LAX98FA211

NTSB accident investigation · Eurocopter AS-350-BA · Mt. Waialeale, HI · June 25, 1998

Accident · FatalField investigationFinal report
Date
June 25, 1998, 09:32 local (19:32 UTC)
Place
Mt. Waialeale, HI
Injuries
6 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N594BKEurocopter AS-350-BA
Weather
Instrument (IMC) · Day
Status
Completed · report May 17, 2001
Report
Approved by Office Director
FAA report
19980625014999A
Case key
29958

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

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Probable cause

The pilot's decision to continue VFR flight into deteriorating weather conditions consisting of lowering ceilings and visibility in mountainous terrain, which resulted in the inadvertent entry into instrument meteorological conditions and a collision with a mountain side. A factor in the accident was the failure of the chief pilot, who had directly observed the deteriorating weather conditions, to direct the following pilots to avoid the area.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight encounter with weatherCruise
Weather condition - low ceiling
Weather condition - rain
Weather condition - obscuration
Vfr flight into imc - continuedPilot in commandCause
In flight collision with terrain/waterCruise
Terrain condition - mountainous/hilly
Remedial action - continuedPilot in commandCause
Supervision - inadequatePilot in commandFactor

Analysis

While operating under visual flight rules on an on-demand for hire aerial sight seeing tour, the helicopter encountered instrument meteorological conditions and impacted the 80-degree upsloping face of a mountain, 200 feet below its ridge crest. The tour was to circumnavigate a mountainous area on the island, with a visit to an extinct volcanic crater in a mountain valley. Three helicopters departed on the tour, with about 2 minutes between each departure. The pilot, who was employed by the operator 2.5-months earlier, was in trail behind the company's most experienced (chief) pilot, and second most experienced pilot. None had received a weather briefing from an FAA approved source as required in the company operations specifications. Throughout the flight they were in radio contact with each other. The two lead pilots were a few minutes ahead of the accident pilot as he approached an area of the valley near the crater where inclement weather existed. The second pilot ahead of the accident helicopter said that when he exited the crater near the accident site, he encountered heavy rain showers and lowering ceilings and visibilities. Although the accident pilot attempted to follow the company pilots ahead of him, he did not observe the valley entrance to the Waialeale crater viewpoint and flew past it. As the flight progressed, the pilot encountered lowering ceilings, heavy intensity rain showers, and reduced flight visibility. The pilot became disoriented, misjudged his location, and while cruising toward what he believed was the prescribed crater entranceway inadvertently entered instrument meteorological conditions. Just before the collision, the pilot transmitted to the pilots ahead of him that the weather was getting worse and that he could not see. The second pilot then provided a suggested heading that would take the accident pilot away from the mountainous terrain. The helicopter impacted the mountain on a heading nearly opposite of the one suggested. The helicopter was subsequently recovered and examined. No evidence of any preimpact mechanical malfunction was noted. Between 30 and 45 minutes after the accident, one of the operator's tour pilots reported receiving the signal of an emergency locator transmitter (ELT). This pilot proceeded to pass by the general accident site area but was unable to observe the crashed helicopter due to the low level of clouds.

Factual narrative

History of flight

On June 25, 1998, about 0932 hours Hawaiian standard time, a Eurocopter, AS-350-BA, N594BK, operated by Ohana Helicopter Tours, collided with steep upsloping mountainous terrain near Mt. Waialeale, on the island of Kauai, Hawaii. Instrument meteorological conditions (IMC) existed in the vicinity of the accident site. The helicopter was destroyed, and the commercial pilot and the five passengers were fatally injured. A visual flight rules (VFR) company flight plan was filed with the operator. The accident occurred during an on-demand air taxi sightseeing flight that was performed under 14 CFR Part 135. The flight originated from the Lihue Airport, Kauai, about 0843.

The tour operator's president indicated that the purpose of the flight was to provide the fare-paying passengers with an aerial tour of the island of Kauai. The route of flight had previously been established, and it was known by the operator as its "Mokihana" tour route. This route circumnavigates the island, and provides for viewing specific topographical features. The flight normally lasts 48 to 50 minutes.

The operator's president reported that on June 25, it commenced flight operations for the day upon the departure of its three AS-350 helicopters from the Lihue Airport. The Lihue air traffic control personnel indicated that the helicopters took off in trail about 0840, 0842, and 0843. The helicopters' registration numbers were, respectively, N592BK, N593BK, and N594BK.

The operator's president also reported that the helicopters were scheduled to fly identical tours. Piloting the first helicopter was the company's chief pilot. The company's second most experienced line pilot flew the second helicopter, and the accident pilot, who had been employed for about 2.5 months, was the last to depart.

The pilots flying the first and second helicopters reported that they maintained radio contact with each other and with the accident pilot throughout their flights. At no time did they hear any indication from the accident pilot that he was experiencing any mechanical problems with the helicopter. These pilots reported to the National Transportation Safety Board investigator that they believed their flights had been performed in a manner consistent with the operator's previously anticipated route of flight. No unusual conditions were encountered. The first and second helicopters landed back at the Lihue Airport about 0929 and 0931, respectively. Neither of the pilots reported having observed the accident.

Minutes prior to the crash the company pilot flying the second helicopter was in radio contact with the accident pilot. Subsequently, the second pilot made a statement to the Safety Board investigator regarding his recollection of these communications, as follows:

He reported that, by regulation, he had announced his position using the common aircraft radio frequency by stating "three bravo kilo north wall." At this time it was about 0920. Light to moderate intensity rain was falling but the rain stopped at the mouth of the crater. The ceiling was about 3,000 feet mean sea level (msl) at the crater's entrance. The second pilot indicated that it took him about 2 minutes to fly in and out of the crater. The rain intensity was increasing and was becoming heavy as he was leaving. At this time he heard the accident pilot broadcast his position by stating that the "Hanalie ridge (about 3 miles north of the crater) does not look so good." The second pilot responded, "Chuck when I came across it it was light rain and the ceiling was good."

About 3 minutes later, the second pilot heard the accident pilot say "Boy the weather is looking bad right here." In reply to this remark, the second pilot stated "Chuck take a heading of one hundred twenty (a southeasterly course of 120 degrees) take your time." Review of an aeronautical chart revealed this heading would have taken the helicopter away from the mountains.

The second pilot subsequently gave the Safety Board investigator a written statement. In this statement the pilot provided a drawing showing his tour route, and additional information about his recollections during the flight.

Personnel information

The accident pilot held a commercial certificate with rotorcraft-helicopter and instrument helicopter privileges. His total flight time was about 3,170 hours. His experience flying the accident model of helicopter was about 220 hours, and this flight time was acquired during flights in the 90-day period that preceded the accident.

The pilot's personal flight record logbook was not provided to the Safety Board investigator for examination. A family member reported that it was not located.

In November 1997, the pilot retired from the armed forces of the United States after 20 years of service. In his subsequent employment resume for a civilian job, he indicated that he had experience flying H-3 Sikorsky helicopters and had functioned as a safety officer and an instrument check pilot. He was knowledgeable of the Hawaiian Islands having been stationed on Kauai for 2.5 years.

After the pilot completed the operator's training program, on April 10, 1998, the pilot passed a Federal Aviation Administration (FAA) administered 14 CFR Part 135 Airman Competency/Proficiency examination conducted by an FAA inspector. A Eurocopter, AS-350, was used during the flight test. Thereafter, the pilot assumed the duty position of pilot-in-command with the operator.

Aircraft information

Equipment and Certification.

The helicopter was equipped with flight instruments, including an attitude indicator (artificial horizon), and other gyroscopic instruments including a directional gyroscope (DG) and a turn coordinator. Regarding navigational instruments, the helicopter was equipped, in part, with a very high frequency omni directional range (VOR) receiver. Also, the helicopter was equipped with a transponder having Mode C (altitude reporting) capability. The FAA authorized operation of the helicopter only under visual flight rules.

History and Maintenance.

The helicopter was manufactured in December 1993. Its total airframe time was about 6,875 hours. The helicopter had been operated about 35 hours since receiving its last 100-hour inspection on June 18, 1998.

On June 24, after the last flight prior to the accident, the helicopter was inspected by company maintenance personnel in accordance with their "daily check" procedure. No outstanding squawks or deficiencies were noted in the records, and no maintenance was performed. In the maintenance log, there was no reference to the Mode C transponder being inoperative.

The FAA participant reviewed the maintenance records and reported that all pertinent airworthiness directives had been complied with. A series of record keeping and procedural deficiencies were noted. These events were documented by the inspector in his "Inspector's Statement."

Meteorological information

Between 30 and 45 minutes after the accident, one of the operator's tour pilots reported receiving the signal of an emergency locator transmitter (ELT). This pilot proceeded to pass by the general accident site area but was unable to observe the crashed helicopter due to the low level of clouds.

Local Weather Conditions.

The accident site is about 1 nautical mile (nm) east of Mt. Kawaikini's peak, elevation 5,243 feet msl, which is about the highest elevation on Kauai. The area is known as being one of the wettest locations on earth, and records annually over 400 inches of rain.

The accident helicopter collided into a mountainside south of the Waialeale Crater. The pilot flying the lead helicopter reported to the Safety Board investigator that during his flight he had observed the center of the island was covered with clouds, and rain showers were prevalent. The pilot said it was a typical weather condition for the

Aircraft

Registration
N594BK
Reported as
Eurocopter AS-350-BA
Category
Helicopter
Serial number
2735
Airframe hours
6,875
Engine
Turbomeca ARRIEL 1B, 641 horsepower, turbo shaft
Damage
Destroyed
Flight
Part 135
Registered owner
Ohana Aviation, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · June 18, 1998 · 35 hours before
Departed
LIH · Lihue, HI
Flight plan
Company VFR

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
45
Certificate
Commercial
Instrument ratings
Helicopter
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Right
Toxicology
Performed
Flight hours
3,170 total · 220 in this make and model · 1,900 as pilot in command · 220 in the last 90 days · 63 in the last 30 days · 7 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
60° at 12 knots
Visibility
3 statute miles
Lowest ceiling
2,100 ft overcast
Temperature
70 °F, dew point 68 °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.