# NTSB LAX04FA329: Bell 206B, N16849, Kalaheo, HI, September 25, 2004 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 1 · Field · Final report - Date: September 24, 2004, 16:42 local (Sep 25, 2004, 02:42 UTC) - Place: Kalaheo, HI - Coordinates: 21.996665, -159.498336 - Nearby events: https://openairdocs.org/map.md?lat=21.9967&lon=-159.4983&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 5 fatal - Status: Completed, report March 26, 2007 - Report: Board-adopted at Board Meeting - Investigation class: Class 1 - Parties: Transportation Safety Board of Canada, National Transportation Safety Board, Bell Helicpter, Rolls-Royce, Federal Aviation Administration - Safety recommendations: Yes - NTSB case key (mKey): 60198 - NTSB case page: https://www.ntsb.gov/investigations/Pages/LAX04FA329.aspx - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/60198/pdf - Board report AAR0703 (PDF): https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR0703.pdf - Page: https://openairdocs.org/ntsb/LAX04FA329 ## Probable cause 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. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, maneuvering - weather condition - turbulence - weather condition - rain - vfr flight into imc - continued, pilot in command (cause) - lack of experience, pilot in command (contributing factor) - weather condition - obscuration - inadequate surveillance of operation, faa(organization) (contributing factor) - inadequate initial training, company/operator management - physiological condition, pilot in command (contributing factor) - Loss of control - in flight, maneuvering - spatial disorientation, pilot in command (cause) - aircraft control - not maintained, pilot in command (cause) - In flight collision with terrain/water, maneuvering - terrain condition - mountainous/hilly ## Analysis The Safety Board adopted the final report of this accident investigation, including the analysis and probable cause, on February 13, 2007. The Safety Board's full report will be available soon at http://ntsb.gov/Publictn/publictn.htm. The Aviation Accident Report number is NTSB/AAR-07/03. -------------------------------------------------------------------------------- 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, 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 (SFAR) 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. ## Factual narrative The Safety Board adopted the final report of this accident investigation, including the analysis and probable cause, on February 13, 2007. The Safety Board's full report will be available soon at http://ntsb.gov/Publictn/publictn.htm. The Aviation Accident Report number is NTSB/AAR-07/03. -------------------------------------------------------------------------------- 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 (PAK), 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 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 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 segments at 1,000 feet agl, cross ridgelines at 500 feet agl, and cross razorback ridgelines 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, including Waimea Canyon, the Na Pali Coast, Waialeale Crater, and Manawaipuna Falls. 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. A review of air traffic control radar data from the FAA's air route traffic control center and radar approach control facility in Honolulu showed the helicopter's ground track entered the area north of Mount Waialeale about 1635; however, the helicopter's flight altitudes could not be determined. The radar data showed that, about 1641, the helicopter crossed a 2,000-foot ridge that extended east from Kahili Ridge, the main ridgeline 3,000 feet south of Waialeale Crater. Shortly 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 180-degree 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. When the helicopter failed to return to PAK as scheduled, Bali Hai personnel notified the tower controllers at Lihue Airport 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. ## Aircraft - Registration: [N16849](https://openairdocs.org/deregistered/N16849-2006-07-19), registration cancelled 2006-07-19, S/N 2355, built 1978 (OpenAirDocs) - Reported make and model: Bell 206B - Registry model: [Bell 206B](https://openairdocs.org/model/bell-206b) (registry code 1181511) (OpenAirDocs) - Registry engine: [Allison 250 SER 400HP](https://openairdocs.org/engine/allison-250-ser-400hp) (registry code 03013, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 2355 - Airframe hours: 15982.3 - Engines: Allison 250-C20B 420 horsepower turbo shaft - Damage: Destroyed - Fire: On-Ground - Flight: Aerial observation, Part 91 - Registered owner: Bali Hai Helicopter Tours, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, September 1, 2004, 19.2 hours before - Departed: PAK, Hanapepe, HI ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 39; injuries: fatal; commercial, military; medical: class 1, without waivers/limitations; last flight review May 1, 2004; seat: right; toxicology performed; flight hours: 4,125 total, 126 in this make and model, 2,820 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 50° at 14 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 81 °F, dew point 70 °F - Altimeter: 30.00 inHg - Observed at: LIH, 9 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20040924027559A](https://openairdocs.org/incident/20040924027559A), Sep 24, 2004: Bell 206B, Kalaheo, HI, Destroyed, 5 fatal. (-23) On September 24, 2004, approximately 1640 hawaiian standard time, a Bell 206B single-engine helicopter, N16849, was destroyed when it impacted… From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.