The pilot’s decision to continue flying under visual flight rules into deteriorating weather conditions caused the December 2019 fatal crash of a Safari Aviation sightseeing helicopter in Hawaii, the NTSB said May 10 in a probable cause finding that faults the FAA for poor leadership and oversight of air tour operators.

The pilot and all six passengers were killed when the single-engine Airbus Helicopters AS350B2 crashed in a remote, wooded area on the island of Kauai on Dec. 26, 2019, while on a sightseeing flight. Investigators could not determine if the accident resulted from a loss of control in flight or a controlled flight into terrain because the helicopter was not equipped with crash-resistant flight recorders and they lacked ADS-B flight tracking data.

“This accident was 100% preventable,” said NTSB Chair Jennifer Homendy, who presided over the safety board’s first in-person meeting since February 2020. “Some watching might feel this was all on the pilot,” she added. “But others should be able to help the pilot … Most concerning to me is the lack of leadership, safety action and oversight provided by the regulator, which is charged by law with assigning and maintaining safety as the highest priority in air commerce.”

According to information provided during the meeting, the 69-year-old pilot controlling the aircraft was Safari’s chief pilot and check airman. He was highly experienced, with 6,000 hr. on the helicopter type, but not instrument-rated. He had completed seven of eight scheduled 50-min. sightseeing flights when he flew into a mountainous region shrouded in low clouds and fog—weather that investigators described as atypical for the northwest region of the island. Three other air tour pilots avoided the area.

Safety board members noted that although the other pilots diverted before reaching the accident area, video evidence indicated that all flew in low-visibility conditions that may have been below the required 3 mi. minimum flight visibility. This was “an obvious sign of procedural drift that occurred with the air tour operators in Hawaii,” board member Michael Graham said.

Board members stressed that Safari Aviation had not established a safety management system (SMS), something the NTSB first recommended for Part 135 operators in 2016 but the FAA currently does not require. The board reiterates Safety Recommendation A-16-36 for SMS in the latest accident report.

As of February 2022, only 30 of 1,940 Part 135 certificate holders in the U.S. had FAA-accepted SMS programs under a voluntary process the agency started in 2017, investigators said. Another 165 operators had applied for acceptance. “That’s a very discouraging statistic,” board member Thomas Chapman said of the 30 approved programs.

At the time of the accident, Safari Aviation had not equipped its aircraft with flight-data recorders or to signal their position by ADS-B Out, also not mandated by the FAA for low-flying helicopters.

In addition to advocating for SMS programs, Homendy noted that the NTSB since 2013 has repeatedly recommended to the FAA that helicopters be required to have crash-resistant flight data and cockpit voice recorders. The board recommended that Part 135 operators establish flight-data monitoring programs in 2016. In 2007, it called on the FAA to develop “cue-based” training programs for pilots in Hawaii to help them assess and react to hazardous local weather conditions.

“The NTSB has issued recommendation after recommendation to the FAA following accident after accident which would have, if implemented, prevented the deaths of the four adults and three children, the youngest of which was just 10 years old, who died in this tragedy,” Homendy said.

Safety board members were critical of the role of the FAA’s Honolulu Flight Standards District Office (FSDO) specifically in providing oversight of the local air tour industry. Separately, in 2020, the U.S. Senate Commerce, Science and Transportation Committee announced that it had received information from multiple whistleblowers alleging misconduct by FAA managers at the same FSDO. The Senate committee referred the allegations to the U.S. Transportation Department inspector general’s office for investigation. The IG’s office did not immediately respond to an inquiry about the status of its investigation.

“Locally, there was minimal FAA oversight of the safety of air tour operations in Hawaii, particularly with respect to the kinds of decisions pilots were actually making during tour flights,” Homendy said. “The FSDO was understaffed and as described by inspectors had an extremely high workload. There were six inspector positions available; only two were filled with fully trained inspectors at the time of the accident despite the presence of 17 helicopter air tour operators in Hawaii.”