The decision by an experienced Kauai pilot to fly his helicopter and six sight-seeing passengers into fast-deteriorating weather during his last scheduled flight of the day — weather that three other tour pilots chose to avoid — clearly played a role in the 2019 crash that killed everyone aboard, federal investigators say.

But the National Transportation Safety Board also lays much of the Safari Aviation crash’s blame on the agency that regulates Hawaii’s air tours and their pilots: the Federal Aviation Administration.

The FAA has failed to take key steps in response to previous fatal crashes in Hawaii that would make local tour flights safer, the board says.

“Real safety change comes when our recommendations are implemented, and in this case we talk about several recommendations we’ve issued that could have prevented this accident,” NTSB Chair Jennifer Homendy said bluntly last month during the group’s meeting to discuss the agency’s findings into the crash.

A helicopter flies on Maui. The NTSB remains concerned that FAA air tour regulations are too lax. Nathan Eagle/Civil Beat/2020

The scathing Kauai report, released late last month, comes amid a decades-long tug of war between the NTSB and FAA over how strict the rules governing air tours and skydiving should be.

Neither the FAA nor local tour operators responded to requests for comment this week. Industry insiders, however, have previously said that the FAA must consider impacts to tour operators’ ability to stay in business while the NTSB, as an independent investigator, doesn’t have to consider those financial consequences when it issues safety recommendations.

Yet, local tour crashes continue to occur fairly regularly. On Wednesday, Hawaii saw its latest air tour accident when a Paradise Helicopters tour crashed in a lava field on the Big Island, near South Point.

No fatalities were reported but authorities say all six people on board were injured, two of them seriously. The pilot was trapped in the wreck but was later “extracted.” It’s not yet clear what caused the accident.

From 2000 through 2019, Hawaii saw 11 fatal helicopter tour crashes resulting in 45 deaths, according to NTSB records. Six of those fatal crashes were weather-related, NTSB staff said at the board meeting held in May.

For the Safari accident, the NTSB’s final report points to nearly a dozen previous recommendations to the FAA that it says could have helped prevent the Airbus AS350’s crash into the remote Kokee terrain that had been blanketed in late-afternoon clouds and rain. The wreckage was found about a half-mile off the standard course to Na Pali Coast.

Those recommendations include installing and maintaining weather cameras at critical locations across the island state, where the local conditions can turn on a dime, so that tour pilots can watch for potentially dangerous changes in real time.

Parts of the helicopter rests along Oneawa Street in Kailua after helicopter crashed in a the Kailua neighborhood.
Parts of a helicopter rest along Oneawa Street in Kailua after the aircraft crashed in a Kailua neighborhood in 2019. Cory Lum/Civil Beat/2019

The FAA has installed several cameras around the state but still has a long way to go to install all 26 that are planned, officials say. Only two have been installed on Kauai and neither of them are in the northwest part of the island where the Safari helicopter crashed, according to the NTSB.

The independent agency has also been pushing for more than a decade for the FAA to develop a specialized “cue-based” training program customized for tour pilots in Hawaii. That program, similar to one that already exists in Alaska, would teach local pilots to watch for the signs of bad weather so that they can avoid it before the situation gets dangerous.

Several of those recommendations, including one for cue-based training, stemmed from a similar weather-related helicopter tour crash on Kauai in 2004 — the Bali Hai Helicopters accident in Kalaheo that killed five people.

The Kauai report follows another recently released report into a separate fatal air tour crash in 2019 – the Novictor crash in a densely populated Kailua neighborhood that killed the pilot, 28-year-old Joseph Berridge, and his two passengers.

For that accident, the NTSB found that the pilot, who had been hired by Novictor to fly its Robinson R44-model helicopters just two and a half weeks prior to the crash and had logged only three days flying the local tours, was flying faster than he should have been when the helicopter ran into heavy storm gusts. “Excessive flapping” caused the main rotor blade to hit the cabin, and the helicopter broke apart mid-air, according to that report, landing on a busy residential street.

“Those recommendations still haven’t been implemented and as a result more lives were lost,” Homendy said of the 11 total previous recommendations flagged in the Kauai report.

An ‘Overwhelmed’ FAA Field Office

The NTSB, which is responsible for investigating civil transportation accidents across the U.S., further found that at the time of the deadly 2019 accident on Kauai, the FAA’s Honolulu field office only had two fully trained investigators out of six total positions. It had two trainees helping, and the remaining two positions were vacant.

The field office relied on mainland field offices to help with its oversight. Its manager lacked any operational flight or maintenance experience, according to NTSB investigators.

“This person was set up to fail, in my view.” — NTSB Vice Chairman Bruce Landsberg

“This person was set up to fail, in my view,” NTSB Vice Chairman Bruce Landsberg said at the May meeting. “I find it hard to believe that the FAA can with a straight face say that they were effectively overseeing the safety of any and all flight operations in Hawaii.”

NTSB staff described the FAA’s Honolulu field office as overworked, overwhelmed and unable to attract sufficient staff in part due to the islands’ cost of living. That’s made it difficult, they say, to oversee tour flights that the NTSB conservatively estimates carry some 200,000 people around the Hawaiian Islands each year.

In 2020, an FAA whistleblower said that he was denied a travel request to inspect Safari Aviation weeks before the crash. That whistleblower, Joseph Monfort, further alleged inappropriately close ties between local FAA managers and Novictor, the company whose helicopter crashed in Kailua.

A ‘Drift’ Toward Risky Behavior?

In their report on the Kauai crash, NTSB analysts raise concerns that amid the lack of robust FAA oversight local pilots in the industry are gradually taking greater risks during flights when they encounter bad weather.

The pilot who took that flight, 69-year-old Paul Matero, was Safari’s chief pilot and he may have misjudged the severity of the weather because such thick, cloudy weather usually descends on Kauai from the northeast, not the northwest, the report said. He may have concluded that the atypical weather front was relatively minor, or he was “overconfident in his abilities,” the report said. He might not have realized that the flight was in trouble until it was too late, the report said.

In 2010 Matero had his pilot license revoked when he tested positive for drugs but got a new one the following year when he was eligible again. NTSB investigators ruled out any impairment due to drugs, alcohol or a medical condition as a cause in the crash.

Safari helicopter crash air tours NTSB
Footage taken from another helicopter at the time of the 2019 Safari crash shows thick clouds developing north of Waimea Canyon. It also shows other nearby helicopters, such as the one circled, violating a Hawaii air tours rule to maintain at least three miles of visibility, investigators say. NTSB/2019

Because there was no flight data recorder or black box — and no special on-board equipment to track the helicopter’s path through steep terrain — there’s no way to know whether Matero had control of the chopper when it crashed into a slope, the NTSB added.

Helicopter video footage shared with NTSB investigators of Waimea Canyon’s northern rim at the time of the 2019 crash showed a blanket of clouds moving into the area. Other tour helicopters nearby diverted from their path and avoided the same, ill-fated route as the Safari chopper.

Nonetheless, the footage also showed that those helicopters, from two companies other than Safari, violated a Hawaii air tours rule that requires pilots to maintain at least three miles of visibility around them, agency board members noted.

“They were getting way too deep in,” Landsberg said of the helicopters in the footage. “We know that the rules say three miles, and yet helicopters (are) being surrounded by fog and clouds and rain and pilots (are) pushing and pushing and pushing and then finally they say, ‘whoops we’re over our heads.’”

Chances For Legislative Change

The NTSB’s report on the 2019 Kauai crash doesn’t mention the Kailua one that occurred earlier that year, but “the theme is still there,” U.S Rep. Ed case said last week. In each situation the pilot “got himself into a problematic situation” that he didn’t anticipate and then wasn’t able to adjust to avoid catastrophe.

Case has spent much of his latest term in Congress scrutinizing air tours and the noise and safety concerns voiced by locals on the ground in Hawaii. His Safe and Quiet Skies Act, introduced in 2019 to help reform the industry, has thus far failed to gain traction.

Congressman Ed Case FAA Whistleblower Helicopters Press Conference
U.S. Rep. Ed Case on the upcoming FAA reauthorization: “That’s your opening” to implement air tour reforms. Kuʻu Kauanoe/Civil Beat/2020

However, Case sees an opportunity to codify the key provisions in that bill, which include forcing the FAA to adopt NTSB recommendations, when the FAA comes up for reauthorization before Congress in 2023.

“That’s your opportunity, that’s your opening — and that’s the purpose of reauthorization,” Case said.

The state Legislature this year also passed a measure that would require air tour operators to file monthly reports with information on all of their flights, including disclosures of any aircraft that deviate from their flight plans and fly over sensitive areas.

The bill now awaits a decision from Gov. David Ige on whether it should become law.

A Decades-Long Tug Of War

Homendy made the long-standing tensions between the NTSB and FAA clear when she traveled to Hawaii in June 2019 — about six months before the Safari crash — to survey the wreckage of a skydiving plane at Dillingham Airfield that killed all 11 people aboard.

NTSB Member Jennifer Homendy gives presser at Ala Moana Hotel Hibiscus Room.
NTSB Member Jennifer Homendy made the long-standing tensions between the NTSB and FAA clear when she traveled to Hawaii in June 2019. Cory Lum/Civil Beat/2019

Addressing reporters at Ala Moana Hotel, Homendy implored the FAA to impose stricter maintenance, inspections and pilot-training standards on the skydiving industry.

“Are we trying to put the FAA on notice on this? Yes,” Homendy said during the press briefing.

Historically, the NTSB has issued at least 138 recommendations aimed at making air tours safer. It considers the FAA’s response to at least 29 of those unacceptable, including several that stem from Hawaii crashes.

In the 2019 Safari crash, 47-year-old entrepreneur Amy Gannon, Gannon’s 13-year-old daughter, Jocelyn, and a family of four from Switzerland all died along with Matero.

Gannon’s husband, Mike, and their 16-year-old son, Aaron, did not join that tour, which occurred during the Wisconsin  family’s vacation on Kauai.

Mike Gannon later told the Wisconsin State Journal that he and Aaron had planned to fly on a tour several days later. “Jocelyn really wanted to go first,” Gannon said.

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