aviation

Weather Encounter and Subsequent

Collision into Terrain

Bali Hai Helicopter Tours, Inc.

Bell 206B, N16849

Kalaheo, Hawaii

September 24, 2004

ACCIDENT REPORT

NTSB/AAR-07/03

PB2007-910404

Aircraft Accident Report

Weather Encounter and Subsequent

Collision into Terrain

Bali Hai Helicopter Tours, Inc.

Bell 206B, N16849

Kalaheo, Hawaii

September 24, 2004

NTSB/AAR-07/03

PB2007-910404 National Transportation Safety Board

Notation 7862A 490 L’Enfant Plaza, S.W.

Adopted February 13, 2007 Washington, D.C. 20594

E PLUR IBUS UNUM

NATIONAL TRA S PORTATION

B OAR D

SAFE T Y

N
National Transportation Safety Board. 2007. Weather Encounter and Subsequent Collision into

Terrain, Bali Hai Helicopter Tours, Inc., Bell 206B, N16849, Kalaheo, Hawaii, September 24, 2004.

Aircraft Accident Report NTSB/AAR-07/03. Washington, DC.

Abstract: This report explains the accident involving a Bell 206B helicopter, N16849, registered to and

operated by Bali Hai Helicopter Tours, Inc., of Hanapepe, Hawaii, which impacted mountainous terrain in

Kalaheo, Hawaii, on the island of Kauai, 8.4 miles northeast of Port Allen Airport, in Hanapepe. The safety

issues discussed in this report include the influence of pilot experience and operator scheduling on in-flight

decision-making; the lack of Federal Aviation Administration (FAA) oversight of 14 Code of Federal

Regulations 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.

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine,

pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board

Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study

transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board

makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and

statistical reviews.

Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications also

may be obtained from the Web site or by contacting:

National Transportation Safety Board

Records Management, CIO-40

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To

purchase this publication, order report number PB2007-910404 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports

related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. 
iii Aircraft Accident Report

Contents

Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii

1. Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.1 History of Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.2 Injuries to Persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

1.3 Damage to Helicopter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

1.4 Other Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

1.5 Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

1.5.1 The Pilot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

1.5.1.1 Flight Time and Duty Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.5.1.2 72-hour History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

1.6 Helicopter Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

1.6.1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

1.6.2 Maintenance Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

1.7 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

1.7.1 Federal Aviation Administration Weather Radar Data . . . . . . . . . . . . . . . . . . . . . . . 9

1.7.2 Airmen’s Advisories and Area Forecast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

1.7.3 Witness Weather Observations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

1.7.4 Local Weather Information Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

1.7.5 Hawaii-Specific Weather Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

1.8 Aids to Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

1.9 Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

1.10 Airport Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

1.11 Flight Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

1.12 Wreckage and Impact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

1.13 Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

1.14 Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

1.15 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

1.16 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

1.17 Organizational and Management Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

1.17.1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

1.17.2 Pilot Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

1.17.3 Pilot-Scheduling Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

1.17.3.1 Daily Tour Schedules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

1.17.3.2 Pilot Lunch and Rest Breaks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

1.17.4 Weather-Related Tour Cancellations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

1.17.5 Ridge-Crossing Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

1.17.6 Federal Aviation Administration Surveillance – Honolulu 

Flight Standards District Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
iv Aircraft Accident Report

1.17.6.1 Staffing Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

1.17.6.2 Geographical Surveillance Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

1.18 Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

1.18.1 Helicopter Operations in Reduced Visibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

1.18.2 Spatial Disorientation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

1.18.3 Helicopter Pilot Fatigue Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

1.18.4 Flight Time and Duty Period Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

1.18.5 Special Federal Aviation Regulation 71 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

1.18.5.1 Certificate of Waiver or Authorization to Deviate from 

Special Federal Aviation Regulation 71 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

1.18.5.2 Formal Air Tour Safety Meetings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

1.18.6 Automatic Dependent Surveillance-Broadcast Program . . . . . . . . . . . . . . . . . . . . . 30

1.18.7 Previous Related Safety Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

1.18.8 National Air Tour Safety Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

1.18.8.1 Notice of Proposed Rulemaking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

1.18.8.2 Final Rule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

1.18.9 Requirements for Part 135 Air Tour Operators . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

2. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

2.1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

2.2 Accident Sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

2.3 Human Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

2.3.1 Spatial Disorientation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

2.3.2 Pilot’s Decision-making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

2.3.2.1 Inexperience with Local Weather Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

2.3.2.2 Overconfidence and Decision Bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

2.3.2.3 Bali Hai’s Pilot-Scheduling Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

2.3.2.4 Management Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

2.4 Federal Aviation Administration Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

2.4.1 Oversight of Part 91 Air Tour Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

2.4.2 Honolulu Flight Standards District Office Surveillance of Bali Hai . . . . . . . . . . . 43

2.4.3 Honolulu Flight Standards District Office Staffing Issues . . . . . . . . . . . . . . . . . . . 44

2.4.4 Air Tour Safety Meeting Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

2.5 Safety Impact of Special Federal Aviation Regulation 71 . . . . . . . . . . . . . . . . . . . . . . 46

2.6 Need for National Air Tour Safety Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

2.7 Implementing Automatic Dependent Surveillance-Broadcast in Hawaii . . . . . . . . . . . 48

3. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

3.1 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

3.2 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

4. Safety Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

5. Appendixes

A: Investigation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Contents
v Aircraft Accident Report

Figures

1. Map of Kauai, showing accident site and some of 

Bali Hai’s site-specific locations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

2. Radar data for the last 2 minutes of the accident flight 

plotted over a topographical map . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

3. Weather radar at 1634 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

4. Weather radar at 1639 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

5. Weather radar at 1645 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
vi Aircraft Accident Report

Abbreviations

ADS-B automatic dependent surveillance-broadcast

agl above ground level

AIRMET airmen’s meteorological information

ASI aviation safety inspector

ATC air traffic control

ATIS automated terminal information service

CERAP air route traffic control center and radar approach control

CFR Code of Federal Regulations

dBZ decibels

DOT Department of Transportation

DUATS direct user access terminal system

FAA Federal Aviation Administration

FSDO Flight Standards District Office

FSS flight service station

GAATA General Aviation and Air Taxi Activity

GSU geographical surveillance unit

IFR instrument flight rules

IMC instrument meteorological conditions

IOE initial operating experience

LIH Lihue Airport, Lihue, Hawaii

LOA letter of authorization

McIDAS Man computer Interactive Data Access System

msl mean sea level

NOE nap of the Earth or nape of the Earth

NPG National Flight Standards Work Program Guidelines

NPRM notice of proposed rulemaking
Abbreviations vii Aircraft Accident Report

NWS National Weather Service

PAK Port Allen Airport, Hanapepe, Hawaii

PIC pilot-in-command

POI principal operations inspector

S/N serial number

SIC second-in-command

SFAR Special Federal Aviation Regulation

UTC coordinated universal time

VFR visual flight rules 

VMC visual meteorological conditions

WSR-88D Weather Surveillance Radar-1988 Doppler
viii Aircraft Accident Report

Executive Summary

On September 24, 2004, about 1642 Hawaiian standard time, a Bell 206B

helicopter, N16849, registered to and operated by Bali Hai Helicopter Tours, Inc., of

Hanapepe, Hawaii, impacted mountainous terrain in Kalaheo, Hawaii, on the island of

Kauai, 8.4 miles northeast of Port Allen Airport, in Hanapepe. The commercial pilot and

the four passengers were killed, and the helicopter was destroyed by impact forces and

postimpact fire. The nonstop sightseeing air tour flight was operated under the provisions

of 14 Code of Federal Regulations 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. 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 7.5 15 Miles 3.75

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

thereafter, the helicopter tracked west toward a pass at the top of Kahili Ridge, then

crossed Kahili Ridge. About 1642, the radar track depicted the helicopter on the west side

of Kahili Ridge as it turned toward the north. The helicopter’s ground track then made a

180o clockwise turn toward the south and crossed back to the east side of the Kahili Ridge

in a zigzag pattern before it was lost from radar at 1642:46. The wreckage was located on

the east side of Kahili Ridge about 200 feet below the top of the ridgeline and southeast of

the last radar return.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

1.2 Injuries to Persons

Table 1. Injury chart.

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

Injuries Flight Crew Cabin Crew Passengers Other Total

Fatal 1 0 4 05

Serious 0 0 0 00

Minor 0 0 0 00

None 0 0 0 00

Total 1 0 4 05

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

flight hours, which included 3,900 hours in turbine-powered helicopters, 2,820 hours

pilot-in-command (PIC), 1,350 hours second-in-command (SIC), and 800 hours as an

instructor pilot.

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 to the

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

helicopter, and he did not leave the helicopter to take a lunch break.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

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.

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

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

1.5.1.2 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

1.6 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

component times, types of maintenance or overhaul, installation and/or maintenance

dates, and S/Ns. Further, the records indicated no evidence of compliance with a number

of mandatory inspections, including special retorque inspections.

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

(msl). The weather radar echo intensities are represented in decibels (dBZ) (see color bar

on the right side of each figure). In the figures, the ground track of the accident flight from

1635:11 to 1642:46 is plotted in white, and selected radar plot times are noted in blue.

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

Figure 4. Weather radar at 1639.

Figure 5. Weather radar at 1645.
Factual Information 12 Aircraft Accident Report

1.7.2 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.

29 Airmen’s weather information products are transmitted in coordinated universal time. However, the

times in this section have been converted to Hawaiian standard time.
Factual Information 13 Aircraft Accident Report

1.7.4 Local Weather Information Sources

According to Bali Hai personnel, weather information was available from local

television broadcasts, the Internet, and the FAA’s flight service station (FSS) in Honolulu,

but they did not know what resources, if any, the pilot used the day of the accident. There

was no record that the pilot obtained a weather briefing from the local FSS. Bali Hai did

not have a direct user access terminal system (DUATS) at its office.

There were no weather information update capabilities at Bali Hai’s ramp area at

PAK. After a pilot left the company office, he or she could visually assess the weather

from the airport or during tour flights, or the pilot could request reports from other tour

pilots using the helicopter’s communications radios or by cellular telephone. A pilot

would also have the option of contacting other Kauai airports at Princeville, Barking

Sands military airfield, or LIH by cellular telephone.

1.7.5 Hawaii-Specific Weather Challenges

Many local air tour pilots,30 some with several years’ flying experience on the

island of Kauai, stated that helicopter operations there could be particularly challenging

because of the terrain, mountain winds, and rapidly changing cloud conditions. They also

stated that conditions were more challenging in winter. Many reported that, because

weather conditions on Kauai changed so rapidly, traditional sources of pilot weather

information, such as automated reporting stations, automated terminal information service

(ATIS), and FSS briefings, were not very useful for flight planning.

Of the eight weather-related31 air tour accidents that occurred in Hawaii since

SFAR 71 was implemented, four involved pilots, including the accident pilot, who were

relatively new to air tour operations in Hawaii, three of whom had been flying in the

islands for less than 2 months.32 For example, on September 23, 2005, an Aerospatiale

AS350BA air tour helicopter crashed off the northern coast of Kauai after encountering

heavy rain and other adverse weather conditions, killing three of the five passengers.33 The

pilot had been conducting tour flights in Kauai since August 8, 2005. The pilot survived

and reported to investigators that he obtained a weather printout from a DUATS before his

first flight that morning. He also stated that he listened to the LIH ATIS before he departed

from LIH on the accident flight and that he observed good weather and visibility at the

airport. One surviving passenger reported that, when the tour began, the visibility was

30 Air tour pilots contacted during the investigation included former Bali Hai pilots and pilots who had

flown or were flying for other air tour operators in Hawaii.

31 When these data were compiled, some accidents remained under investigation, and the classification

“weather-related” was derived from collected factual information. For completed investigations, the

classification was derived from published probable causes and factors.

32 The four accidents are this accident, LAX98FA211, LAX04FA190, and SEA05MA199.

33 The description of this accident, SEA05MA199, can be found on the Safety Board’s Web site at

<http://www.ntsb.gov>.
Factual Information 14 Aircraft Accident Report

good, but, as the tour progressed, the helicopter entered thick clouds and encountered

heavy rain and reduced visibility.

Another pilot, who was involved in the April 18, 2004, accident on the island of

Hawaii, had been employed by the tour company for 11 days and was conducting her first

14 CFR Part 135 revenue tour flight.34 Interviews with Honolulu FSDO inspectors

revealed that, after that accident, they discussed whether initial operating experience

(IOE)35 should be required for all local new-hire tour pilots to familiarize them with not

only the tour routes, but also the changing weather patterns in the islands. The FSDO

inspectors stated that they believed IOE would be the best way to provide guided

experience to new air tour pilots, but a requirement for IOE was not implemented.

The experienced Kauai air tour pilots interviewed stated that they believed that a

pilot’s ability to assess local weather-related changes and to anticipate the effect of such

changes on flying conditions improved as the pilot’s local flying experience increased.

During its investigation of the previously mentioned September 23, 2005, air tour

accident, the National Transportation Safety Board identified three relatively experienced

Kauai air tour pilots who encountered the same storm as the accident pilot. Of the three,

one pilot chose to cancel his tour and return to base rather than attempt to enter the storm.

The other two pilots chose to enter the storm and, although neither flight resulted in an

accident, both pilots encountered visibility conditions below what is allowed under

SFAR 71.

1.8 Aids to Navigation

Not applicable.

1.9 Communications

There were no known radio communications between the accident flight and any

ATC facilities or other aircraft.

1.10 Airport Information

Bali Hai operated its tour flights from PAK, a general aviation airport 1 mile

southwest of Hanapepe on the southwest side of Kauai. Located on a flat peninsula, PAK

34 The accident involved a Piper PA-28-161 airplane. The description for this accident, LAX04FA190,

can be found at the Safety Board’s Web site at <http://www.ntsb.gov>.

35 IOE is described as the initial actual aircraft flying experience a pilot performs after completing

simulator training and ground school. IOE is usually performed under the oversight of an instructor or check

airman, and a minimum number of IOE hours are typically required before a pilot is allowed to fly as part of

a crew during a revenue flight. This type of oversight of flights is most commonly encountered in 14 CFR

Part 121 operations, though some Part 135 operators choose to use this training method.
Factual Information 15 Aircraft Accident Report

has one paved 2,400-foot runway and an adjacent, unpaved helicopter-parking apron that

has no buildings or shelters.

1.11 Flight Recorders

Not applicable.

1.12 Wreckage and Impact Information

The helicopter’s wreckage was located on the east side of Kahili Ridge about

200 feet below the crest of the ridge at an elevation of 2,850 feet. According to Kauai Fire

Department personnel, who were the first to reach the accident site, the wreckage was

located on a 75o slope covered by thick vegetation. The wreckage was oriented

west-southwest, and the debris field remained within a 50-foot radius of the main impact

area with the main concentration of debris scattered to the southwest up the steep slope.

Nearly all the wreckage was recovered and transported to a hangar at LIH for

examination.

Most of the fuselage structure was destroyed by impact and fire damage. The

landing skids and crossover tubes were fragmented into numerous pieces. The top of the

cockpit and cabin structure was crushed and was deformed upward. The left side cabin

and cockpit doors were deformed; the right side cabin and cockpit doors were

significantly more fragmented and deformed than the left side doors. Cockpit flight

controls were found in the wreckage debris, but damage prevented investigators from

determining control continuity.

The tail boom was separated from the fuselage at the fuselage junction area, was

not fire-damaged, and was deformed downward. The transmission and the main rotor mast

remained intact and were attached to the roof structure. Examination of the airframe, flight

control system components, main rotor system, transmission components, and the tail

rotor system components revealed no evidence of a precrash mechanical malfunction.

Examination of the main rotor mast revealed no evidence of a mast-bumping event.36

The engine was separated from the airframe attach mounts, and the oil, air, and

fuel lines showed impact and/or fire damage. From November 2 to 3, 2004, the engine was

examined at the Rolls-Royce Corporation facility in Indianapolis, Indiana, under Safety

Board supervision. Examination revealed that the compressor impeller shroud displayed

rotational scoring and gouging throughout the entire circumference of the shroud, heavy

rub damage was evident within the turbine section, and the engine fuel control unit’s

36 According to the FAA’s Rotorcraft Flying Handbook, Chapter 11, “Helicopter Emergencies,” a

mast-bumping event occurs when the main rotor hub comes in contact with the rotor mast, which could

result in severe damage to the rotor mast or the separation of the main rotor system from the helicopter.

Mast-bumping events typically result from improper pilot control inputs or from turbulence that can subject

the helicopter to low-gravity conditions.
Factual Information 16 Aircraft Accident Report

pointer indicated the throttle was full open. No evidence of precrash engine malfunction

was observed.

On May 13, 2005, the attitude indicator from the cockpit instrument panel was

disassembled and was examined at the Safety Board’s materials laboratory. Visual and

microscopic examination of the internal rotor and its housing revealed that each showed

circumferential scoring consistent with rotor rotation at impact.

Damage precluded testing of the helicopter’s mode C transponder.

1.13 Medical and Pathological Information

Tissue and fluid specimens from the pilot were sent to the FAA’s Civil Aerospace

Medical Institute in Oklahoma City, Oklahoma, for toxicological testing. According to the

toxicology report, the specimens tested negative for carbon monoxide, cyanide, and a

wide range of legal and illegal drugs.37 Traces of pseudoephedrine, a drug found in

common, over-the-counter decongestants, were found in the pilot’s liver. Quantities of

ethanol were detected in the brain, muscle, and blood; however, the report noted, “the

ethanol found in this case may be the result of postmortem ethanol production.”

1.14 Fire

A fuel-fed fire erupted after the helicopter impacted the ground.

1.15 Survival Aspects

An autopsy was performed on the pilot on September 29, 2004, by the Wilcox

Memorial Hospital Department of Pathology, Lihue. According to the autopsy report, the

cause of death for the pilot was “multiple traumatic injuries.”

According to the autopsy reports for the passengers, the cause of death for each

was “multiple traumatic injuries sustained in a helicopter crash and fire.”

1.16 Tests and Research

None.

37 The drugs tested for included the following: amphetamine, opiates, marijuana, cocaine,

phencyclidine, benzodiazepine, barbiturates, antidepressants, antihistamines, meprobamate, methaqualone,

and nicotine.
Factual Information 17 Aircraft Accident Report

1.17 Organizational and Management Information

1.17.1 General

Bali Hai began conducting its Part 91 sightseeing operations in 1986. Its office

included an enclosed garage, which served as the company’s maintenance facility. The

company had two Bell 206B helicopters that operated from PAK, which was about 1 mile

from the office. The helicopters were transported each day from the office to the airport on

a flatbed trailer pulled by the company’s fuel truck and were returned each evening in the

same manner.

The company operated tours 7 days per week. Company personnel stated that the

summer season and the Christmas and New Year’s holidays were the company’s busiest

tour periods. Bali Hai did not record operating statistics, but the owner estimated that the

company flew 1,000 to 1,200 flight hours and carried about 4,500 passengers per year.

Review of company scheduling records for the 60 days preceding the accident indicated

that the company flew 410 tours, 335 revenue flight hours, and 1,479 passengers during

that time period.

At the time of the accident, Bali Hai was the only Part 91 helicopter air tour

company on Kauai; the other helicopter air tour companies on the island were certificated

and operated under Part 135. Bali Hai was a family-operated business in which the owner

himself was pilot-certificated, his son was the company’s sole mechanic,38 his daughter

was the office manager, and his son-in-law served as a customer service representative.39

Nonfamily employees included the senior pilot, the accident pilot, and the line

service technician. The pilots received a flat monthly salary plus flight-hour pay, which

was an hourly rate applied to the number of revenue flight hours flown.

1.17.2 Pilot Training

Bali Hai’s owner, mechanic, and other company pilots40 provided the accident

pilot some initial company training, as their tour schedule permitted. Bali Hai was not

required to have company-specific initial training;41 the owner stated that each pilot

received as much training as the owner felt was needed for the pilot to fly safely and to

38 The mechanic held an aviation mechanic’s certificate with airframe and powerplant ratings. He stated

that he gained his helicopter knowledge through on-the-job training at Bali Hai.

39 The customer service representative’s duties included providing the passenger safety briefing and

providing a calculated weight and balance sheet in the form of a “boarding pass” to the passengers while

they were at the company’s office. After the passengers arrived at the helicopter staging area at PAK, they

would give the weight and balance sheet to the line service technician, who would give it to the pilot before

the flight.

40 Besides the senior pilot, Bali Hai had one other pilot when the accident pilot was hired. That pilot

was no longer with the company on the date of the accident.

41 Part 91 air tour operators, unlike Part 135 and Part 121 operators, are not subject to any initial

pilot-training requirements.
Factual Information 18 Aircraft Accident Report

pass the initial SFAR 71 checkride. Because Bali Hai held a certificate of waiver or

authorization to deviate from SFAR 71, its pilots were required by the FAA to pass an

SFAR 71 checkride every 12 calendar months. The owner stated that, whenever a pilot

required a biennial flight review,42 the company would pay a certificated flight instructor

and supply a helicopter so that the pilot could complete the required ground and flight

training.

Bali Hai did not provide, and was not required to provide, recurrent flight

training.43 According to the owner, he believed the required SFAR 71 checkrides and

annual air tour safety meetings44 provided an opportunity for the pilots to refresh their

knowledge of SFAR 71 and Bali Hai’s deviation authorization. The accident pilot had not

been employed with Bali Hai long enough to have attended one of the air tour safety

meetings.

1.17.3 Pilot-Scheduling Practices

1.17.3.1 Daily Tour Schedules

According to company personnel, unless there was a gap in the tour schedule, the

helicopter would be kept running with its rotors turning continuously all day, to reduce

engine wear associated with engine start cycles. On the day of the accident, the pilot did

not shut down the helicopter.

The customer service representative stated that the pilots typically flew no more

than seven or eight tours per day. A review of scheduling records for the 3-month period

before the accident showed that the senior pilot and the accident pilot averaged six tours

per day when serving as primary pilot.45 During that timeframe, the accident pilot flew as

many as 8 tours per day, and the senior pilot flew as many as 10 tours per day.

Former Bali Hai pilots stated that the company sometimes added tours to the end

of the day’s schedule, which would depart at 1700 or later, and that they sometimes felt

too tired to fly these tours. Some former pilots reported flying as many as 13 tours per day.

One former pilot stated, “There are only so many flights you can do where you feel strong

enough.”

42 According to 14 CFR 61.56, a flight review requires ground and flight training from a certificated

flight instructor.

43 Part 91 air tour operators, unlike Part 135 and Part 121 operators, are not subject to any recurrent

pilot-training requirements.

44 For air tour pilots who are approved to deviate from SFAR 71, the FAA requires, in addition to the

SFAR 71 checkride, that pilots participate in at least one formal air tour safety meeting each year. For more

information about the meetings, see section 1.18.5.2.

45 Company personnel stated that Bali Hai typically scheduled pilots each week to fly 2 full days and

2 half-days, plus 1 additional full or half-day, depending on the demand for tours. The pilot scheduled to

work a full day was considered the primary pilot.
Factual Information 19 Aircraft Accident Report

1.17.3.2 Pilot Lunch and Rest Breaks

According to Bali Hai’s Policies and Procedures Manual, employees could take a

30-minute lunch break “provided all flight line ... needs are met.” However, former Bali

Hai pilots stated that they either ate lunch while sitting in the helicopter between tours or

did not eat lunch at all. One former pilot stated, “I would have appreciated a half-hour

[break], but that’s just the way it was. I wasn’t overly fatigued by that, as long as I got

something to eat.”

Another former pilot stated, “[Bali Hai’s management] simply pushed the flights

out. Pilots were just a cog in the wheel to make sure it happened. There was disregard for

any fatigue or lunches or long hours, they just wanted pilots to keep flying.” Former pilots

reported that management strongly encouraged them to return from tours on time.

According to the line service technician, on the day of the accident, the pilot told

him about 1200 that he was getting hungry and that the pilot asked him to buy a sandwich

for him at a nearby store. According to the technician, the pilot ate the sandwich, while

sitting in the helicopter, after returning from his fifth tour about 1345.

Bali Hai did not provide shelter or restroom facilities at the airport for its

employees or customers. Former company pilots stated that, when they needed to go to the

bathroom, they would ask the line service technician to hold the helicopter’s flight

controls so they could exit the helicopter to go relieve themselves on the ground behind

the fuel truck or in nearby bushes.

1.17.4 Weather-Related Tour Cancellations

Bali Hai’s owner stated that the minimum visibility requirement for tours was

3 miles. He said that he told each pilot to assess the weather conditions and his own

personal safety limits and make a go/no-go decision about flying in marginal weather. The

company’s senior pilot said that the company tried to abide by the Part 91 minimum VFR

weather requirements and the more restrictive minimums outlined in the company’s

SFAR 71 operations specifications document.46

Bali Hai’s senior pilot said that, because the accident pilot was new to Kauai, he

and the owner “kept [an] eye on him” and briefed him numerous times about avoiding

areas of poor weather. He stated that he had taken the pilot off the tour schedule for

weather-related reasons on more than one occasion, even when conditions exceeded the

company’s minimums. A review of Bali Hai’s flight-scheduling records indicated that,

during the 8 weeks before the accident, one or more tours were canceled because of

weather on 7 days that the accident pilot was working. On September 21, 2004, for

example, the accident pilot’s 1200 and 1400 tours were rescheduled “due to [weather].”

46 As a Part 91 operator, Bali Hai was not required to have an operations specifications document. The

Honolulu FSDO issued this document to Bali Hai after the owner applied for the authorization to deviate

from SFAR 71.
Factual Information 20 Aircraft Accident Report

The senior pilot stated that the accident pilot had informed him that he had avoided

the Hanalei Valley and Waialeale Crater on more than one occasion when he had become

uncomfortable about the weather conditions there. The senior pilot described the accident

pilot’s flying as, “conservative,” “very controlled,” and “he tended to avoid weather at all

costs.” The FAA inspector who administered the pilot’s SFAR 71 checkride stated that the

pilot demonstrated good decision-making during the checkride by choosing not to enter

Waialeale Crater during marginal weather conditions.

A passenger on the accident pilot’s fourth tour on the day of the accident stated

that the helicopter did not enter clouds. Passengers from another tour that day stated that

the pilot maneuvered the helicopter carefully around clouds to show them Manawaipuna

Falls.

A professional helicopter pilot who rode as a tour passenger with the accident pilot

on August 17, 2004, stated that the pilot crossed some ridges approximately 50 feet above

terrain. The passenger stated that, while crossing a ridge during the latter portion of the

tour, the pilot flew the helicopter into thin, light clouds. The passenger stated that he told

the pilot that he did not want to fly in clouds and that the pilot replied that it was “OK”

because he could “see through them.”

The senior pilot stated that he had not experienced pressure to fly in marginal

weather conditions. However, six of seven former Bali Hai pilots reported feeling at least

some pressure from the company to fly in marginal weather conditions. One former pilot

told investigators that the company’s go/no-go criteria for winds, clouds, and visibility

were, “None. Put together whatever tour you can, fly in a little corner of the island if you

have to.” He stated, “There was always implied pressure to fly.” Some former pilots

reported that Bali Hai’s owner came out to the airport and yelled at them when they

refused to fly because of poor weather. However, Bali Hai’s owner and office manager

were out of town the week of the accident, and they were not on Kauai when the accident

occurred.

The accident pilot’s wife said that she had asked him how the flying was in Hawaii

and that he told her that he enjoyed it but that he had expressed concern about challenging

weather conditions. She said that he told her that it was more difficult to cancel his flights

at Bali Hai than it had been in the military because Bali Hai was a commercial operation.

She stated that he told her, “If it’s too bad, we won’t go, but if it’s just OK, we’ll go,” and

that, “[the senior pilot] goes and comes back.” The pilot’s wife also stated, however, that

he had not told her of any instances of being pressured by management to fly in poor

weather.

1.17.5 Ridge-Crossing Practices

Bali Hai’s certificate of waiver or authorization to deviate from SFAR 71 included

a transition segment that crossed the south end of Kahili Ridge at a landmark called the

billboard. According to the transition segment approval, ridge crossings at this location

could be executed as low as 500 feet agl. The ridge pass near the accident site was more
Factual Information 21 Aircraft Accident Report

than 1 mile from the centerline of the company’s approved transition segment; therefore,

any crossing at that location would have to be performed in compliance with the SFAR 71

minimum altitude of 1,500 feet agl.

The FAA inspector who administered the pilot’s SFAR 71 checkride stated that,

during the checkride, he and the pilot discussed the rules for crossing Kahili Ridge near

the accident site. He stated that he told the pilot that he was not permitted to cross there at

low altitudes, and the pilot stated that he understood. Bali Hai’s owner stated that his

pilots were allowed to cross the ridge at that location, but he incorrectly thought that a

crossing could be performed there at 500 feet agl. Bali Hai’s senior pilot correctly stated

the crossing altitude for that location. Interviews with five former Bali Hai pilots indicated

that they varied in their understanding of the regulations and company practices for

ridge-crossing locations and altitudes.

The senior pilot estimated that 10 percent or less of the company’s tours crossed

the ridge at the location near the accident site. He stated that a pilot might choose to cross

there if the weather near the billboard was bad or for “scenic reasons.” A former Bali Hai

pilot stated that he had often crossed the ridge where the accident occurred because

passengers liked taking photographs there and because it reduced flight time by 2 to

3 minutes, which he considered helpful if the tour was running long.

The chief pilot for another helicopter tour company stated that he had observed the

accident pilot cross Kahili Ridge near the accident site on previous days and twice on the

day of the accident. He considered this crossing location unsafe because it brought

helicopters closer to clouds and challenging winds. Passengers from the pilot’s seventh

tour stated that the pilot crossed Kahili Ridge near the accident site and that the helicopter

encountered strong wind and rain in that area. One passenger stated that he was worried at

times that the helicopter might not clear a ridge because the pilot would descend before

crossing a ridge, then pull up to clear it.

1.17.6 Federal Aviation Administration Surveillance – Honolulu 

Flight Standards District Office

Bali Hai’s operations and its certificate of waiver or authorization were under the

jurisdiction of the Honolulu FSDO. The FSDO manager stated that oversight of a Part 91

air tour operator47 would only occur during random ramp inspections, during an SFAR 71

checkride conducted on the operator’s pilots, or in response to a customer complaint. The

FSDO manager stated that the only complaints about Bali Hai that he could recall

involved homeowners’ complaints about low-flying aircraft, and he said that he received

similar complaints about other operators. He stated that he followed up on the complaints

but that none resulted in any enforcement action against Bali Hai. One Honolulu FSDO

47 FAA Order 1800.56D, “National Flight Standards Work Program Guidelines (NPG),” lists the

required surveillance items that inspectors must perform for Part 135 and Part 121 commercial air tour

operators; however, the NPG does not contain any provisions that mandate inspector surveillance of Part 91

air tour operators.
Factual Information 22 Aircraft Accident Report

inspector recalled receiving past complaints from Bali Hai pilots about

maintenance-related issues, and he stated that one such complaint resulted in enforcement

action after inspectors found deficiencies with the life vests on board Bali Hai’s

helicopters.

The Honolulu FSDO inspectors stated that, when they were at PAK conducting

their mandatory inspections of a Part 135 air tour operator based at that airport, they would

occasionally also conduct ramp inspections of Bali Hai’s helicopters and/or pilots. Review

of the Program Tracking and Reporting Subsystem database revealed that the last

maintenance-related ramp inspection of Bali Hai took place in 2002 and revealed a few

mechanical discrepancies.48 According to the inspectors, because Part 91 surveillance was

not mandatory and because Bali Hai had not been involved in an accident or incident since

its inception in 1986, no emphasis was placed on monitoring its operations.

1.17.6.1 Staffing Levels

As of February 22, 2005,49 the Honolulu FSDO employed 45 inspectors

(22 operations inspectors, 18 airworthiness inspectors, and 5 avionics inspectors) and

6 managers (4 for the operations unit and 2 for the airworthiness unit). As of March 2005,

the Honolulu FSDO was responsible for the oversight of 6 Part 121 operators, 46 Part 135

operators, 14 Part 133 operators, 6 Part 137 operators, and 5 Part 141 flight schools. Also,

as of March 2005, the FSDO had 22 current approvals for Part 135 operator certificate of

waiver or authorization for SFAR 71 deviations and 2 current approvals for Part 91

operator SFAR 71 deviations.50 The FAA estimates that there are about 400,000 air tour

flights per year in Hawaii.

Since 1990, Honolulu FSDO staffing issues and their potential impact on safety

have been the subject of numerous Safety Board recommendations.51 Although the FAA

has taken action in response, Honolulu FSDO staffing has remained below its authorized

level.52 According to the Honolulu FSDO manager, at the time of the Bali Hai accident,

the FSDO was about 10 inspectors short.53 The FSDO manager stated he was not

authorized to hire more inspectors to fill those positions because the FAA’s

Western-Pacific Region as a whole was overstaffed, and a hiring freeze was in effect.

48 These discrepancies included screws missing in the top engine cowling, safety wire missing for

cannon plug for fuel filter assembly, and rubber boot missing for oil chip plug assembly.

49 On February 22, 2005, Safety Board and FAA investigators met with Honolulu FSDO personnel to

conduct interviews about the FSDO’s staffing situation, work requirements, work scheduling, and budget

issues, among others. The interviewees attending the meeting included the Honolulu FSDO manager, the

operations unit managers, and the airworthiness unit managers.

50 One Part 91 approval was for Bali Hai, and the other was for an air tour company that was in the

process of obtaining a Part 135 operating certificate.

51 For more information about the safety recommendations, see section 1.18.7.

52 According to the Honolulu FSDO manager, the FSDO has historically experienced staffing problems

because it is not easy to recruit qualified personnel willing to relocate to Honolulu due to the cost-of-living

expenses associated with the area. Over the years, some inspectors retired or transferred to other FSDOs or

other areas in the FAA.
Factual Information 23 Aircraft Accident Report

During interviews, Honolulu FSDO inspectors stated that they were

time-constrained in trying to complete their mandatory inspections. They stated that,

because of the staffing situation that existed at the time of the Bali Hai accident, the

Part 135 operations inspectors focused on Part 135 surveillance and certification oversight

and had little or no time for nonmandatory oversight duties, such as Part 91 oversight

and/or surveillance.

1.17.6.2 Geographical Surveillance Unit

In October 1995, the Honolulu FSDO formed a geographical surveillance unit

(GSU), which provided direct oversight of all air tour operators in Hawaii, regardless of

whether they operated under Part 135 or Part 91, and was responsible for ensuring

compliance with SFAR 71.54 The GSU was originally established with eight inspectors,

one clerical assistant, and one supervisor. All inspectors used in surveillance operations

were trained to recognize standoff distances55 and elevations above terrain.

The GSU was equipped with surveillance cameras, binoculars, video cameras, and

other equipment that the inspectors used to monitor operations and to ensure that pilots

and tour companies were complying with cloud and terrain clearance requirements. The

GSU 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.56 These methods resulted in some pilots being cited for violating cloud and terrain

clearance restrictions.

As part of its duties, the GSU primarily focused its surveillance on operators that

were the subject of air tour customer complaints. A former GSU inspector recalled at least

one instance in which a passenger complaint, combined with the passenger’s photographic

evidence, resulted in FAA enforcement action against an operator. Former GSU

inspectors recalled that the unit had performed some surveillance of Bali Hai that resulted

53 According to the FSDO manager, he completed a 2004 staffing allocation model, and it indicated that

the FSDO was 13 inspectors short. By September 2006, FSDO personnel reported that the total FSDO

staffing level was similar to that at the time of the accident; however, due to retirements and transfers, fewer

inspectors were dedicated to Part 121 oversight and five more inspectors, including the newly hired ones,

were dedicated to Part 135 oversight. The newly hired inspectors were not expected to be fully trained and

able to resume full responsibilities until the end of fiscal year 2007.

54 The “Geographical Surveillance Unit – SFAR Manual” contains the guidelines for the Honolulu

FSDO’s GSU program and lists GSU inspectors’ duties, which include traveling to all airports, heliports,

landing sites, remote locations, and tour routes frequented by the air tour/sightseeing industry; performing

ramp inspections, en route inspections, maintenance functions, and any other surveillance to ensure

compliance with SFAR 71; investigating accidents, incidents, and complaints in regards to air

tour/sightseeing; and reviewing and making recommendations about problem areas or improvement of the

SFAR 71 deviation process/approval, among other duties.

55 Standoff distance refers to a defined horizontal radius to be maintained between the aircraft and any

person, structure, vehicle, vessel, or raw terrain.

56 The GSU also used inspectors from mainland FSDOs to help conduct this type of en route oversight;

using non-Honolulu FSDO inspectors reduced the likelihood that the tour pilots would recognize the

inspectors. This provided the FAA the opportunity to observe typical flight operations.
Factual Information 24 Aircraft Accident Report

in the correction of minor discrepancies, but they did not recall that any in-depth

inspections had been performed or any violations issued.

According to Honolulu FSDO personnel, the GSU was highly successful at

performing surveillance of air tour operations. However, by late 2003, the FSDO needed

to fill operations and airworthiness inspector positions, and, because the National Flight

Standards Work Program Guidelines stated that oversight of certificated operators was the

priority, inspectors from the GSU were reallocated to fill those positions instead. In

May 2004, the GSU was officially disbanded. After the GSU disbanded, there were no

inspectors dedicated to providing direct surveillance of air tour flights in Hawaii.

1.18 Additional Information

1.18.1 Helicopter Operations in Reduced Visibility

Reduced visibility conditions pose a significant challenge for helicopter operations

for multiple reasons. Helicopters are usually flown at lower altitudes than fixed-wing

aircraft, which imposes high visual demands on helicopter pilots to maintain obstacle and

terrain clearance. When visual references are obscured, such as by fog or clouds, the risk

of a collision with obstacles or terrain increases.

Helicopters are more maneuverable, but less stable, than fixed-wing aircraft, and

require relatively continuous pilot control inputs unless equipped with stability

augmentation systems. Most helicopters that are certificated for single-pilot flight under

IFR are equipped with stability augmentation systems, such as control stabilization and

autopilot systems, which are designed to reduce pilot workload.57 However, most older

helicopters, including the accident helicopter (which was not certificated for IFR

operations), do not have this equipment; research has shown that these helicopters can

impose a high workload on pilots who attempt to fly them in reduced visibility conditions

by reference to flight instruments alone.

Accidents that occur in reduced visibility conditions after a pilot has attempted

VFR flight into IMC are much more likely to be fatal than accidents that occur in visual

meteorological conditions (VMC). In a 2005 study,58 the Safety Board reported that, in

2004, only 6 percent of all general aviation accidents occurred in IMC, but 70 percent of

those accidents were fatal.59 A review of Safety Board helicopter accident data indicated

that, from 1995 to 2004, about 20 percent of fatal helicopter general aviation accidents and

52 percent of fatal helicopter air taxi accidents occurred in either IMC or dark night VMC.

None of the pilots who experienced fatal accidents in those conditions had activated an

IFR flight plan.

57 S.G. Hart, “Helicopter Human Factors,” Human Factors in Aviation (1988): 591-638.

58 National Transportation Safety Board, Risk Factors Associated with Weather-Related General

Aviation Accidents, Safety Study NTSB/SS-05/01 (Washington, DC: NTSB, 2005).

59 In 2004, there were 103 general aviation accidents that occurred in IMC, resulting in 143 deaths.
Factual Information 25 Aircraft Accident Report

Reduced visibility conditions, such as IMC or dark night VMC, also greatly

increase the risk of spatial disorientation. One recent study of U.S. Army rotary-wing

operations found that sudden loss of visual cues preceded about 25 percent of helicopter

accidents attributed to spatial disorientation.60

1.18.2 Spatial Disorientation

Spatial disorientation occurs when a pilot develops an incorrect perception of

aircraft attitude, altitude, or motion relative to the Earth’s surface. It results when a pilot’s

normal visual cues to aircraft attitude are inaccurate, unavailable, or inadequately

monitored, and the pilot, instead, relies on other cues to aircraft attitude that may be

misleading.

These cues are provided by the motion-sensing vestibular organs in each inner ear.

The sensory organs of the inner ear detect angular accelerations in the pitch, yaw, and roll

axes, as well as gravity and linear accelerations. The vestibular system provides useful

sensory information under conditions of self-locomotion on the ground but provides

misleading sensations in the flight environment. Vestibular sensations are easily ignored

when pilots have a clear view of the horizon, but they become compelling illusions when

external visual references are not available. Instrument-rated pilots are taught to ignore

misleading vestibular sensations in favor of the visual cues from flight instrumentation

when operating in IMC. However, even experienced, instrument-rated pilots can

experience episodes of spatial disorientation in reduced-visibility conditions. Situational

risk factors for spatial disorientation include false surface planes created by sloping clouds

or terrain, transitions between VMC and IMC that require the shifting of visual attention

between external visual references and cockpit flight instruments, sustained turns, and

high workload.61 Spatially disoriented pilots are at risk of making inappropriate control

inputs that can result in loss of aircraft control.

A survey examining disorientation phenomena among naval helicopter pilots

found that the most common form of pilot disorientation involved illusions of the

helicopter banking.62 In fact, most surveys examining the incidence of in-flight spatial

disorientation among pilots have produced similar findings. For example, in one survey of

Indian Air Force pilots, 55 percent of helicopter pilots reported having experienced a false

sensation of “one wing low,” and 45 percent reported having felt as if they were banking

in the opposite direction. Also, 54 percent of helicopter pilots reported having experienced

spatial disorientation illusions in clouds, and 32 percent reported experiencing such

illusions in poor visibility conditions. The average duration of spatial disorientation

60 M.G. Braithwaite, S.J. Durnford, J.S. Crowley, N.R. Rosado, and J.P. Albano, “Spatial Disorientation

in U.S. Army Rotary-wing Operations,” Aviation, Space, and Environmental Medicine, Vol. 69 (1998):

1031-1037.

61 (a) F.H. Previc, “Visual Illusions in Flight,” Spatial Disorientation in Aviation (2004): 283-323; and

(b) L.R. Young, “Spatial Orientation,” Human Factors in Aviation (2003).

62 F.R. Tormes and F.E. Guedry, “Disorientation Phenomena in Naval Helicopter Pilots,” Aviation,

Space, and Environmental Medicine, Vol. 46, No. 4 (1975): 387-393.
Factual Information 26 Aircraft Accident Report

illusions experienced by Indian Air Force pilots flying fixed- and rotary-wing aircraft was

46 seconds.63

1.18.3 Helicopter Pilot Fatigue Issues

Little research has examined the unique effect of time-on-task as a cause of fatigue

and an influence on performance among helicopter pilots. One such study64 examined the

effect of a vibrating, noisy, helicopter cockpit environment and continuous flying activity

on subjective fatigue and pilot performance. Flight legs were designed to simulate

repetitive circular, helicopter air taxi flights conducted under IFR in a metropolitan area,

with complete circuits lasting about 1 hour and including three approaches and landings.

Pilots flew either 3-, 4-, 6-, or 8-hour flight periods.65 Rest breaks were permitted during

the 4- and 8-hour flight periods but not during the 3- and 6-hour flight periods. Pilot

performance was measured, and the pilots also provided ratings of subjective fatigue each

hour.

Time-on-task and subjective fatigue were found to have no effect on some basic

aspects of flying performance, but they were associated with increased “lapses” in

performance, such as navigational errors, which were excluded from the performance

analysis. The study found that subjective fatigue increased with time-on-task, peaking

during the last hour of flight, but scheduled breaks delayed the onset of subjective fatigue.

The 6-hour flight period without breaks was the most fatiguing condition (more fatiguing

than the 8-hour flight period with scheduled breaks). During the last hour of the 6-hour

period, average subjective fatigue ratings were between “looking forward to a rest period”

and “just hanging on till [sic] end of period.” Some pilots who participated in the study

stated that they would not feel safe to fly an actual helicopter by the end of the 6-hour

period with no breaks.

1.18.4 Flight Time and Duty Period Limitations

Title 14 CFR 1.1 defines “flight time” as “pilot time that commences when an

aircraft moves under its own power for the purpose of flight and ends when the aircraft

comes to rest after landing.” This definition is the same for helicopters and airplanes. By

comparison, U.S. Army flight regulations provide a unique definition of flight time for

helicopters, stating that flight time begins when a helicopter lifts off the ground and ends

when it lands and either the engines are stopped or the flight crew changes.

Federal regulations do not impose maximum flight time or duty period limitations

on Part 91 air tour pilots, but they do impose flight time limits for Part 135 operations.

63 P.D. Navathe and B. Singh, “Prevalence of Spatial Disorientation in Indian Air Force Aircrew,”

Aviation, Space, and Environmental Medicine, Vol. 65 (1994): 1082-5.

64 A.M. Stave, “The Effects of Cockpit Environment on Long-Term Pilot Performance,” Human

Factors, Vol. 19 (1977).

65 Sleep was not intentionally restricted for this study; however, flight periods were conducted between

1700 and 0100, after the pilots had already performed 8 hours of office work.
Factual Information 27 Aircraft Accident Report

Under 14 CFR 135.267, pilots flying nonscheduled Part 135 flights are limited to 8 hours

of flight time per consecutive 24-hour period for single-pilot operations and 10 hours of

flight time per consecutive 24-hour period for two-pilot crews. More flight time is

permitted as long as the anticipated duty period will not exceed 14 hours and is preceded

and followed by rest periods of at least 10 hours. These flight time limits for nonscheduled

Part 135 flights are the same for helicopter and airplane pilots.

Army flight regulations66 allow local commanders flexibility in developing flight

time limitations for helicopter pilots, but they recommend that flight time be limited to

8 hours per 24-hour period, 15 hours per 48-hour period, and 37 hours per week. Army

regulations also recommend that maximum helicopter pilot flight times be reduced by

factors of 1.3 for day contour or low-level flight and 1.6 for day, NOE flight. These

recommendations were developed after questionnaire data from Army pilots gathered in

1980 indicated that low-altitude flight profiles following terrain contours and

lower-altitude, terrain-hugging flights were more fatiguing for pilots than higher-altitude

flights.67

1.18.5 Special Federal Aviation Regulation 71

After two helicopter air tour accidents occurred on the same day in Hawaii on

July 14, 1994, the FAA issued SFAR 71 in the form of an emergency final rule on

September 26, 1994, to establish certain procedural, operational, altitude, and equipment

requirements for air tour operations in Hawaii.68 The final rule became effective on

October 26, 1994. FAA headquarters personnel indicated that the 1,500-foot altitude

restriction in SFAR 71 was not based on specific accident or incident data but was

arbitrarily selected based on the rationale that operating at a higher altitude would provide

more time for decision-making action in the event of a loss of engine power or other

in-flight emergency.

In a letter to the FAA dated October 27, 1994, the Safety Board commented that it

was pleased to recognize the FAA’s initiative to improve the safety of air tour operations

in Hawaii but that it was also concerned that the SFAR 71 altitude restriction could result

in unintended degradation of the existing level of safety because of increased compression

of traffic at the 1,500-foot limit. The Board urged the FAA to review the SFAR 71 altitude

restriction “to [ensure] that there is no increase in the potential for in-flight collisions or

inadvertent encounters with cloud layers.” The Hawaii Helicopter Operators Association,

Air Line Pilots Association, air tour operators, and other groups also expressed concerns

66 Headquarters Department of the Army, Aviation Flight Regulations, U.S. Army Regulation 95-1

(Washington, DC: HQDA, 1997).

67 U.S. Army Aeromedical Research Laboratory, Evaluation of Army Aviator Human Factors (Fatigue)

in a High-Threat Environment, USAARL Report No. 80-8 (Fort Rucker, AL: USAARL, 1980).

68 In addition to the minimum altitude requirements, other rules specified in SFAR 71 include flotation

equipment for certain helicopter tour flights (external helicopter floats were required only for single-engine

helicopter flights conducted beyond the shore of any island); a helicopter performance plan; operations

suited to the helicopter’s operating limitations; and a passenger briefing on the use of flotation equipment,

water-ditching procedures, and emergency-egress procedures.
Factual Information 28 Aircraft Accident Report

that SFAR 71 could result in an increased likelihood of midair collisions and encounters

with cloud layers.

The FAA attempted to lessen these concerns by developing a means to allow air

tour operators to request FAA approval to deviate below the SFAR 71 minimum altitude

at specified locations. Such approvals are granted in a certificate of waiver or

authorization, which, according to the FAA, provide separation between the fixed-wing

aircraft and helicopters around the scenic areas where the air tour traffic is most dense. At

the time of the accident, almost every helicopter tour operator conducting business in

Hawaii held an authorization to deviate below the specified SFAR 71 minimum altitude

along transition routes and at site-specific locations.

A comparison of Hawaii air tour accident data69 for the 10-year period before

SFAR 71 was implemented with data for the 10-year period after SFAR 71’s

implementation revealed that 40 air tour accidents occurred between 1986 and 1995,

resulting in 41 fatalities and that 22 air tour accidents occurred between 1996 and 2005,

resulting in 43 fatalities. Because the FAA does not collect air tour passenger and flight

hour data, accident rates for these two periods are not known.70

In the 10-year period before SFAR 71 was implemented, only 5 percent of Hawaii

air tour accidents (2 of 40 accidents, resulting in 16 fatalities) involved encounters with

weather. In the 10-year period after SFAR 71, 36 percent of the accidents (8 of

22 accidents) involved adverse weather and accounted for most of the fatalities (31 of

43 fatalities).71

1.18.5.1 Certificate of Waiver or Authorization to Deviate from Special 

Federal Aviation Regulation 71

To obtain a certificate of waiver or authorization to deviate from the SFAR 71

minimum altitude, operators were required to demonstrate to the FAA that they would be

able to provide a level of safety equivalent to that provided by operating at the higher

altitude. Operators did this by adding other safety measures to their operations. An

October 30, 1997, FAA document supporting the extension of SFAR 71 stated that the

FAA grants deviations case by case after scrutinizing each air tour operation to determine

whether the deviation will achieve the desired safety goals.72 According to Honolulu

FSDO management, as part of obtaining the deviation approval, the operator’s pilots must

demonstrate knowledge of the site-specific locations during annual FAA checkrides, and

helicopter pilots must demonstrate the ability to autorotate73 the helicopter successfully to

an alternate emergency landing area at each site-specific location.74

69 These data were compiled from the National Transportation Safety Board accident database and its

special investigation report: National Transportation Safety Board, Safety of the Air Tour Industry in the

United States, Special Investigation Report NTSB/SIR-95/01 (Washington, DC: NTSB, 1995).

70 The Safety Board has issued several safety recommendations to the FAA requesting that the FAA

obtain improved data. For more information about some of the recommendations, see section 1.18.7.

71 When these data were compiled, some accidents remained under investigation, and the classification

“weather-related” was derived from collected factual information. For completed investigations, the

classification was derived from published probable causes and factors.
Factual Information 29 Aircraft Accident Report

The FAA has the ability to revise an operator’s certificate of waiver or

authorization to require any safety enhancements that it feels are necessary, or it can

revoke an authorization at any time. During interviews, Honolulu FSDO inspectors

showed differences in their understanding of what they could require of operators seeking

an approval to deviate from SFAR 71. Some inspectors indicated that they could require

anything they deemed necessary to ensure operational safety, while others believed they

were restricted as to how much they could demand on the basis of set precedent.

Interviews conducted with Kauai air tour pilots after the accident indicated that

pilots showed differences in their understanding of their respective companies’

FAA-approved ridgeline crossing requirements. As mentioned previously, present and

former Bali Hai pilots provided various answers for permissible crossing altitudes, and a

number of pilots not associated with Bali Hai believed that they were permitted to cross

any ridgeline at 200 feet agl, even if it were not on a transition segment. Some pilots also

did not realize that, when flying outside of a transition segment, they were required to

maintain the SFAR 71 minimum altitude of 1,500 feet agl.

1.18.5.2 Formal Air Tour Safety Meetings

The SFAR 71 deviation authorizations for all operators require that air tour pilots

must “participate in at least one formal air tour safety meeting each 12 calendar months to

review SFAR 71 and sightseeing/air tour issues and procedures.” Although the Honolulu

FSDO requires air tour pilots to attend the annual safety meetings, the FSDO does not run

the meetings or propose the agenda, and FSDO personnel do not always attend.75 Instead,

individual air tour industry participants host each meeting as they see fit. A FSDO

inspector who attended some meetings stated that some had disintegrated rapidly into a

complaint session about SFAR 71. The most recent safety meeting for the island of Kauai

before the accident took place in January 2004. Bali Hai’s senior pilot headed that

meeting, and he stated that it concentrated mostly on concerns surrounding the FAA’s

proposed revisions to 14 CFR Part 136.76

72 Air tour operators seeking approval for an SFAR 71 deviation were required to identify their selected

site-specific locations on the FSDO’s master map, document the suitable emergency landing areas for each

site, and provide the FAA with ingress and egress descriptions and minimum altitudes in their selected

site-specific locations. Operators seeking approval to deviate from the 1,500-foot transition segment altitude

were also required to provide the FAA information on their intended transition segments and the minimum

altitude along that transition segment. The FAA stated that each deviation is site-specific and allows

operation only over areas of raw terrain (devoid of any persons, vessels, vehicles, or structures).

73 Autorotation is a rotorcraft flight condition in which the lifting rotor is driven entirely by the action

of the air when the rotorcraft is in motion. In the event of a loss of engine power, a helicopter pilot would

have to perform an autorotation to land the helicopter. During training scenarios and checkrides,

autorotations are typically performed with a simulated loss of engine power.

74 Pilots of fixed-wing aircraft who are authorized to deviate from the SFAR 71 minimum altitudes and

conduct air tour operations at 1,000 feet agl are not required to demonstrate the aircraft’s ability to reach a

suitable landing site.

75 The Honolulu FSDO kept the attendance sheets for each meeting. For meetings not attended by

FSDO personnel, the host operator would forward the attendance sheets to the FSDO, and FSDO personnel

had no knowledge of what safety topics, if any, may have been covered.
Factual Information 30 Aircraft Accident Report

1.18.6 Automatic Dependent Surveillance-Broadcast Program

In 1998, the FAA developed an initiative for implementing the National Automatic

Dependent Surveillance-Broadcast (ADS-B) Program to support the next-generation air

transportation system. The program, which includes ground-based stations, satellites, and

aircraft avionics, among other technologies, is designed to provide pilots with radarlike

information in the cockpit and to enable air traffic controllers to monitor low-flying

aircraft in those areas with limited or no radar coverage. For Hawaii air tour pilots, who

are faced with challenging local weather conditions, high-density air tour traffic, and

island geography that makes large areas of low-altitude airspace invisible to FAA radar

systems, an ADS-B system could provide enhanced in-flight navigation, air traffic,

terrain, and weather information, and, through data-link, provide the same information to

ground-equipped personnel, such as operator dispatchers, air traffic controllers, or other

FAA personnel.

In 1999, the FAA began to test ADS-B program applications in some regions of

Alaska, including high-volume air tour areas, such as southeast Alaska. The FAA also

worked with the Cargo Airline Association and installed transceivers and tested ADS-B

program applications in the Ohio River Valley. These and other tests have been highly

successful. The FAA has stated that the National ADS-B Program ground infrastructure

will be in place nationwide by 2013. The FAA has stepped up the implementation

timeframe for the Gulf of Mexico and plans to have the infrastructure in place by 2010.77

Louisville, Kentucky; Philadelphia, Pennsylvania; and Juneau, Alaska, are also scheduled

for completion by 2010.

Hawaii is not singled out for early attention as part of this plan, however; its

ADS-B ground infrastructure is scheduled to be installed by 2013, with the rest of the

national airspace system. In a recent communication,78 the FAA indicated that the

surveillance services and broadcast program planned to award a contract in July 2007 for

the installation of ADS-B ground infrastructure covering all the areas in which there are

now surveillance services for national airspace users and air traffic controllers. The FAA

also indicated that, once the new infrastructure is in place, the program office and its

vendors will explore options for providing surveillance services to other areas.

76 At the time of the meeting, Part 136 pertained to National Parks Air Tour Management. However, in

an October 22, 2003, notice of proposed rulemaking, the FAA proposed a new subpart A in Part 136 that

would establish general safety regulations for all commercial air tours.

77 Safety Recommendation A-06-21, issued March 24, 2006, asked the FAA to “ensure that the

infrastructure for the National Automatic Dependent Surveillance-Broadcast Program in the Gulf of Mexico

is operational by fiscal year 2010.” On July 17, 2006, the Board classified A-06-21, “Open—Response

Received,” after the FAA surveillance and broadcast services program manager provided a June 15, 2006,

briefing on the ADS-B program to the Board Members and staff, which included a discussion of the

progress of the program for the Gulf of Mexico.

78 The Safety Board received an electronic communication from Vincent Capezzuto, FAA Air Traffic

Organization (ATO)-E surveillance and broadcast services program manager, on October 25, 2006.
Factual Information 31 Aircraft Accident Report

1.18.7 Previous Related Safety Recommendations

From October 1, 1988, to April 1, 1995, the Safety Board investigated 139 air tour

accidents and incidents and issued numerous safety recommendations to the FAA and the

Honolulu FSDO about air tours and FSDO staffing. During its investigation of the

October 28, 1989, accident in Hawaii involving a de Havilland DHC-6 operated by Aloha

IslandAir as a scheduled Part 135 passenger-carrying flight,79 the Board noted specific

deficiencies with Honolulu FSDO staffing and oversight of general aviation and Part 135

operators and concluded that “at least three accidents in the Hawaiian Islands might have

been prevented if [Honolulu] FSDO-13 had personnel and guidance to maintain adequate

surveillance of its assigned ... Part 135 operators.”80 As a result, among several

recommendations, the Safety Board issued Safety Recommendation A-90-136, which

asked the FAA to do the following:

Perform a special study of the adequacy of Flight Standards District Office

staffing considering the availability of work hours, the geographic area of

responsibility, and the size and complexity of the assigned operations.

On February 8, 1991, the FAA responded that it had procured a contractor to

develop the required analyses and revalidated staffing standard. On May 11, 1993, the

FAA reported that, among other improvements, it updated the safety inspector staffing

standards, that the standards were developed at the regional level and were applied using

the most current data providing regional staffing estimates, and that field office staffing

estimates were generated and were being analyzed against current on-board employment

for accuracy.

In a June 7, 1994, response, the Safety Board noted that the FAA also reviewed

aviation safety inspector (ASI) job tasks and elements, analyzed ASI job tasks by time and

frequency, and planned a means to identify needed workforce distribution adjustments by

option, specialty, and location. As a result, the Board classified Safety

Recommendation A-90-136 “Closed—Acceptable Action.”

After the April 22, 1992, accident on the island of Maui involving a Beech Model

E18S operated by Tomy International, Inc. (doing business as Scenic Air Tours),81 the

79 National Transportation Safety Board, Aloha IslandAir, Inc., Flight 1712, de Havilland Twin Otter,

DHC-6-300, N707PV, Halawa Point, Molokai, Hawaii, October 28, 1989, Aviation Accident Report

NTSB/AAR-90/05 (Washington, DC: NTSB, 1990).

80 In its report, the Safety Board also concluded, “Inadequate surveillance [was] a result of the POI’s

[principal operations inspector] heavy workload and insufficient qualitative guidance from FAA

headquarters. ... Turnover of personnel and the lack of experienced personnel resulted in only two POIs

having responsibility for all the general aviation and Part 135 surveillance activities for FSDO-13 from June

until August 1989.”

81 National Transportation Safety Board, Tomy International, Inc., d/b/a Scenic Air Tours, Flight 22,

Beech Model E18S, N342E, In-flight Collision with Terrain, Mount Haleakala, Maui, Hawaii, April 22,

1992, Aviation Accident Report NTSB/AAR-93/01 (Washington, DC: NTSB, 1993).
Factual Information 32 Aircraft Accident Report

Safety Board issued Safety Recommendation A-93-11, among others, to request that the

FAA do the following:

Ensure that the regulatory basis and surveillance resources are in place to oversee

the operations, equipment, airmen, and airspace associated with any selective

attention directed toward commercial air tour operations.

Safety Recommendation A-93-11 was classified, “Closed—Acceptable Action” on

February 22, 1994, after the FAA responded that it was considering rulemaking action and

that it had taken action to provide better oversight of air tour operators in Hawaii and over

the Grand Canyon.

The Safety Board’s 1995 air tour special investigation report82 contained 11 safety

recommendations; four of which are described below.

Safety Recommendation A-95-57 asked the Department of Transportation (DOT)

to do the following:

Establish and maintain a database of all air tour operators that would provide data

for use in determining the scope of air tour operations and accident rates that can

be used to assess the safety of the air tour industry.

On July 14, 1999, the Safety Board classified A-95-57 “Closed—Unacceptable Action”

due to the DOT’s failure to take action in a timely manner.

The other three recommendations, Safety Recommendations A-95-58, -61, and

-64, respectively, asked that the FAA do the following:

Develop and implement national standards by December 31, 1995, within 14 CFR

Part 135, or equivalent regulations, for all air tour operations with powered

airplanes and rotorcraft to bring them under one set of standards with operations

specifications and eliminate the exception currently contained in 14 CFR

Part 135.1.

Use the data for air tour operators as recommended in A-95-57 to the Department

of Transportation to provide adequate staffing at all FSDOs that have air tour

operations within their geographic boundary.

As soon as possible, conduct meetings with interested parties in Hawaii to resolve

the issues of optimum flight altitudes and stand-off distances for air tour flights.

These discussions should consider any positive or negative effects on safety of the

current provisions of SFAR 71.

The FAA responded to Safety Recommendation A-95-58 on September 15, 1995,

stating that it was considering a notice of proposed rulemaking (NPRM) to address the

issues in the recommendation. On June 18, 2001, the Safety Board concluded that the

82 National Transportation Safety Board, NTSB/SIR-95/01 (1995).
Factual Information 33 Aircraft Accident Report

delays were unacceptable, and it classified A-95-58 “Open—Unacceptable Response,”

pending issuance of the NPRM and the final rule. The NPRM, “National Air Tour Safety

Standards,”83 was issued on October 22, 2003; the final rule was issued February 13, 2007.

The Board notes that the final rule differs substantially from the NPRM and has not yet

issued a response to the FAA.84

In a July 25, 2001, response, the Safety Board classified A-95-61 “Closed—

Acceptable Alternate Action,” noting that, although the DOT failed to take the action on

which the recommendation was dependent, the FAA created an alternative system to

acquire data on air tour operators and use these data to provide adequate staffing at all

FSDOs that have air tour operations in their geographic boundary. The FAA gathers the

data through its mandatory drug-testing program for all air tour pilots.85

On October 29, 1996, the Safety Board classified A-95-64 “Closed—Acceptable

Action” after the FAA responded on July 8, 1996, that it met with helicopter operators in

Hawaii and decided to grant deviations from SFAR 71 to individual operators.

As a result of the Safety Board’s analysis of the FAA’s procedures for collecting

and reporting general aviation activity, on May 12, 2005, the Safety Board issued Safety

Recommendation A-05-13 to supersede Safety Recommendation A-03-3886 and to ask the

FAA to do the following:

Develop, validate, and document an unbiased method for generating and revising

activity estimates based on surveys or reporting of general aviation operations.

On August 2, 2005, the FAA responded that it agreed that credible data on flight

hours and flight characteristics are among the most basic requirements of safety analysis.

The FAA stated that it would focus on improving the General Aviation and Air Taxi

Activity (GAATA) survey distribution to include a larger portion of the general aviation

fleet. On January 4, 2006, the Safety Board classified A-05-13 “Open—Acceptable

Response” due to the FAA’s anticipated improvements to the GAATA survey process.

83 The NPRM was issued on October 22, 2003, in 68 Federal Register 60572. For more information,

see section 1.18.8.1.

84 The final rule was issued on February 13, 2007, in 72 Federal Register 6884. For more information,

see section 1.18.8.2.

85 Part 91, Part 135, and Part 121 operators must participate in the program. The information gathered

through the testing program enables the FAA to monitor the number of air tour operators throughout the

country, but it does not provide the FAA any flight-hour or passenger data for each operator for use in

determining the scope of air tour operations and accident rates.

86 Safety Recommendation A-03-38 had been issued August 20, 2003, as a result of the Safety Board’s

previous analysis of the FAA’s accident data and activity data.
Factual Information 34 Aircraft Accident Report

1.18.8 National Air Tour Safety Standards

1.18.8.1 Notice of Proposed Rulemaking

The FAA’s original NPRM for national air tour safety standards sought to increase

the safety of commercial air tours nationally by proposing requirements for the

certification of air tour operators and establishing new safety requirements. The NPRM

proposed to create a new Subpart A in Part 136 that would establish the general safety

regulations for all air tours. The proposed Subpart A of Part 136 included a uniform

definition for all commercial air tours and defined the terms “air tour operator,” “raw

terrain,” “suitable landing area,” and “shoreline.”

The NPRM also proposed that, in addition to the provisions of Part 136, air tour

operators would still have to comply with Part 91, Part 135, or Part 121, however, Part 91

air tour flights would be limited to charitable or community events. The

14 CFR 119.1(e)(2) and 135.1(a)(5) exception, which currently allows for air tour

operators like Bali Hai to conduct business under Part 91, would be amended to allow only

flights that are conducted as part of infrequent functions that enable the general aviation

community to contribute in a positive way to charitable and local causes.87 These events

would be limited to a 3-day timespan and limited to four or fewer events per calendar year.

According to the NPRM, the Part 91 air tour operators that were operating under the

14 CFR 119.1(e)(2) and 135.1(a)(5) exception, such as Bali Hai, would have to begin the

process of obtaining a Part 135 or Part 121 operating certificate.

The Safety Board responded to the NPRM on January 22, 2004, by supporting the

proposed rule and by indicating that its implementation would establish safety

requirements for commercial air tours that were long overdue. The Board also noted that

the NPRM attributed a decrease in air tour accidents in Hawaii to the issuance of

SFAR 71. However, the Board commented that it does not believe that there is a reliable

basis for this conclusion because of the current lack of an accurate, verifiable method of

collecting and tracking flight-hour activity data for specific segments of nonscheduled

Part 135 flight operations. The Board also commented that these data-collection

deficiencies hinder the Board’s and the FAA’s ability to calculate safety statistics.

In addition to the Safety Board’s response, however, the FAA received thousands

of complaints from within the air tour industry indicating that, if the proposals under the

NPRM are implemented, a number of businesses, such as single-aircraft, single-pilot,

Part 91 air tour operators (for example, operators who sell rides in open-cockpit, antique

biplanes), would go out of business if required to comply with Part 135 regulations. The

FAA responded by substantially revising several aspects of the NPRM before releasing

the final rule.

87 According to the NPRM, to qualify for an exception under 14 CFR 119.1(e)(2), a charitable or

community event must be conducted to raise funds for either of the following: a charity identified by the

U.S. Department of Treasury; a nonprofit entity, with one of the entities’ purposes being the promotion of

aviation safety; or a local community cause not covered by the first two exceptions. The sponsor of the

charitable or community flight(s) would also be required to provide the local FSDO with at least 7 days

advance notice.
Factual Information 35 Aircraft Accident Report

1.18.8.2 Final Rule

On February 8, 2007, the FAA issued the final rule for National Air Tour Safety

Standards. Among the final rule’s provisions, Subpart A of Part 136, as proposed under

the NPRM, provides definitions for the terms “commercial air tours,” “air tour operator,”

“raw terrain,” “suitable landing area,” and “shoreline.” The final rule also permanently

establishes the requirements outlined under SFAR 71 by including those requirements in

Part 136 of Appendix A.

In contrast to what the NPRM proposed, the final rule allows most Part 91 air tour

operators to still operate under the 14 CFR 119.1(e)(2) and 135.1(a)(5) exception;88

however, these operators must also comply with the safety requirements of Part 136,

Subpart A, and must also apply for, receive, and comply with a letter of authorization

(LOA) from the FAA in accordance with 14 CFR 91.147. The LOA requirements include

the operator’s name; principal business address; principal place of business; the name of

the person responsible for management; the name of the person responsible for aircraft

maintenance; the make, model, and series of each aircraft; and the registration number of

each aircraft. According to the FAA, the LOAs will enable the FAA to develop a database

of all air tour operators, and the LOAs will be maintained in the same database as the

operations specifications for certificated air tour operators. The final rule does not require

operations specifications for Part 91 air tour operators, and it does not require air tour

activity data reporting.

1.18.9 Requirements for Part 135 Air Tour Operators

In addition to the mandatory FAA oversight requirements for Part 135 air tour

operators, in general, operators that hold Part 135 operating certificates are required to do

the following: prepare operating, maintenance, and training manuals and have them

accepted or approved by the Administrator; acquire and install any equipment required for

their operations under Part 135, as appropriate; train and test their crewmembers to show

that those crewmembers are qualified to serve under Part 135, as appropriate; maintain

flight-locating or dispatch procedures; and develop record-keeping systems to show that

they can comply with Part 135 crewmember and maintenance requirements on an ongoing

basis. In addition, all Part 135 certificated air tour operators have specific authority in their

operations specifications to conduct commercial air tours. The operations specifications

also list any special authority or deviations granted to the operator.

Part 135 regulations, which were originally established for nonscheduled air taxi

operations, also include restrictions and training requirements that are pertinent for air-taxi

related operations, such as cargo handling, hazardous material carriage, hazardous

material training programs, and international operations, among others. Air tour operators

that hold Part 135 operating certificates must comply with these requirements, even

though their daily operations may never involve such activities.

88 According to the final rule, an operator may not conduct tour flights over the Grand Canyon National

Park under the exception.
36 Aircraft Accident Report

2. Analysis

2.1 General

The pilot was properly certificated and qualified under Federal regulations to

conduct the Part 91 nonstop sightseeing air tour flight. No evidence indicated any

preexisting medical condition that might have adversely affected his performance during

the flight.

Although the operator inaccurately tracked the helicopter’s hours and kept

inadequate maintenance records, examination of the wreckage revealed no evidence that

powerplant, system, or structural failures of the helicopter contributed to the accident. The

helicopter’s weight and balance were within limits for the duration of the flight.

The accident was not survivable for any of the occupants because they were

subjected to impact forces that exceeded the limits of human tolerance.

This analysis discusses numerous human performance issues that contributed to

this accident, including the role of spatial disorientation, the pilot’s inexperience with

local weather patterns, his decision-making, and the effect that the operator’s

pilot-scheduling practices and other cognitive factors had on the pilot’s ability to assess

risks and make decisions. This analysis also discusses the lack of FAA oversight of

Part 91 air tour operators, FAA oversight of commercial air tour operations, the inability

of the Honolulu FSDO to provide direct surveillance of air tour operations in Hawaii, and

the benefits of ADS-B in Hawaii.

2.2 Accident Sequence

The air tour flight was conducted under VFR and collided with mountainous

terrain during IMC. The pilot had encountered deteriorating visibility and cloud

conditions during his previous tour, and those conditions were also present several

minutes before the accident. Moderate turbulence was forecast, and passengers from

previous tours reported that the helicopter encountered some turbulence, rain, and high

winds. Weather radar data indicated that a line of weather echoes containing rain showers

was converging on the ridge near the accident location about the time of the accident.

This line of echoes was associated with a lowering of cloud bases below 2,400 feet

msl and obscuration of the higher terrain in the area where the accident occurred. ATC

radar data indicate that the helicopter passed over terrain elevations as high as 3,000 feet;

thus, the pilot likely encountered areas of restricted visibility as he attempted to cross the

ridge.
Analysis 37 Aircraft Accident Report

ATC radar data was of limited use in helping investigators understand the

helicopter’s movements because the helicopter’s mode C transponder was not functioning

properly and transmitted erroneous altitude data; damage precluded postaccident testing

of the unit. As a result, the available data provided only a two-dimensional ground track

for the flight. The data showed that, as the helicopter crossed the top of the ridge, it

entered a clockwise, spiral pattern for the remaining 47 seconds of flight. This spiral track

grew increasingly erratic before ending near the location of the aircraft wreckage, which

suggests that the pilot was unable to maintain a stable heading. Without accurate altitude

data, however, it is impossible to know what changes in altitude may have accompanied

these changes in ground track.

The accident site was on a 75o slope, and the wreckage debris was scattered up the

slope. Observed wreckage damage included fragmented skids and cross tubes, heavier

crush damage on the right side of the cabin than the left, downward deformation of the tail

boom, and evidence of a high engine-power setting. These damage characteristics and the

wreckage debris distribution suggest that, when the helicopter struck the sloping terrain, it

was in an extreme nose-high attitude with a high engine-power setting, neither of which

are consistent with what would be expected for controlled cruise or maneuvering flight.

Although it is possible that the pilot may have seen the terrain through the clouds

moments before impact and added control inputs in an attempt to avoid it, the erratic,

zigzagging ground track that preceded the impact suggests that the pilot lost control of the

helicopter before the collision.

2.3 Human Performance

2.3.1 Spatial Disorientation

Spatial disorientation has contributed to many accidents involving loss of control.

In these cases, loss of control follows the pilot’s inappropriate control resulting from

confusion about the aircraft’s attitude. Major situational risk factors for spatial

disorientation include sustained turns, high workload, false surface planes created by

sloping clouds or terrain, and transitions between VMC and IMC that require shifting

visual attention between external visual references and cockpit flight instruments. All of

these risk factors were present for the pilot during the last minute of the accident flight.

Attempts to continue visual flight into IMC may be even more problematic for

helicopter pilots than for pilots of fixed-wing aircraft because helicopters are inherently

less stable and require near continuous control inputs from the pilot. Helicopters, like the

accident helicopter, that are not equipped for IFR flight and do not have control

stabilization or autopilot systems can impose high perceptual and motor demands on the

pilot. These helicopters can make it very challenging for pilots to maintain stable flight by

referring to flight instruments alone. When the accident pilot attempted to continue visual

flight into IMC, he would have been subjected to a high workload in order to maintain

control of the helicopter. Moreover, the extent of the weather echoes and the duration of

the sustained turn captured by the radar track suggest that the encounter with IMC was
Analysis 38 Aircraft Accident Report

prolonged. This would have further complicated the pilot’s workload and increased the

potential for spatial disorientation resulting from hazardous illusions, thereby, increasing

the potential for inappropriate control input responses.

In the absence of evidence indicating a mechanical malfunction, severe

turbulence,89 or some other factor that would explain the accident pilot’s apparent loss of

control of the helicopter, spatial disorientation is the most likely explanation. The Safety

Board concludes that the helicopter’s descending spiral flightpath, which became

increasingly erratic in the final seconds of the flight, was consistent with pilot spatial

disorientation.

2.3.2 Pilot’s Decision-making

Although the pilot likely encountered areas of deteriorating weather and IMC near

the accident site, photographs recovered from a passenger’s camera showed areas of

clearer weather along the coastline, east of the helicopter’s position, as it exited Waialeale

Crater. The lower terrain between the helicopter and the coastline and the height of the

clouds would have permitted a safe deviation in that direction. Furthermore, Bali Hai

pilots were authorized to fly as low as 1,000 feet agl from the crater toward the coast; thus,

the pilot could have flown in the direction of better weather, while remaining in

compliance with SFAR 71 and the certificate of waiver or authorization requirements.

Rather than deviate to the east, however, the pilot chose to fly south, along his usual tour

route adjacent to Kahili Ridge, as the advancing line of clouds closed in on the high

terrain. The pilot’s decision to fly into an area of deteriorating weather and high terrain,

despite the availability of a safer route to the east, was an error that played an important

causal role in this accident, and the Safety Board considered many factors that may have

influenced that decision.

2.3.2.1 Inexperience with Local Weather Patterns

The accident pilot had been flying commercial air tours for Bali Hai on Kauai for

less than 2 months. Nearly all of his previous flight experience had been gained as a

military pilot with the Indian Air Force. Though the pilot was experienced in helicopter

operations and claimed previous mountain and coastal flying experience, he had few flight

hours as a commercial air tour pilot and had limited knowledge of Kauai’s weather

patterns. The pilot had no previous experience flying in Hawaii before he was hired by

Bali Hai, and he began conducting tour flights after accruing just 6.7 hours of flight

training from company personnel, none of which included specific training on Kauai

weather.

Many experienced local air tour pilots interviewed after the accident stated that

VFR helicopter operations on Kauai were unusually challenging because of the rugged

terrain, mountain winds, and rapidly changing visibility and cloud conditions. They stated

89 The forecast included only moderate turbulence, and the weather study found no evidence to indicate

a likelihood of severe turbulence.
Analysis 39 Aircraft Accident Report

that these conditions rendered traditional sources of pilot weather information, such as

automated reporting stations and FSS briefings, not very useful, and that this heightened

the importance of a pilot’s skill in visually assessing changes in weather conditions during

tour flights. The experienced pilots indicated that a pilot’s skill in assessing changing

weather conditions and anticipating the effect of any changes on flying conditions was

critical for effective decision-making. They stated that such skills improved as local flying

experience increased. This raises concern about the impact of local inexperience on the

safety of pilot decision-making. A review of the eight weather-related air tour accidents

that have occurred in Hawaii since SFAR 71’s implementation revealed that four of the

accidents involved pilots who had relatively low experience flying air tours in Hawaii. In

fact, three of the accidents involved pilots who had flown there for less than 2 months.

It is highly unlikely that the accident pilot would have decided to continue into the

area of deteriorating weather conditions and attempted to cross in the vicinity of the

accident site if he had accurately assessed the changing weather and had appreciated how

it would likely affect flight visibility in those areas. Therefore, the pilot’s decision to fly in

the vicinity of the accident site indicates that he was unable to accurately assess how

rapidly or to what extent the weather was deteriorating in that area. As described earlier in

this report, the pilot had previously told a passenger that he had flown through thin clouds

during a ridge crossing because he could see through the clouds. The pilot may have

expected that this would be the case during the accident flight; however, visibility was

dramatically reduced along the top of the ridge as the incoming line of weather reached

the high terrain.

The Safety Board concludes that the pilot’s inexperience with Hawaii weather

conditions affected his ability to make appropriate in-flight decisions when faced with

deteriorating weather. The Board also concludes that other pilots who are inexperienced

with Hawaii weather conditions may also be hindered in their ability to make appropriate

in-flight decisions when faced with deteriorating weather. FAA-sponsored, human-factors

research conducted by aviation psychologists suggests that cue-based training programs

can improve pilots’ weather-related decision-making during VFR flights.90 The Safety

Board concludes that cue-based training, tailored to the dynamic local island climate

conditions of Hawaii, could provide an important safety benefit to pilots who are new to

flying in the state. There are currently no FAA guidance materials providing specialized

training on the recognition of local weather cues that are critical for in-flight

decision-making in the Hawaiian Islands. Therefore, the Board believes that the FAA, in

cooperation with Hawaii commercial air tour operators, aviation psychologists, and

meteorologists, among others, should develop a cue-based training program for

commercial air tour pilots in Hawaii that specifically addresses hazardous aspects of local

weather phenomena and in-flight decision-making. The Board also believes that, once a

cue-based training program that specifically addresses hazardous aspects of local weather

phenomena and weather-related, decision-making issues is developed, as requested in

90 M. Wiggins and D. O’Hare, “Weatherwise: Evaluation of a Cue-Based Training Approach for the

Recognition of Deteriorating Weather Conditions During Flight,” Human Factors. Human Factors and

Ergonomics Society, Vol., No. 2 (2003): 337-345.
Analysis 40 Aircraft Accident Report

Safety Recommendation A-07-18, the FAA should require all commercial air tour

operators in Hawaii to provide this training to newly hired pilots.

2.3.2.2 Overconfidence and Decision Bias

FAA-sponsored research indicates that pilots who demonstrate a willingness to fly

under VFR into IMC in a simulated context tend to be more confident in their own

abilities and less concerned about the associated risks.91 The pilot had expressed concerns

to his family about flying in the challenging weather conditions on Kauai. However,

passengers on tour flights he conducted before the accident flight reported that the pilot

was willing to fly into areas of clouds and reduced visibility. Digital photographs taken

during the accident flight showed that the pilot flew through at least two such areas before

reaching the Kahili Ridge. These decisions had not previously resulted in an accident.

This may have increased the pilot’s confidence in his own abilities and decreased his

estimation of the risk associated with such decisions.

The pilot’s decision to continue flying into deteriorating weather may also have

been influenced by a cognitive bias. Deviating east toward the coastline would have

required the pilot to disappoint his passengers by eliminating the last major scenic area on

his tour and would have resulted in a late return to the airport. These outcomes represented

certain inconveniences for the pilot. However, the pilot had the option of avoiding these

inconveniences by continuing along his usual flightpath adjacent to the Kahili Ridge and

attempting to cross the ridge at the high pass. Although the pilot may have recognized the

increased safety risk associated with this option, the decision to accept a riskier choice to

avoid a certain set of inconveniences would be consistent with a human decision bias that

is often observed when people weigh potential decision outcomes in terms of the potential

losses associated with each choice.92 Although it is possible that the pilot’s decision was

influenced by overconfidence or decision-making bias, the extent to which either of these

factors might have influenced his decision to continue flying into the area of deteriorating

weather could not be determined.

2.3.2.3 Bali Hai’s Pilot-Scheduling Practices

Bali Hai’s pilots remained at the helicopters’ flight controls nearly continuously

for up to 8 hours per day because of the company practice of keeping the helicopters

running between tour flights. The pilots did not have scheduled breaks, and they ate lunch

while sitting in the helicopter between tours, if at all. There was no shelter at Bali Hai’s

staging area, nor were there any restroom facilities. The lack of scheduled breaks, the

short turnaround times between flights, and the unavailability of private restroom facilities

probably discouraged consumption of food and liquids during the workday because there

91 Human Factors and Ergonomics Society, “An Investigation of the Factors that Contribute to Pilots’

Decisions to Continue Visual Flight Rules into Adverse Weather,” (Santa Monica, CA: 2001).

92 D. O’Hare and T. Smitheram, “Pressing On Into Deteriorating Conditions: An Application of

Behavioral Decision Theory to Pilot Decision-Making,” International Journal of Aviation Psychology,

Vol. 5 (1995): 351-370.
Analysis 41 Aircraft Accident Report

was little opportunity to go to the bathroom. This increased the risk of dehydration and

other physiological problems, which could have degraded performance.

These working conditions were also conducive to fatigue. Research on pilot

fatigue in a noisy, vibrating helicopter simulator found considerable increases in

subjective fatigue after 6 hours of short repetitive flights. At the end of this period, some

helicopter pilots who participated in the study said they were so fatigued that they did not

feel safe to fly a real helicopter. As subjective fatigue increased, study pilots demonstrated

increasingly frequent “lapses” in performance. The study also found that routine, hourly

rest breaks outside the cockpit reduced the buildup of pilot fatigue to manageable levels,

even when flight periods were extended to 8 hours.93

The day of the accident was the pilot’s second-longest day of flying since he began

working for Bali Hai. By the time of the accident, he had been at the controls of the

helicopter with the rotors turning for about 7.7 hours and had been observed to leave the

cockpit briefly only once, about 1500. Passengers waiting to board the pilot’s 1500 flight

later described him as appearing fatigued at that time. This evidence suggests that the pilot

was likely to have been fatigued during the accident flight.

Bali Hai operated under Part 91 and was, therefore, not subject to flight time, duty

period, or rest requirements. However, the pilot’s cumulative flight time of approximately

6.5 hours did not exceed single-pilot limitations specified under Part 135. Part 135 allows

a maximum of 8 hours of flight time per consecutive 24-hour period, with additional flight

time permitted when the anticipated duty period will not exceed 14 hours and is preceded

and followed by rest periods of at least 10 hours. By comparison, U.S. Army flight

regulations94 also recommend that helicopter pilot flight time be limited to 8 hours per

24-hour period. However, the Army has recognized the stresses associated with helicopter

flying, and its regulations recommend that maximum flight times be reduced to 6.15 hours

for day contour flight or low-level flight at or below 200 feet agl. Army regulations also

contain a broader definition of flight time. Army regulations consider a pilot’s flight time

to begin when a helicopter lifts off the ground and ends when it lands and either its

engines are stopped or the flight crew changes. The accident pilot’s air tours included a

combination of low-level ridge crossings and higher-altitude flying. Although not subject

to Army regulations, depending on how this flying was classified, the accident pilot’s

cumulative time at the controls might have exceeded Army safety limitations.

It is difficult to evaluate the relative extent to which dehydration, unmet

physiological needs, or fatigue might have contributed to the accident pilot’s decision to

continue flying into an area of deteriorating weather rather than deviate around the

weather and risk a delayed return. However, it is likely that one or more of these factors

was affecting the pilot at the time of the accident, any one of which would have negatively

affected the pilot’s concentration and decision-making. The Safety Board concludes that

Bali Hai’s pilot-scheduling practices, although permitted under Federal aviation

93 Stave (1977): 503-514.

94 U.S. Army Regulation 95-1 (1997).
Analysis 42 Aircraft Accident Report

regulations, likely had an adverse impact on pilot decision-making and performance. The

Board also concludes that existing Federal aviation regulations do not adequately address

the pilot fatigue issues associated with the continuous, repetitive, high-frequency flight

operations that are unique to commercial air tour helicopter operations. Therefore, the

Safety Board believes that the FAA should establish operational practices for commercial

air tour helicopter pilots that include rest breaks and that will ensure acceptable pilot

performance and safety, and require commercial air tour helicopter operators to adhere to

these practices.

2.3.2.4 Management Pressure

Several pilots who had previously been employed by Bali Hai stated that the

company owner and office manager had inappropriately pressured them to conduct tour

flights in poor weather conditions on multiple occasions, and some reported being told it

was unacceptable to allow tours to exceed scheduled times. In addition, the accident

pilot’s wife stated that the pilot had expressed concern about the commercial pressure to

continue flying when weather conditions were “just OK.”

Despite these statements, the influence of management pressure on the accident

pilot’s decision-making during the accident flight is uncertain. The pilot’s wife stated that

he had not told her of being directly pressured by company managers to fly in poor

weather, and both the company’s senior pilot and a pilot who left the company in

August 2004 stated that they had not been pressured. Also, Bali Hai’s owner and office

manager were out of town the week of the accident and were not on Kauai when the

accident occurred; thus, their physical absence likely diminished their ability to monitor

and directly influence the pilot’s activities on the day of the accident. The Safety Board

concludes that, although there is evidence that Bali Hai managers had inappropriately

pressured some pilots to fly in poor weather conditions and to avoid late returns, the extent

to which management pressure might have influenced the pilot’s decision-making during

the accident flight could not be determined.

2.4 Federal Aviation Administration Surveillance

2.4.1 Oversight of Part 91 Air Tour Operations

Bali Hai was able to conduct its 45- and 55-minute commercial air tour flights

under Part 91 because of the exception listed under 14 CFR 119.1(e)(2) and 135.1(a)(5)

for nonstop flights within a 25-mile radius of the departure and arrival airport. The island

of Kauai offers a unique opportunity in that its small size and large number of seasonal

tourists enable an air tour operator to conduct tours of the entire island without exceeding

the distance limit. Although the exception does not stipulate any operator flight-hour or

passenger limitations, the intent behind the exception was likely to enable provisions for

small operations, such as single-aircraft, single-pilot operators. It likely did not consider

that an operator like Bali Hai could keep two helicopters running continuously daily to
Analysis 43 Aircraft Accident Report

transport an estimated annual passenger load of about 4,500 to 8,50095 people under the

relatively lenient regulations of Part 91.

For example, in the NPRM titled “National Air Tour Safety Standards,” issued on

October 22, 2003, the FAA acknowledged that “commercial air tours conducted in

accordance with Part 121 or Part 135 are subject to a higher level of safety than those

conducted in accordance with Part 91 because of the number of passengers they carry, the

type of aircraft used ... and the frequency of operations.” This assertion implies that the

FAA expects that an air tour operator that carries a large number of passengers should be

subject to a higher level of safety, yet Bali Hai was subject to no pilot training

requirements, no pilot duty time limitations, relatively fewer aircraft maintenance

requirements, and minimal FAA oversight and surveillance requirements.

2.4.2 Honolulu Flight Standards District Office Surveillance of 

Bali Hai

Bali Hai conducted its sightseeing air tours since 1986 and, before this accident,

did not receive any FAA national, regional, or office inspections or focused, multiperson,

team inspections because such inspections are not required for Part 91 operators.

According to FAA Order 1800.56D, the National Flight Standards Work Program

Guidelines for FAA inspectors, “surveillance is one of the most important functions

performed by AFS [Flight Standards Service] field office personnel to ensure safety and

regulatory compliance in the aviation system.” The FSDO manager stated that oversight

of a Part 91 operator would only be performed as needed, such as during an SFAR 71

checkride or in response to a customer complaint. With the exception of SFAR 71 pilot

checkrides, the FAA performed no meaningful oversight of Bali Hai since 2002.

During the Safety Board’s investigation of this accident, the FAA inspected Bali

Hai and noted numerous maintenance-records discrepancies for the accident helicopter,

such as the failure to record all operating hours on the helicopter and its components; the

failure to maintain consistent records of component times; and the failure to record daily

discrepancies, repairs, and replacements. These record-keeping discrepancies represent

careless maintenance practices in which Bali Hai systematically underreported the hours

on the helicopter and its components.

Although maintenance issues were not a factor in this accident, proper

record-keeping and proper tracking of the time that components are in use are crucial

elements in any aircraft maintenance program, and, when not performed properly, they

pose a serious threat to the safety of operations. If the FAA had required and had

performed any systematic oversight of Bali Hai’s maintenance programs and operations, it

likely would have detected the maintenance discrepancies and would have required that

the operator correct these issues before any flights, revenue or otherwise, could resume.

95 The owner estimated that the company flew 4,500 passengers annually. However, in the 60 days

before the accident, the company flew 1,479 passengers, and that time period was not part of the company’s

busiest season.
Analysis 44 Aircraft Accident Report

2.4.3 Honolulu Flight Standards District Office Staffing Issues

FSDO staffing issues and their effect on safety have been subjects of Safety Board

concern for years. In 1990, staffing deficiencies at the Honolulu FSDO, in particular, led

the Board to conclude that “at least three accidents in the Hawaiian Islands might have

been prevented if [Honolulu] FSDO-13 had personnel and guidance to maintain adequate

surveillance of its assigned ... Part 135 operators.” The Board subsequently issued Safety

Recommendation A-90-136, which asked the FAA to “perform a special study of the

adequacy of Flight Standards District Office staffing considering the availability of work

hours, the geographic area of responsibility, and the size and complexity of the assigned

operations.” Five years later, Safety Recommendation A-95-61 was issued, asking the

FAA to use data collected for air tour operations to provide adequate staffing at all FSDOs

that have air tour operations in their geographic boundary.

The FAA’s actions in response to Safety Recommendations A-90-136 and

A-95-61, which included plans for a means to identify needed adjustments to workforce

distribution by option, specialty, and location, have resulted in these recommendations

being classified as “Closed—Acceptable Action” and “Closed—Acceptable Alternate

Action,” respectively. However, the continued staffing deficiencies at the Honolulu FSDO

clearly show that the FAA has not effectively implemented its plans. At the time of the

accident, the FSDO manager estimated he was about 10 inspectors short but stated he was

not authorized to hire any new inspectors. At the time of the Bali Hai accident, FSDO

inspectors reported they were time-constrained in performing even the minimum required

oversight for their Part 135 operator—a problem the Safety Board noted in its

recommendation some 15 years earlier.

Without FAA enforcement, repeated noncompliance with SFAR 71 and the

certificates of waiver or authorization has persisted, some of which is likely unintentional.

Interviews revealed that some Kauai air tour pilots differed in their understanding of their

respective companies’ existing approvals and incorrectly identified their authorized

ridge-crossing altitudes. Thus, these pilots likely crossed ridgelines in some locations

during tour flights at altitudes lower than permitted under SFAR 71 or their respective

authorizations, and, without FAA surveillance and intervention, they likely believed that

such practices were permissible and safe.

Because the FAA is not enforcing SFAR 71 and the deviation authorizations for all

air tour operators, some pilots may be intentionally disregarding the rules with no

consequences, thus, fostering hazardous in-flight decision-making practices and placing

passenger safety at risk. For example, photographic evidence from the accident flight and

passengers’ descriptions of flight conditions during previous tours indicate that the

accident pilot had repeatedly flown the helicopter into clouds and areas of highly degraded

in-flight visibility. Moreover, a Safety Board investigation of another air tour accident on

Kauai found that, in addition to that accident’s pilot, two other air tour pilots chose to

enter areas of highly degraded in-flight visibility. Thus, the Safety Board concludes that,

because the Honolulu FSDO is not providing direct surveillance and enforcement of

SFAR 71, pilots continue to violate SFAR 71 and the certificate of waiver or authorization
Analysis 45 Aircraft Accident Report

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

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

Between October 1995 and May 2004, the Honolulu FSDO’s GSU had been

tasked to enforce SFAR 71 by monitoring all air tour operators, including those operating

under Part 91. The GSU performed periodic, direct surveillance of the flight operations of

air tour operators, and this resulted in the identification of a number of in-flight violations

of SFAR 71 operating requirements. Before it was disbanded, the GSU also performed

some surveillance of Bali Hai that resulted in the correction of some discrepancies, but the

GSU had not performed in-depth inspections of the company. Although FSDO personnel

considered the GSU to be highly effective, the FSDO had to disband the GSU to reallocate

the unit’s personnel to fill operations and airworthiness inspector positions. The Safety

Board concludes that the FAA has not provided sufficient resources for the Honolulu

FSDO to implement air tour surveillance. Such surveillance, in the months before the

accident, may have detected and corrected the accident pilot’s risky flying practices, such

as low-altitude, off-route ridge crossings, and flight into clouds and reduced visibility.

Therefore, the Board believes that the FAA should 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.

2.4.4 Air Tour Safety Meeting Requirements

In addition to the required FAA-administered initial and annual knowledge tests

and checkrides, operators approved to deviate from SFAR 71 were required to ensure that

their tour pilots participate in at least one formal air tour safety meeting annually. The

FAA stated that the purpose of the safety meetings was to review SFAR 71 and

sightseeing/air tour issues and procedures, and Bali Hai’s owner stated that he believed

that the meetings provided his pilots an opportunity to refresh their knowledge of

SFAR 71 and the SFAR 71 deviation requirements.

Safety Board interviews with meeting attendees, however, revealed disparity

between the intent of these meetings and the actual discussion topics and followup

discussions that occurred. Although the Honolulu FSDO requires meeting attendance, it

does not run the meetings or dictate the agenda. A FSDO inspector stated that some past

meetings disintegrated rapidly into a complaint session or strayed into other topics.

As mentioned previously, many Kauai air tour pilots demonstrated a lack of

understanding of their respective companies’ minimum altitudes for ridge crossings.

Improved refresher training may increase their knowledge of these issues. In addition, the

annual safety meeting could be used to discuss pertinent safety issues, such as lessons

learned, hazardous and/or consistent weather phenomena, and hazards related to

site-specific areas, among other topics. Therefore, the Safety Board concludes that the

annual SFAR 71 safety meetings have not been effective because the Honolulu FSDO has

not ensured that the meetings are focused on safety trends and SFAR 71 procedures.

Therefore, the Board believes that the FAA should direct the Honolulu FSDO to ensure

that the annual safety meetings, as required under approved certificates of waiver or
Analysis 46 Aircraft Accident Report

authorization, focus on pertinent and timely commercial air tour safety issues, including,

but not limited to, reviews of Hawaii air tour accidents, local weather phenomena, and

SFAR 71 procedures.

2.5 Safety Impact of Special Federal Aviation 

Regulation 71

In its air tour safety NPRM, the FAA attributed a decrease in the number of air tour

accidents in Hawaii to the issuance of SFAR 71. The FAA also stated that the benefits

associated with minimum altitude, visibility, and cloud clearance requirements “can be

attributed to: (1) Increased time available for the pilot to react in an emergency,

(2) prevention of situations in which the pilot unexpectedly encounters IMC, and

(3) avoidance of adverse weather conditions.”

Because of the current lack of an accurate, verifiable method of collecting and

tracking flight-activity data for specific segments of nonscheduled Part 135 and Part 91

flight operations, the Safety Board concluded in a January 22, 2004, letter to the FAA

about the NPRM, that, without the required safety and accident rate data, there is not a

reliable basis for the FAA’s assertion that SFAR 71 has resulted in a decrease in air tour

accidents.

Safety Board review of Hawaii air tour accident data for the 10-year periods before

and after SFAR 71’s implementation showed that, although the total number of air tour

accidents decreased after SFAR 71’s implementation, the proportion of weather-related

accidents increased and was responsible for 31 of the 43 total fatalities. While the rising

trend in weather-related accidents appears to support the Board’s concerns that SFAR 71

altitude restrictions may increase the potential for inadvertent encounters with cloud

layers, the Board acknowledges that there is not enough data to determine its significance.

Therefore, the Safety Board concludes that the safety impact of SFAR 71, in terms of a

potential decrease in the Hawaii air tour accident rate or a potential increase in the rate of

weather-related accidents, cannot be established with the current data. Therefore, the

Board believes that the FAA should reevaluate the altitude restrictions in the State of

Hawaii to determine if they may have resulted in any unintended degradation of safety

with regard to weather-related accidents and fatalities.

2.6 Need for National Air Tour Safety Standards

In its 1995 special investigation report, the Safety Board expressed concern that

the provisions of Part 91 were inadequate to ensure sufficient FAA oversight of air tour

companies to identify and correct important safety deficiencies that could expose the

traveling public to unacceptable safety risks. To address this concern, the Board issued

Safety Recommendation A-95-58, which asked the FAA to “develop and implement

national standards by December 31, 1995, within 14 CFR Part 135, or equivalent

regulations, for all air tour operators ... to bring them under one set of standards with
Analysis 47 Aircraft Accident Report

operations specifications and eliminate the exception currently contained in 14 CFR

Part 135.1.” This accident, involving a Part 91 air tour operator that carried a large number

of passengers annually yet had numerous safety deficiencies and lacked FAA oversight,

serves to illustrate the very scenario the Board’s recommendation sought to prevent.

The FAA shared the Board’s concern. In its 2003 NPRM, “National Air Tour

Safety Standards,” the FAA recognized that Part 91 air tour operators do not have the

equivalent safety measures that are implemented by Part 135 operators and that action was

needed. The FAA also indicated that it agreed that the same safety standard should be

applied to all commercial air tours, wherever they are conducted. In the NPRM, the FAA

proposed to require that all commercial air tour operators be certificated under Part 135 or

Part 121 and that Part 91 air tour operations be limited to infrequent, charitable events.

In response to the NPRM, however, the FAA received an overwhelming number

of complaints from air tour operators that conduct business under Part 91, indicating that a

number of businesses (such as single-aircraft, single-pilot operations) would go out of

business if required to comply with Part 135 regulations. As a result, the FAA made

substantial revisions to the proposed rule. The final rule, which was released February 8,

2007, still allows for Part 91 air tour operations under the 14 CFR 119.1(e)(2) and

135.1(a)(5) exception. The final rule also requires these operators to obtain an LOA from

the FAA and abide by the new commercial air tour safety regulations defined in Subpart A

of Part 136.

Although the NPRM had proposed to place all commercial air tour operations

under Part 135, the Safety Board acknowledges that Part 135 is an air taxi rule with which

smaller air tour operators would have difficulties complying. Part 135 regulations were

originally established for nonscheduled air taxi operations, which focused on the transport

of passengers or cargo from one location to another. These regulations specify restrictions

and training requirements for additional issues that would not usually be associated with

air tour operations, such as cargo handling, hazardous material carriage, hazardous

material training programs, and international operations.

In the final rule, the FAA effectively withdraws its proposal to place all air tours

under Part 135, and the Safety Board agrees that, though a number of the regulations

under Part 135 enhance safety when compared to the requirements for Part 91 operations,

the additional and unrelated rules would burden the smaller air tour operators with

additional training and operational requirements that do not necessarily relate to their

daily operations. Additionally, there may be some requirements under Part 135 that may

not be stringent enough for the air tour industry, such as flight time and duty period

limitations. However, the Board concludes that the public would benefit from air tour

regulations that provide increased oversight and additional safety requirements for Part 91

air tour operators that carry large numbers of passengers annually, such as Bali Hai.

The Safety Board acknowledges that, although the final rule establishes some

national air tour safety standards in the form of Part 136, Subpart A, the regulation still

does not contain provisions that would prevent the types of deficiencies highlighted by

this accident. Specifically, for Part 91 air tour operations, the new LOA and Part 136
Analysis 48 Aircraft Accident Report

requirements do not provide for mandatory FAA oversight. And, for all air tour

operations, the final rule does not incorporate any initial and recurrent pilot training

programs that address local geography and meteorological hazards and special airspace

restrictions; maintenance policies and procedures; flight scheduling that fosters adequate

breaks and flight periods; and operations specifications that address management,

procedures, route specifications, and altitude restrictions, as necessary.

The Safety Board concludes that a regulation specific to commercial air tour

operations would be more appropriate than an air taxi regulation, and it would allow the

FAA inspectors responsible for air tour operators to focus on the daily safety requirements

unique to those operations. Therefore, the Board believes that the FAA should develop

and enforce safety standards for all commercial air tour operations that include, at a

minimum, initial and recurrent pilot training programs that address local geography and

meteorological hazards and special airspace restrictions; maintenance policies and

procedures; flight scheduling that fosters adequate breaks and flight periods, as

established by the implementation of Safety Recommendation A-07-20; and operations

specifications that address management, procedures, route specifications, and altitude

restrictions, as necessary.

2.7 Implementing Automatic Dependent 

Surveillance-Broadcast in Hawaii

The Safety Board commends the FAA for recognizing the safety benefits of

ADS-B for oil industry operators in the Gulf of Mexico and for taking action in response

to Safety Recommendation A-06-21 to advance the timeline for installing ADS-B system

infrastructure there by 2010. According to a 2006 proposed schedule for deploying of

ADS-B services nationwide, the FAA plans to install ADS-B infrastructure in the state of

Hawaii by 2013.

Hawaii’s mountainous landscape, limited ATC radar coverage, challenging

weather, and high-density air tour traffic make it a prime candidate for the National

ADS-B Program.96 ADS-B will support avionics features that enable pilots to see the

location, extent, and movement of weather systems; thus, improving pilot awareness and

helping pilots make safer decisions in flight. For example, if the accident helicopter had

been equipped with avionics capable of displaying ground-based, weather-radar

information transmitted via ADS-B infrastructure, the pilot would have been able to see

the full extent of the weather converging on the Kahili Ridge, and his decision to continue

into the weather may have been different.

In addition to providing in-flight weather information to pilots, ADS-B also has

the potential to reduce the risk of midair collisions, a concern commonly cited by air tour

helicopter operators and their pilots. As Hawaii’s air tour industry continues to grow,

96 Initial ADS-B program testing was originally slated to take place in Alaska and Hawaii, but, due to

the lack of funding in the Hawaii area, the initial testing was instead conducted in Alaska and Ohio.
Analysis 49 Aircraft Accident Report

increasing numbers of aircraft will be flying over rugged, scenic terrain in a finite

airspace, and some of these flights will occur in conditions of reduced visibility. ADS-B

will support cockpit displays of traffic information that could improve pilot awareness of

the position and movement of other aircraft in high-density tour areas.

ADS-B services will also allow operators to remotely monitor the progress of their

own tour flights. Operators could use this information to identify pilot excursions from

company tour routes or below prescribed altitudes. The detection of such events would

provide an opportunity for operators to discuss such events with the pilots involved and

would allow operators to evaluate the need for any changes to their pilot training, standard

operating procedures, or SFAR 71 deviation authorizations. The Safety Board concludes

that the National ADS-B Program technology could help Hawaii air tour operators reduce

operational risks.

In October 2006, the FAA surveillance and broadcast services program manager

indicated that the FAA planned to award a contract in July 2007 for the installation of

ADS-B ground infrastructure covering all the areas in which there are now surveillance

services for national airspace users and air traffic controllers. The FAA also indicated that,

once the new infrastructure is in place, the program office and its vendors will explore

options for providing surveillance services to other areas. The Safety Board notes,

however, that major portions of the tour routes normally flown by Bali Hai and other air

tour helicopter operators throughout Hawaii do not currently receive air traffic

surveillance services. Thus, the Board concludes that, under the FAA’s current plan for

installing the National ADS-B Program infrastructure in Hawaii, only limited services

would be provided to the Hawaii air tour operators that could achieve significant safety

benefits from the technology. Therefore, the Safety Board believes that the FAA should

accelerate the implementation of ADS-B infrastructure in the State of Hawaii to include

high-quality ADS-B services to low-flying aircraft along heavily traveled commercial air

tour routes.

In order to receive enhanced services that will be supported under the National

ADS-B Program, Hawaii tour operators will first have to equip their aircraft with

compatible avionics to benefit from planned ADS-B infrastructure. The FAA’s proposed

schedule indicates that aircraft operators will have until 2020 to ensure that aircraft

utilizing air traffic services are so equipped. The ADS-B program office has stated that it

has not yet been established whether low-flying aircraft throughout the State of Hawaii

will be required to have ADS-B-compatible avionics installed by 2020.97 The Safety

Board concludes that commercial air tour operators operating under VFR may not be

required to install ADS-B compatible avionics, even after ADS-B infrastructure is

installed, which could lessen the safety-related benefit of these new services on Hawaii air

tour flight operations. Therefore, the Board believes that the FAA should require that

Hawaii air tour operators equip tour aircraft with compatible ADS-B technology within

1 year of the installation of a functional National ADS-B Program infrastructure in

Hawaii.

97 The FAA stated that it intends to release an NPRM in September 2007 that will define the avionics

that will be required to operate in different classes of airspace.
50 Aircraft Accident Report

3. Conclusions

3.1 Findings

1. The pilot was properly certificated and qualified under Federal regulations to conduct

the 14 Code of Federal Regulations Part 91 nonstop sightseeing air tour flight. No

evidence indicated any preexisting medical condition that might have adversely

affected his performance during the flight.

2. There was no evidence that powerplant, system, or structural failures of the helicopter

contributed to the accident. The helicopter’s weight and balance were within limits

for the duration of the flight.

3. The accident was not survivable for any of the occupants because they were subjected

to impact forces that exceeded the limits of human tolerance.

4. The helicopter’s descending spiral flightpath, which became increasingly erratic in

the final seconds of the flight, was consistent with pilot spatial disorientation.

5. The pilot’s inexperience with Hawaii weather conditions affected his ability to make

appropriate in-flight decisions when faced with deteriorating weather.

6. Other pilots who are inexperienced with Hawaii weather conditions may also be

hindered in their ability to make appropriate in-flight decisions when faced with

deteriorating weather.

7. Cue-based training, tailored to the dynamic local island climate conditions of Hawaii,

could provide an important safety benefit to pilots who are new to flying in the state.

8. Bali Hai’s pilot-scheduling practices, although permitted under Federal aviation

regulations, likely had an adverse impact on pilot decision-making and performance.

9. Existing Federal aviation regulations do not adequately address the pilot fatigue

issues associated with the continuous, repetitive, high-frequency flight operations that

are unique to commercial air tour helicopter operations.

10. Although there is evidence that Bali Hai managers had inappropriately pressured

some pilots to fly in poor weather conditions and to avoid late returns, the extent to

which management pressure might have influenced the pilot’s decision-making

during the accident flight could not be determined.
Conclusions 51 Aircraft Accident Report

11. Because the Honolulu Flight Standards District Office is not providing direct

surveillance and enforcement of Special Federal Aviation Regulation (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.

12. The Federal Aviation Administration has not provided sufficient resources for the

Honolulu Flight Standards District Office to implement air tour surveillance. Such

surveillance, in the months before the accident, may have detected and corrected the

accident pilot’s risky flying practices, such as low-altitude, off-route ridge crossings,

and flight into clouds and reduced visibility.

13. The annual Special Federal Aviation Regulation (SFAR) 71 safety meetings have not

been effective because the Honolulu Flight Standards District Office has not ensured

that the meetings are focused on safety trends and SFAR 71 procedures.

14. The safety impact of Special Federal Aviation Regulation 71, in terms of a potential

decrease in the Hawaii air tour accident rate or a potential increase in the rate of

weather-related accidents, cannot be established with the current data.

15. The public would benefit from air tour regulations that provide increased oversight

and additional safety requirements for 14 Code of Federal Regulations Part 91 air

tour operators that carry large numbers of passengers annually, such as Bali Hai.

16. A regulation specific to commercial air tour operations would be more appropriate

than an air taxi regulation, and it would allow the Federal Aviation Administration

inspectors responsible for air tour operators to focus on the daily safety requirements

unique to those operations.

17. The National Automatic Dependent Surveillance-Broadcast Program technology

could help Hawaii air tour operators reduce operational risks.

18. Under the Federal Aviation Administration’s current plan for installing the National

Automatic Dependent Surveillance-Broadcast Program infrastructure in Hawaii, only

limited services would be provided to Hawaii air tour operators that could achieve

significant safety benefits from the technology.

19. Commercial air tour operators operating under visual flight rules may not be required

to install automatic dependent surveillance-broadcast (ADS-B) compatible avionics,

even after ADS-B infrastructure is installed, which could lessen the safety-related

benefit of these new services on Hawaii air tour flight operations.
Conclusions 52 Aircraft Accident Report

3.2 Probable Cause

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 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.
53 Aircraft Accident Report

4. Safety Recommendations

As a result of the investigation of this accident, the National Transportation Safety

Board makes the following recommendations to the Federal Aviation Administration:

In cooperation with Hawaii commercial air tour operators, aviation

psychologists, and meteorologists, among others, develop a cue-based

training program for commercial air tour pilots in Hawaii that specifically

addresses hazardous aspects of local weather phenomena and in-flight

decision-making. (A-07-18)

Once a cue-based training program that specifically addresses hazardous

aspects of local weather phenomena and weather-related, decision-making

issues is developed, as requested in Safety Recommendation A-07-18,

require all commercial air tour operators in Hawaii to provide this training

to newly hired pilots. (A-07-19)

Establish operational practices for commercial air tour helicopter pilots

that include rest breaks and that will ensure acceptable pilot performance

and safety, and require commercial air tour helicopter operators to adhere

to these practices. (A-07-20)

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. (A-07-21)

Direct the Honolulu Flight Standards District Office to ensure that the

annual safety meetings, as required under approved certificates of waiver

or authorization, focus on pertinent and timely commercial air tour safety

issues, including, but not limited to, reviews of Hawaii air tour accidents,

local weather phenomena, and SFAR 71 procedures. (A-07-22)

Reevaluate the altitude restrictions in the State of Hawaii to determine if

they may have resulted in any unintended degradation of safety with regard

to weather-related accidents and fatalities. (A-07-23)

Develop and enforce safety standards for all commercial air tour operations

that include, at a minimum, initial and recurrent pilot training programs

that address local geography and meteorological hazards and special

airspace restrictions; maintenance policies and procedures; flight

scheduling that fosters adequate breaks and flight periods, as established by

the implementation of Safety Recommendation A-07-20; and operations

specifications that address management, procedures, route specifications,

and altitude restrictions, as necessary. (A-07-24)
Safety Recommendations 54 Aircraft Accident Report

Accelerate the implementation of automatic dependent

surveillance-broadcast (ADS-B) infrastructure in the State of Hawaii to

include high-quality ADS-B services to low-flying aircraft along heavily

traveled commercial air tour routes. (A-07-25)

Require that Hawaii air tour operators equip tour aircraft with compatible

automatic dependent surveillance-broadcast (ADS-B) technology within

1 year of the installation of a functional National ADS-B Program

infrastructure in Hawaii. (A-07-26)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

MARK V. ROSENKER

Chairman

ROBERT L. SUMWALT

Vice Chairman

DEBORAH A. P. HERSMAN

Member

KATHRYN O. HIGGINS

Member

STEVEN R. CHEALANDER

Member

Adopted: February 13, 2007
55 Aircraft Accident Report

5. Appendixes

Appendix A

Investigation and Public Hearing

Investigation

The National Transportation Safety Board was initially notified of this accident on

September 24, 2004. An investigator-in-charge (IIC) traveled to the area on September 25,

2004, but was unable to access the accident site due to hazardous terrain and adverse

weather. The IIC was flown over the accident site on October 2, 2004, and subsequently

examined the wreckage as it was recovered to a hangar. The following areas were

assigned to specialists during the course of this investigation: Meteorology, Operations,

and Human Performance.

Parties to the investigation were the Federal Aviation Administration and

Rolls-Royce Corporation. In accordance with Annex 13 to the Convention on

International Civil Aviation, a nontraveling accredited representative from the

Transportation Safety Board of Canada was assigned, and Bell Helicopter Textron, Inc.,

served as technical advisor.

Public Hearing

No public hearing was held for this accident.