procedures that allowed pilots to descend below the SFAR 71 minimum altitudes to avoid 

unforecasted weather, provided that they canceled their tours and returned to base under Part 135 

rules, there is evidence that pilots from multiple operators were not properly following these 

procedures and that there was little threat of enforcement consequences for doing so. Of the three 

pilots who chose to enter the adverse weather, all had to descend below the SFAR 71 minimum 

altitude to maintain visual contact with the shore. Although one pilot reported he canceled his 

tour and returned to base, another pilot (the accident pilot) crashed while attempting to reverse 

course, and the pilot who successfully made it through the storm at 300 feet agl continued his 

tour, rather than cancel it and return to base as required. The Safety Board is concerned that, 

without adequate FAA surveillance, the very safety provisions that were put in place to protect 

passengers from flight in unsafe weather conditions could be used by some pilots to enter—

rather than avoid—such weather to continue revenue flights, placing themselves and their 

passengers at unnecessary risk for accidents. 

Survivability Issues 

Although each occupant on the accident flight wore a PFD and received instruction on its 

use as required under SFAR 71, not all were successful in completing the procedures for donning 

 32 On February 13, 2007, the Safety Board adopted the report, which contained Safety 

Recommendation A-07-21, to recommend that the FAA “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.” 
NTSB/AAB-07/01 

17

the PFD, exiting the helicopter, and properly inflating the PFD, even though all were physically 

capable of doing so. Of the three passengers who were killed, none sustained any serious or 

incapacitating trauma injuries during the impact sequence, and each died of drowning or 

drowning-related circumstances. Staff considered several factors that may have affected each 

passenger’s outcome, including the speed at which the helicopter sank, PFD-donning and egress 

procedures, safety briefing clarity, and the mechanical condition of the PFDs. 

Lack of Helicopter Flotation Equipment 

The helicopter sank quickly; thus, the passengers had little time to help themselves or 

others before they were submerged. According to the FAA, “while the proper donning and 

securing of a life preserver may not take a lot of time under normal non-stressful situations, it 

can be a time-consuming process in a time of high stress.”33 The Safety Board notes that, 

although some survivors reported they either experienced or observed other passengers 

experience difficulties in completing the PFD and egress procedures, none of the difficulties 

alone (such as the one passenger’s difficulties with the headset) should have rendered survival 

impossible. 

In its 1995 special investigation report (SIR) on the safety of the U.S. air tour industry,34

the Safety Board noted that the combined use of PFDs and helicopter flotation equipment would 

provide the optimum level of safety for air tour passengers in the event of emergency ditching. In 

the SIR, the Board pointed out that, although the FAA’s original draft of SFAR 71 called for the 

use of both PFDs and helicopter flotation systems, the final version allowed Hawaii air tour 

operators to provide only one or the other. The Board urged the FAA to reconsider this provision 

of SFAR 71 and to evaluate the use of helicopter floats for other overwater air tour locations. 

In response to the SIR, on October 22, 2003, the FAA issued a notice of proposed 

rulemaking (NPRM) for national air tour safety standards that stated the following: 

The FAA has determined that equipping certain helicopters with floats for overwater operations increases the likelihood of occupant survival in the event of an 

emergency water ditching. Floats would allow the helicopter to remain on the 

surface of the water for a longer period of time, thus allowing the occupants time 

to exit while the helicopter is still on the surface of the water. 

In the NPRM, the FAA also stated that it recognized the need for more stringent flotation 

equipment requirements for commercial air tours and proposed that “single-engine helicopters 

and certain multi-engine helicopters operated in commercial air tours over water would have to 

be equipped with fixed or inflatable floats ... unless the flight over water is necessary only for 

take off or landing.” However, when the FAA issued the final rule on February 8, 2007, the rule 

 33 This statement is in the FAA’s notice of proposed rulemaking, “National Air Tour Safety Standards,” Docket 

No. FAA-1998-4521, Notice No. 03-10, issued on October 22, 2003, in Federal Register, Vol. 68, No. 204. 

34 National Transportation Safety Board, Safety of the Air Tour Industry in the United States, Special 

Investigation Report NTSB/SIR-95/01 (Washington, D.C.: 1995). 
NTSB/AAB-07/01 

18

stated that helicopters need not be equipped with floats if each occupant is wearing a life 

preserver while the helicopter is within power-off gliding distance of the shoreline. 

In this accident, helicopter floats would have likely kept the helicopter on the water 

surface longer. Because all of the passengers (including the nonsurvivors) either donned or 

attempted to don their PFDs and because all likely perceived the immediate need to exit the 

helicopter, the Safety Board concludes all of the passengers would have had the opportunity to 

don their PFDs and egress the helicopter successfully had the helicopter not sunk so quickly. 

The Safety Board also notes that the accident helicopter was initially traveling over the 

shore but ended up over the ocean as the emergency progressed. Further, the ditching emergency 

was not related to a loss of engine power. Therefore, the Board concludes that, with regard to 

helicopter flotation equipment, there should be no exceptions for overwater takeoffs and landings 

and no distinction between single- and multi-engine helicopters. 

Personal Flotation Device Inflation Issues 

During demonstrations of representative PFDs, test subjects reported that it was relatively 

easy to don the PFDs and inflate both chambers, even when the procedures were performed in 

the water. According to the demonstrations of the two PFD models, the test subjects found it was 

not possible to float facedown with both chambers inflated. 

Examination of the recovered PFDs found that, of the three PFDs that were worn by the 

survivors, only one had both chambers inflated. One recovered PFD with an uninflated chamber 

showed no evidence that any attempt had been made to inflate it, and it functioned properly 

when tested. The other recovered PFD with one uninflated chamber showed evidence that 

someone had attempted to inflate it but was unsuccessful, likely because of an incompletely 

seated cylinder. 

Because the PFD worn by the passenger who was found floating facedown was not 

recovered for examination, it was not possible to determine its inflation configuration or to 

conclude whether both chambers could have inflated if the handles were pulled. Also, because it 

is not known at what point in the egress sequence this passenger drowned, it is not possible to 

conclude whether a fully inflated PFD could have saved this passenger’s life. 

Of the two PFDs provided for the water-immersion demonstration, one had a chamber 

that failed to inflate because of an improperly seated cylinder. Also, another Hawaii air tour 

operator reported 18 of 26 cylinders were loose on 13 PFDs examined. All of these PFDs (the 2 

provided for testing and the 13 others examined) had been recently retired from service after 

about 1 year of use in accordance with the manufacturers’ recommendations and the Honolulu 

FSDO’s requirements for air tour operators. Because the PFDs must remain sealed in their 

pouches to meet airworthiness requirements, it is not possible for the operators to inspect the 

cylinders themselves between recommended inspection intervals. The Safety Board is concerned 

that the number of improperly seated cylinders found within such a small sample size may 
NTSB/AAB-07/01 

19

indicate that similar problems exist elsewhere and could include instances in which both 

cylinders on one PFD are not secure. 

The Safety Board concludes that, without a solution to the cause of and how to prevent 

inflation cylinder unseating, passengers are no longer assured that their flotation devices will 

perform as designed in the event of an emergency and that further evaluation is needed to 

determine whether design, maintenance, and/or in-service handling issues are related to the 

problem. Although the PFDs are equipped to allow for oral inflation of the chambers, the Board 

is concerned that, in the case of passengers who cannot swim, the 2-second cylinder inflation 

would be more preferable than attempting oral inflation and that panicked passengers may forget 

about the oral inflation option. 

PROBABLE CAUSE 

The National Transportation Safety Board determines that the probable cause of the 

accident was the pilot’s decision to continue flight into adverse weather conditions, which 

resulted in a loss of control due to an encounter with a microburst. Contributing to the accident 

was inadequate Federal Aviation Administration surveillance of Special Federal Aviation 

Regulation 71 operating restrictions. Contributing to the loss of life in the accident was the lack 

of helicopter flotation equipment.