AIRBUS AS350B2 near Kekaha, HI — 2019-12-27
- Date
- 2019-12-27
- Location
- Kekaha, HI, USA
- Aircraft
- AIRBUS AS350B2
- Registration
- N985SA
- Category
- Helicopter
- Highest injury
- Fatal
- Fatalities
- 7
Probable cause
The pilot’s decision to continue flight under visual flight rules (VFR) into instrument meteorological conditions (IMC), which resulted in the collision into terrain. Contributing to the accident was Safari Aviation Inc.’s lack of safety management processes to identify hazards and mitigate the risks associated with factors that influence pilots to continue VFR flight into IMC. Also contributing to the accident was the Federal Aviation Administration’s delayed implementation of a Hawaii aviation weather camera program, its lack of leadership in the development of a cue-based weather training program for Hawaii air tour pilots, and its ineffective monitoring and oversight of Hawaii air tour operators’ weather-related operating practices.
NTSB narrative
On December 26, 2019, about 1657 Hawaii standard time, an Airbus AS350 B2 helicopter, N985SA, was destroyed when it collided into terrain in a remote, wooded area about 11 miles north of Kekaha, Hawaii, on the island of Kauai. The pilot and the six passengers were fatally injured. Safari Aviation Inc. (Safari), doing business as Safari Helicopters, operated the flight as a Title 14 Code of Federal Regulations (CFR) Part 135 on-demand air tour under visual flight rules (VFR).
NTSB coding
Evidence available
- Video
- ADS-B / radar
- Photos
- 46 docket documents
Docket documents46
- AIR TRAFFIC CONTROL - ATTACHMENT 1 - RADAR GRAPHICSatc
- AIR TRAFFIC CONTROL - ATTACHMENT 2 - RADAR DATAatc
- AIR TRAFFIC CONTROL - SPECIALIST'S FACTUAL REPORTatc
- EVIDENCE CONTROL FORMSform
- OPERATION FACTORS/HUMAN PERFORMANCE - ATTACHMENT 15 - SAFARI AVIATION ADVERTISEMENT - PUBLISHED IN THE KAUAI DRIVE GUIDE VACATION PLANNER - DATED DECEMBER 2019 - MAY 2020form
- OPERATIONAL FACTORS/HUMAN PERFORMANCE - ATTACHMENT 10 - SAFARI AVIATION OPERATIONS SPECIFICATIONS AND OPERATIONS MANUAL EXCERPTform
- OPERATIONAL FACTORS/HUMAN PERFORMANCE - ATTACHMENT 11 - SAFARI AVIATION COMPANY POLICY FOR PILOTS EXCERPTform
- OPERATIONAL FACTORS/HUMAN PERFORMANCE - ATTACHMENT 12 - SAFARI AVIATION COMPANY ADVERSE WEATHER PROCEDURES AND RISK ASSESSMENT TOOLform
- OPERATIONAL FACTORS/HUMAN PERFORMANCE - ATTACHMENT 13 - PILOT SCHEDULING CALENDARform
- OPERATIONAL FACTORS/HUMAN PERFORMANCE - ATTACHMENT 14 - PILOT INITIALED WEATHER PRINTOUTform
- OPERATIONAL FACTORS/HUMAN PERFORMANCE - ATTACHMENT 16 - SAFARI AVIATION DEPARTURE/ARRIVAL TIME RECORDform
- OPERATIONAL FACTORS/HUMAN PERFORMANCE - ATTACHMENT 17 - ANNUAL AIR TOUR SAFETY MEETING ATTENDANCE RECORDS AND AGENDAform
- OPERATIONAL FACTORS/HUMAN PERFORMANCE - ATTACHMENT 2 - PREVIOUS SAFARI FLIGHT'S PASSENGER STATEMENTform
- OPERATIONAL FACTORS/HUMAN PERFORMANCE - ATTACHMENT 3 - HELICOPTER FLYING HANDBOOK, CHAPTER 11form
- OPERATIONAL FACTORS/HUMAN PERFORMANCE - ATTACHMENT 4 - FLIGHT SAFETY FOUNDATION PUBLICATION - MARCH-APRIL 1996form
- OPERATIONAL FACTORS/HUMAN PERFORMANCE - ATTACHMENT 5 - AIRCRAFT DAILY LOG, N985SAform
- OPERATIONAL FACTORS/HUMAN PERFORMANCE - ATTACHMENT 6 - ACCIDENT FLIGHT WEIGHT AND BALANCE FORMform
- OPERATIONAL FACTORS/HUMAN PERFORMANCE - ATTACHMENT 7 - HAWAII AIR TOUR COMMON PROCEDURES MANUALform
- OPERATIONAL FACTORS/HUMAN PERFORMANCE - ATTACHMENT 8 - AIRCRAFT FLIGHT MANUAL SECTION 5 REGULATORY PERFORMANCE DATAform
- OPERATIONAL FACTORS/HUMAN PERFORMANCE - ATTACHMENT 9 - PILOT TRAINING AND COMPETENCY CHECK RECORDSform
- OPERATIONAL FACTORS/HUMAN PERFORMANCE ATTACHMENT 1 - OPERATIONS GROUP INTERVIEWSform
- OPERATIONS AND HUMAN PERFORMANCE FACTUAL REPORTform
- PILOT/OPERATOR AIRCRAFT ACCIDENT REPORT, NTSB FORM 6120.1form
- STATEMENT OF PARTY REPRESENTATIVES TO NTSB INVESTIGATIONform
- ATTACHMENT 1 TO THE WEATHER STUDYother
- ATTACHMENT 2 TO THE WEATHER STUDYother
- BOARD MEETING PRESENTATIONSother
- WEATHER STUDYother
- PHOTOSphotos
- AIRWORTHINESS FACTUAL REPORTreport
- AIRWORTHINESS FACTUAL REPORT - ATTACHMENT 1 - RECORD OF CONVERSATION WITH DIRECTOR OF MAINTENANCEreport
- ANNUNCIATOR PANEL EXAMreport
- ELECTRONIC DEVICES - SPECIALIST'S FACTUAL REPORTreport
- MEDICAL FACTUAL REPORTreport
- TOXICOLOGICAL REPORTreport
- ATTACHMENT 1 TO VIDEO FILES - SPECIALIST'S FACTUAL REPORT_TOURIST_20191121_095030_REDACTED_NOT-FROM-ACCIDENT-AIRCRAFTvideo
- ATTACHMENT 10 TO VIDEO FILES - SPECIALIST'S FACTUAL REPORT_COMPANY-2_201912261639_02_4_REDACTED_NOT-FROM-ACCIDENT-AIRCRAFTvideo
- ATTACHMENT 2 TO VIDEO FILES - SPECIALIST'S FACTUAL REPORT_TOURIST_20191121_095048_REDACTED_NOT-FROM-ACCIDENT-AIRCRAFTvideo
- ATTACHMENT 3 TO VIDEO FILES - SPECIALIST'S FACTUAL REPORT_COMPANY-1_191226_160711_161733_REDACTED_NOT-FROM-ACCIDENT-AIRCRAFTvideo
- ATTACHMENT 4 TO VIDEO FILES - SPECIALIST'S FACTUAL REPORT_COMPANY-1_191226_161733_162714_REDACTED_NOT-FROM-ACCIDENT-AIRCRAFTvideo
- ATTACHMENT 5 TO VIDEO FILES - SPECIALIST'S FACTUAL REPORT_COMPANY-1_191226_162714_163655_REDACTED_NOT-FROM-ACCIDENT-AIRCRAFTvideo
- ATTACHMENT 6 TO VIDEO FILES - SPECIALIST'S FACTUAL REPORT_COMPANY-1_191226_163655_164354_REDACTED_NOT-FROM-ACCIDENT-AIRCRAFTvideo
- ATTACHMENT 7 TO VIDEO FILES - SPECIALIST'S FACTUAL REPORT_COMPANY-2_201912261639_02_1_REDACTED_NOT-FROM-ACCIDENT-AIRCRAFTvideo
- ATTACHMENT 8 TO VIDEO FILES - SPECIALIST'S FACTUAL REPORT_COMPANY-2_201912261639_02_2_REDACTED_NOT-FROM-ACCIDENT-AIRCRAFTvideo
- ATTACHMENT 9 TO VIDEO FILES - SPECIALIST'S FACTUAL REPORT_COMPANY-2_201912261639_02_3_REDACTED_NOT-FROM-ACCIDENT-AIRCRAFTvideo
- VIDEO FILES - SPECIALIST'S FACTUAL REPORTvideo
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