ANC20MA010

NTSB accident investigation · Airbus AS350B2 · Kekaha, HI · December 27, 2019

Accident · FatalClass 1 · MajorFinal report
Date
December 26, 2019, 16:57 local (Dec 27, 2019, 02:57 UTC)
Place
Kekaha, HI
Injuries
7 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N985SAAirbus AS350B2
Defining event
Enroute-cruise: VFR encounter with IMC
Weather
Instrument (IMC) · Day
Status
Completed · report May 10, 2022
Report
Board-adopted at Board Meeting · Board meeting May 10, 2022
Investigation class
Class 1
NTSB office
Alaska Regional Office
Parties
Federal Aviation Administration
Safety recommendations
Yes
FAA report
20191226014219A
Case key
100736

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

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.

Findings · 6

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Ceiling/visibility/precip: below VFR minimaEnvironmental issues › Conditions/weather/phenomena · Effect on operationEurocopter AS 350 B2: 3 casesAll aircraft: 184 casesProbable cause
Safety programs: adequacy of safety programOrganizational issues › Support/oversight/monitoring · OperatorEurocopter AS 350 B2: 1 caseAll aircraft: 24 casesProbable cause
Resources: availability of equipmentOrganizational issues › Management · FAA/RegulatorEurocopter AS 350 B2: 1 caseAll aircraft: 3 casesProbable cause
Oversight: oversight of reg complianceOrganizational issues › Support/oversight/monitoring · FAA/RegulatorEurocopter AS 350 B2: 1 caseAll aircraft: 14 casesProbable cause
Training: emergency proc trainingOrganizational issues › Support/oversight/monitoring · FAA/RegulatorEurocopter AS 350 B2: 1 caseAll aircraft: 8 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Factual 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).

Aircraft

Registration
N985SA
Reported as
Airbus AS350B2
Category
Helicopter
Serial number
3111
Built
1998
Airframe hours
21,854.1
Damage
Destroyed
Fire
Unknown
Flight
Part 135
Operator
Safari Aviation Inc.
Registered owner
Saf Ltd
Airworthiness certificate
Standard, Normal
Departed
Lihue, HI
Destination
Lihue, HI
Flight plan
Company VFR
Equipment
None

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
69
Injuries
Fatal
Certificate
Commercial
Medical
Class 2, With waivers/limitations
Last flight review
July 16, 2019
Seat
Left
Toxicology
Performed
Flight hours
15,718 total · 5,814.2 in this make and model · 15,714 as pilot in command · 126.4 in the last 90 days · 25 in the last 30 days · 5.8 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
310° at 12 knots
Visibility
10 statute miles
Lowest ceiling
3,400 ft broken
Temperature
73 °F, dew point 72 °F
Altimeter
29.89 inHg

Docket · 46

The files NTSB released with the investigation on December 15, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.3 GB in all.

Operations and human performance factual reportItem 1 · PDF · 62 pages · 4.3 MBOperational factors/human performance attachment 1 - operations group interviewsItem 2 · PDF · 950 pages · 2.2 MBOperational factors/human performance - attachment 2 - previous safari flight's passenger statementItem 3 · PDF · 3 pages · 315 KBOperational factors/human performance - attachment 3 - helicopter flying handbook, chapter 11Item 4 · PDF · 28 pages · 8.2 MBOperational factors/human performance - attachment 4 - flight safety foundation publication - march-april 1996Item 5 · PDF · 4 pages · 7.3 MBOperational factors/human performance - attachment 5 - aircraft daily log, N985SAItem 6 · PDF · 31 pages · 35.7 MBOperational factors/human performance - attachment 6 - accident flight weight and balance formItem 7 · PDF · 3 pages · 2.1 MBOperational factors/human performance - attachment 7 - Hawaii air tour common procedures manualItem 8 · PDF · 170 pages · 11.3 MBOperational factors/human performance - attachment 8 - aircraft flight manual section 5 regulatory performance dataItem 9 · PDF · 15 pages · 3.3 MBOperational factors/human performance - attachment 9 - pilot training and competency check recordsItem 10 · PDF · 20 pages · 5.3 MBOperational factors/human performance - attachment 10 - safari aviation operations specifications and operations manual excerptItem 11 · PDF · 22 pages · 4.7 MBOperational factors/human performance - attachment 11 - safari aviation company policy for pilots excerptItem 12 · PDF · 6 pages · 3.7 MBOperational factors/human performance - attachment 12 - safari aviation company adverse weather procedures and risk assessment toolItem 13 · PDF · 4 pages · 1.1 MBOperational factors/human performance - attachment 13 - pilot scheduling calendarItem 14 · PDF · 2 pages · 2.0 MBOperational factors/human performance - attachment 14 - pilot initialed weather printoutItem 15 · PDF · 4 pages · 22.0 MBOperation factors/human performance - attachment 15 - safari aviation advertisement - published in the kauai drive guide vacation planner - dated December 2019 - may 2020Item 16 · PDF · 2 pages · 3.7 MBOperational factors/human performance - attachment 16 - safari aviation departure/arrival time recordItem 17 · PDF · 5 pages · 3.6 MBOperational factors/human performance - attachment 17 - annual air tour safety meeting attendance records and agendaItem 18 · PDF · 6 pages · 2.5 MBAir traffic control - specialist's factual reportItem 19 · PDF · 5 pages · 795 KBAir traffic control - attachment 1 - radar graphicsItem 20 · PDF · 3 pages · 2.3 MBAir traffic control - attachment 2 - radar dataItem 21 · XLSX · 15 KBWeather studyItem 22 · PDF · 17 pages · 2.5 MBAttachment 1 to the weather studyItem 23 · PDF · 29 pages · 106 KBAttachment 2 to the weather studyItem 24 · PDF · 39 pages · 6.2 MBAirworthiness factual reportItem 25 · PDF · 21 pages · 12 photos · 2.0 MBAirworthiness factual report - attachment 1 - record of conversation with director of maintenanceItem 26 · PDF · 2 pages · 143 KBAnnunciator panel examItem 27 · PDF · 2 pages · 1 photo · 680 KBElectronic devices - specialist's factual reportItem 28 · PDF · 5 pages · 757 KBMedical factual reportItem 29 · PDF · 3 pages · 226 KBPilot/operator aircraft accident report, NTSB form 6120.1Item 30 · PDF · 11 pages · 1.9 MBStatement of party representatives to NTSB investigationItem 31 · PDF · 2 pages · 1.9 MBToxicological reportItem 32 · PDF · 1 page · 161 KBPhotosItem 33 · PDF · 8 pages · 12.4 MBVideo files - specialist's factual reportItem 34 · PDF · 9 pages · 190 KBAttachment 1 to video files - specialist's factual report_tourist_20191121_095030_redacted_not-from-accident-aircraftItem 35 · MP4 · 11.5 MBAttachment 2 to video files - specialist's factual report_tourist_20191121_095048_redacted_not-from-accident-aircraftItem 36 · MP4 · 15.7 MBAttachment 3 to video files - specialist's factual report_company-1_191226_160711_161733_redacted_not-from-accident-aircraftItem 37 · MP4 · 708 MBAttachment 4 to video files - specialist's factual report_company-1_191226_161733_162714_redacted_not-from-accident-aircraftItem 38 · MP4 · 767 MBAttachment 5 to video files - specialist's factual report_company-1_191226_162714_163655_redacted_not-from-accident-aircraftItem 39 · MP4 · 774 MBAttachment 6 to video files - specialist's factual report_company-1_191226_163655_164354_redacted_not-from-accident-aircraftItem 40 · MP4 · 564 MBAttachment 7 to video files - specialist's factual report_company-2_201912261639_02_1_redacted_not-from-accident-aircraftItem 41 · MP4 · 1.2 GBAttachment 8 to video files - specialist's factual report_company-2_201912261639_02_2_redacted_not-from-accident-aircraftItem 42 · MP4 · 1.2 GBAttachment 9 to video files - specialist's factual report_company-2_201912261639_02_3_redacted_not-from-accident-aircraftItem 43 · MP4 · 1.2 GBAttachment 10 to video files - specialist's factual report_company-2_201912261639_02_4_redacted_not-from-accident-aircraftItem 44 · MP4 · 537 MBEvidence control formsItem 45 · PDF · 2 pages · 51 KBBoard meeting presentationsItem 46 · PDF · 71 pages · 5.4 MB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N985SA · 1

Matched to the same aircraft by N-number and date.