NTSB Factual Report

1.1 HISTORY OF FLIGHT

On July 21, 2000, about 1020 Hawaiian standard time, an Aerospatiale AS 355F1, N510TG, collided with mountainous terrain while descending in the Iao Valley, about 8.7 nautical miles (nm) miles west-southwest of the Kahului Airport, on the island of Maui, Hawaii. The helicopter was operated by Helicopter Consultants of Maui, Inc., d.b.a. Blue Hawaiian Helicopters. A company visual flight rules (VFR) flight plan was filed for the planned 30-minute-long tour flight that was operated under the provisions of 14 CFR Part 135. Instrument meteorological conditions prevailed in the vicinity of the accident site. The helicopter was destroyed by impact forces and a postimpact ground fire. The commercial pilot and six passengers were fatally injured. The purpose of the flight was to provide the passengers with a sightseeing tour of the northwest portion of the island of Maui. The flight originated from a heliport on the Kahului Airport at 0955.

According to management personnel at Blue Hawaiian Helicopters (BHH), the established tour route involved circling mountains located in the western portion of the island. The operator's tour literature advertises that the tour would provide the fare-paying passengers with views of deep valleys, knife-edged ridges, mist-shrouded peaks, waterfalls cascading down towering cliffs, and a rainforest.

About 0959, after the pilot's takeoff and departure from the airport vicinity, the Federal Aviation Administration (FAA) local air traffic controller advised the pilot that radar services were terminated. The pilot acknowledged the controller and proceeded flying on the tour. Contrary to instructions, the pilot did not reset the helicopter's transponder from its assigned code to the code for flying under visual flight rules (VFR). There were no further recorded radio transmissions to or from the accident pilot.

The majority of the helicopter's flight and altitude tracks were recorded by radar. The National Transportation Safety Board's Vehicle Performance Division performed a "Recorded Radar Study" in which it examined radar data and provided graphs depicting the helicopter's flight route in relation to the surrounding terrain. As evidenced from the radar beacon data, upon departing Kahului, the helicopter proceeded in a counterclockwise direction circumnavigating the western Maui Mountains. Near the completion of the tour flight, the helicopter was cruising in an easterly direction toward the Iao Valley.

About 1018:29, while at 3,400 feet (as evidenced by altitude transmissions from the helicopter's Mode C equipped transponder), the helicopter turned northward, flew over a ridgeline and entered the Iao Valley. By about 1019:34, the helicopter had flown approximately 1 mile northward into the valley while climbing to at least 3,900 feet. The radar data further indicates that the helicopter then reversed direction and commenced a descent while proceeding along a southerly course. At 1019:44, the helicopter had descended to 3,600 feet, and at 1019:58, it was at 3,400 feet.

The helicopter's last recorded radar position (utilizing beacon target data) occurred at 1020:03. At this time the helicopter had descended to 3,000 feet. By the time of the next radar sweep approximately 5 seconds later, the target had disappeared. The accident site was located about 2,850 feet mean sea level (msl), approximately 1/8 mile southeast of its last recorded radar position.

According to BHH's owner, he has an intimate knowledge of the general area where the accident site is located, having flown in or near the vicinity on numerous occasions. The owner indicated that, although alternate routes are available for the accident pilot to have utilized en route back to Kahului, the pilot's choice of transitioning from the Oluwalu valley into the Iao Valley was the "preferred route" as "it is very majestic as well as a more direct" route through the mountains.

A search for the overdue helicopter was initiated when it had not returned to the Kahului Airport within 10 minutes of its planned landing time. According to BHH's chief pilot, the air search in the vicinity of the helicopter's last recorded position on radar was initially hampered due to the presence of the low elevation layer of clouds that obscured the mountainsides. The accident site was located approximately 1503, near the southwestern portion of the Iao Valley.

1.2 PILOT INFORMATION

1.2.1 FAA Certificates Held and Flying Experience.

The pilot held a commercial pilot certificate with a rotorcraft helicopter rating. He also possessed a certified flight instructor certificate for rotorcraft; however, it expired in 1974. On February 29, 2000, the pilot was issued a second-class aviation medical certificate with the following restrictions: "must wear lenses for distant vision and possess glasses for near vision." On the medical certificate application form the pilot reported that his total pilot time was over 12,500 hours.

According to BHH, by the accident date, the pilot's total flight time was approximately 12,650 hours, of which 12,500 hours were as pilot-in-command. All of the pilot's flight time was acquired flying rotorcraft.

During the 90- and 30-day periods that preceded the accident, the pilot had flown for 231.4 and 82.0 hours, respectively. The pilot's total flying experience in the accident model of helicopter was 55.8 hours. Also, during the 90- and 30-day periods that preceded the accident, the pilot had flown the accident model of helicopter for 25.6 and 4.9 hours, respectively. No instrument flying experience was recorded during the previous 90-day period.

The pilot did not hold an instrument rating. Regarding his instrument flying experience, BHH reported that the pilot's total actual and simulated experience was 1.0 and 4.0 hours, respectively. In 1996 Board documents indicated that the pilot's total actual and simulated experience was 0 and 20 hours, respectively.

A review of the pilot's aviation medical records maintained by the FAA indicates that in June 1996, he reported his total civilian pilot time to date was 8,000 hours, and during the past 6 months he had flown 20 hours. In July 1997, his pilot time was reported at 10,000 hours, and during the past 6 months he had flown 150 hours.

In February 1998, he also reported his pilot time at 10,000 hours, and he indicated having flown 50 hours during the past 6 months. One year later, in February 1999, the pilot reported his pilot time at 11,500 hours, and indicated he had flown 50 hours during the past 6 months. On the pilot's last medical certificate application form he indicated having over 12,500 hours of flying experience. He indicated that he had flown over 500 hours during the past 6 months.

The pilot's personal flight record logbook was not provided to Safety Board investigators for examination.

1.2.2 Preemployment Clearance and Hiring.

BHH hired the pilot in April 1999. According to the Pilot Records Improvement Act of 1996, before hiring an applicant as a pilot, air taxi operators must request and receive records from any company who employed the pilot during the past 5 years. The records address such items as the pilot's history of drug and alcohol testing, completion of training due to poor performance, removal from flying status for any performance or professional competency reason, and disciplinary action. The requisite records were not received from Briles Wing & Helicopter, Inc., the company at which the pilot had worked immediately prior to being hired by BHH.

BHH's chief pilot reported to the Safety Board investigator that one of its pilots had known the prospective employee for 22 years and was "very familiar" with the applicant's experience. Had BHH an indication that the applicant's background was "unfavorable" he would not have been hired.

1.2.3 Accident, Violation, and Driving History Review (Past 5 Years).

Safety Board accident records indicate that on August 4, 1996, the pilot was involved in a midair collision while flying a helicopter during a 14 CFR Part 135 flight with passengers. In pertinent part, the Safety Board's probable cause of the accident was related to the pilot's inadequate visual lookout.

The FAA conducted an investigation and sanctioned the pilot for (1) his careless or reckless operation of the helicopter in such manner so as to endanger the life or property of another, and (2) his failure to maintain vigilance in the operation of the helicopter so as to see and avoid the other aircraft. The folloiwng year, the pilot was sanctioned for operation of a helicopter on a 14 CFR Part 135 flight with an expired Second Class medical certificate.

A review of motor vehicle driving records in the states of Hawaii and California was performed. No evidence of accidents was noted. No violation history was noted in Hawaii. According to the State of California Department of Motor Vehicles in October 1998, and in March 1999, the pilot was convicted of vehicle code violations for driving upon a highway at a speed greater than is reasonable or prudent.

1.2.4 Currency and Inadvertent Flight into Instrument Meteorological Condition (IMC) Procedures.

BHH's management reported that it instructs and examines its pilot on their ability to operate the helicopter under simulated IMC. The company's FAA Operations Specification requires that it have an approved inadvertent IMC procedure in its training program, and that the accident pilot complete yearly training on the emergency procedures.

On April 4, 2000, the pilot received 0.2 hours of flight training in the approved procedures to escape from an inadvertent entry into IMC. According to BHH's FAA accepted training program, while wearing an instrument hood the pilot was trained to perform the following maneuvers: (A) straight and level flight; (B) 180-degree climbing turns, left and right; and (C) recovery from unusual attitudes. The pilot satisfactorily completed the requisite training.

The pilot's last required FAR Part 135 pilot competency/proficiency flight check was accomplished on April 14, 2000. BHH's chief pilot conducted the examination. The indicated flight duration was 0.6 hours and the results were noted as satisfactory.

According to the chief pilot, during the check flight the accident pilot's instrument flying procedures were examined. The pilot was instructed to adhere to the company policy that specified upon entering IMC, he should "check the gyros, slow down and make a level 180-degree turn." Following completion of the course reversal turn, the pilot was permitted to climb or descend, depending on situational requirements.

1.2.5 Required Rest and 48-Hour Activities.

The FAA reported that a review of the BHH's flight time limitations and rest requirements for the pilot revealed no irregularities. They conformed to requirements.

Regarding the pilot's activities during the 48 hours prior to the accident, July 19 was his scheduled day off from work, and the pilot did not work at BHH. The pilot's wife reported that her husband awoke about 0700, and throughout the day was engaged in the performance of duties around their home. In the evening they went on a picnic with neighbors, and they retired about 2200.

On July 20, the pilot awoke at 0615, and arrived at work at 0715. During the day he performed seven tour flights for a total of about 6 hours of flight time. He completed the last tour flight at 1710. The pilot's wife reported that she picked up her husband from work because he was still having mechanical problems with his motorcycle. They drove home, ate dinner, and retired between 2130 and 2200.

On July 21 they awoke at 0515, and departed home at 0540. She drove her husband to work, arriving about 0615. (BHH's records indicated the pilot arrived at 0610.) The pilot's first flight of the day was an operational test flight resulting from previous maintenance (not in the accident helicopter). The pilot departed on this "Ops" flight at 0735 and landed at 0800. The pilot's first tour flight was scheduled to depart at 0815. However, the flight did not depart until 0839. The pilot completed the tour at 0944. The next tour (accident flight) was scheduled to depart at 0930, but it did not depart for another 24 minutes.

1.3 HELICOPTER INFORMATION

The helicopter was manufactured in 1982. BHH maintained the helicopter under an annual/100-hour (manufacturer's) inspection program, with the last 100-hour inspection accomplished 52.7 hours prior to the accident. The helicopter had accumulated a total flight time of 8,384 hours.

The FAA authorized BHH to only operate the helicopter under day and night visual flight rules. In pertinent part, the helicopter was equipped with a magnetic compass, a turn and bank indicator, a directional gyroscope, and an attitude indicator (artificial horizon).

The last recorded pitot-static, altimeter and transponder inspections were accomplished on November 16, 1998. A review of the helicopter's historical maintenance files, and BHH's maintenance records, did not reveal evidence of any mechanical irregularities, squawks, or open maintenance items germane to the accident flight.

1.3.2 Weight and Fuel Reserve Computation.

According to BHH's dispatch documents, the helicopter's gross weight was 5,291 pounds. At the time of departure the helicopter weighed 4,639 pounds. The fuel load was listed for takeoff and landing at 303 and 121 pounds, respectively.

Safety Board investigator calculations indicate that the 182 pounds of fuel burn off during the planned 30-minute flight equals a burn off rate of 364 pounds per hour. At this consumption rate, upon landing the fuel reserve would be 20 minutes, which is in accordance with FAA mandated fuel supply requirements for helicopter operations.

1.4 METEOROLOGICAL INFORMATION

1.4.1 Weather Briefing and FAA Requirements.

The pilot's wife indicated that on the morning of the accident, her husband did not use a computer to check the weather conditions prior to departing for work. According to BHH's other pilots, when they received their morning weather briefings the accident pilot was not nearby, and they cannot verify that he received the briefing information. According to the FAA's air traffic manager at the Honolulu Flight Service Station, the facility did not have any communications with the accident pilot during the morning of July 21.

BHH's FAA approved operations specifications state, in pertinent part, that "for local flights...the Pilot in Command will contact Honolulu Flight Service Station to obtain weather data prior to the first flight of the day...." In addition, "the Pilot in Command must obtain current and forecast weather information along the route and for the destination."

1.4.2 Weather Reports and Forecasts.

The accident site is located on a mountainside near the western portion of the Iao Valley, which has the anecdotal reputation for being the second wettest location on earth in terms of rainfall. Maui residents report that the weather conditions frequently change with respect to cloud formation and the elevation of the cloud bases and tops.

BHH's owner reported that at Maui's latitude, the trade wind direction is principally from the northeast. As moisture-laden air encounters the northeast shore of the island and ascends over the mountainous regions, the weather conditions can change dramatically within a few minutes.

A Safety Board meteorologist investigated the meteorological conditions that prevailed at the time of the accident. The following area forecast and terminal weather conditions were noted:

1. A modest easterly airflow was depicted over the area with diminishing and brief trade showers, typical for the region. No Airmen's Meteorological Information (AIRMET) was in effect for flights over the area.

2. The National Weather Service synoptic discussion indicated that a new shower area was arriving over the windward (northeast) side of Maui.

3. Scattered clouds were forecast over the windward section of mountains with bases at 2,000 feet; scattered to broken clouds at 4,500

NTSB Probable Cause

The pilot's inadequate decision by which he continued visual flight rules flight into instrument meteorological conditions. Also causal was his failure to maintain terrain clearance resulting in a collision with mountainous terrain. A contributing factor was the low ceiling.