Individually Owned: 150,657
Corporate Owned: 137,281
Aircraft Accident/Incident Report
Kalaheo, Hawaii 96741
Friday, September 24, 2004 16:42 HST
NTSB Narrative Summary Released at Completion of Accident
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.
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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.
NTSB Probable Cause Narrative
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.
Event Information
| Type of Event | Accident |
| Event Date | 9/24/2004 |
| Event Day of the Week | Friday |
| Time of Event | 1642 |
| Event Time Zone | Hawaii Standard Time |
| Event City | Kalaheo |
| Event State | HAWAII |
| Event Country | -- |
| Zipcode of the event site | 96741 |
| Event Date Year | 2004 |
| Event Date Month | 9 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | 215948N |
| Event Location Longitude | 1592954W |
| Event Location Airport | -- |
| Event Location Nearest Airport ID | -- |
| Indicates whether the acc/inc occurred off or on an airport | Off Airport/Airstrip |
| Distance from airport in statute miles | -- |
| Degrees magnetic from airport | -- |
| Airport Elevation | -- |
| Weather Briefing Completeness | -- |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 1653 Hawaii Standard Time |
| Direction of event from weather observation facility (degrees) | 90 |
| Weather Observation Facility ID | LIH |
| Elevation of weather observation facility | 153 |
| Distance of event from weather observation facility (units?) | 9 |
| Time Zone of the weather observation | HST |
| Lighting Conditions | Day |
| Lowest Ceiling Height | -- |
| Lowest Non-Ceiling Height | 2700 |
| Sky/Lowest/Cloud Conditions | Scattered |
| Sky Condition for Lowest Ceiling | None |
| Visibility Runway Visual Range (Feet) | -- |
| Visibility Runway Visual Value (Statute Miles) | -- |
| Visibility (Statute Miles) | 10 |
| Air Temperature at event time (in degrees celsius) | 27 |
| Dew Point at event time (in degress fahrenheit) | 21 |
| Wind Direction (degrees magnetic) | 50 |
| Variable Wind Indicator | Wind direction could be determined |
| Wind Speed (knots) | 14 |
| Wind Velocity Indicator | -- |
| Wind Gust Indicator | Not Gusting |
| Wind Gust (knots) | -- |
| Altimeter Setting at event time (in. Hg) | 30 |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | -- |
| METAR weather report | -- |
| Event Highest Injury | Fatal |
| On Ground, Fatal Injuries | -- |
| On Ground, Minor Injuries | -- |
| On Ground, Serious Injuries | -- |
| Injury Total Fatal | 5 |
| Injury Total Minor | -- |
| Injury Total None | -- |
| Injury Total Serious | -- |
| Injury Total All | 5 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 21080 |
| NTSB Notification Source | |
| NTSB Notification Date | Sep 24 2004 12:00AM |
| NTSB Notification Time | 1905 |
| Fiche Number and/or location -used to find docket information | DMS |
| Date of most recent change to record | Mar 26 2007 9:33AM |
| User who most recently changed record | NTSB\lema |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | WP HNL FSDO |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N16849 |
| NTSB Number | LAX04FA329 |
| Missing Aircraft Indicator | -- |
| Federal Aviation Reg. Part | Part 91: General Aviation |
| Type of Flight Plan filed | None |
| Flight plan Was Activated? | -- |
| Damage | Destroyed |
| Aircraft Fire | Ground |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | Bell |
| Aircraft Model | 206B |
| Aircraft Series Identifier | -- |
| Aircraft Serial Number | 2355 |
| Certified Max Gross Weight | 3350 |
| Aircraft Category | Helicopter |
| Aircraft Registration Class | -- |
| Aircraft is a homebuilt? | No |
| Flight Crew Seats | -- |
| Cabin Crew Seats | -- |
| Passenger Seats | -- |
| Total number of seats on the aircraft | 5 |
| Number of Engines | 1 |
| Fixed gear or retractable gear | Fixed |
| Aircraft, Type of Last Inspection | 100 Hour |
| Date of Last Inspection | Sep 1 2004 12:00AM |
| Airframe hours since last inspection | 19.2 |
| Airframe Hours | 15982.3 |
| ELT Installed | No |
| ELT Activated | -- |
| ELT Aided Location of Event Site | -- |
| ELT Type | -- |
| Aircraft Owner Name | Bali Hai Helicopter Tours, Inc. |
| Aircraft Owner Street Address | P.O. Box 1052 |
| Aircraft Owner City | Kalaheo |
| Aircraft Owner State | HI |
| Aircraft Owner Country | USA |
| Aircraft Owner Zipcode | 96741 |
| Operator is an individual? | No |
| Operator Name | -- |
| Operator Same as Owner? | Yes |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | Yes |
| Operator Street Address | -- |
| Operator City | -- |
| Operator State | -- |
| Operator Country | -- |
| Operator Zip code | -- |
| Operator Code | XBXA |
| Owner has at least one certificate | None |
| Other Operator of large aircraft? | -- |
| Certified for Part 133 or 137 Operation | -- |
| Operator Certificate Number | -- |
| Indicates whether an air carrier operation was scheduled or not | -- |
| Indicates Domestic or International Flight | -- |
| Operator carrying Pax/Cargo/Mail | -- |
| Type of Flying (Per_Bus / Primary) | Aerial Observation |
| Second Pilot on Board | No |
| Departure Point Same as Event | No |
| Departure Airport Code | PAK |
| Departure City | Hanapepe |
| Departure State | HI |
| Departure Country | USA |
| Departure Time | 1605 |
| Departure Time Zone | HST |
| Destination Same as Local Flt | dest & departure same, accident can occur anywhere |
| Destination Airport Code | -- |
| Destination City | -- |
| Destination State | -- |
| Destination Country | -- |
| Specific Phase of Flight | Maneuvering |
| Report sent to ICAO? | No |
| Evacuation occurred | No |
| Date of most recent change to record | Jan 22 2007 2:21PM |
| User who most recently changed record | COOS |
| Since inspection or accident | Time of Accident |
| Event Location Runway Number and Location | NA |
| Runway Length | -- |
| Runway Width | -- |
| Sight Seeing flight | Yes |
| Air Medical Flight | No |
| Medical Flight | -- |