NTSB Lays Into FAA For Inaction On Safety Management System Mandate


The National Transportation Safety Board has placed a substantial amount of blame on the FAA for a 2019 fatal air tour helicopter crash in Hawaii. In a statement released today (May 10), Board Chair Jennifer Homendy wrote, “The NTSB previously made 11 recommendations to the FAA to prevent accidents like this one, but our recommendations only work when they are implemented. It’s time for the FAA to act.” She added, “When the NTSB issues safety recommendations, they are data-driven, supported by factual evidence developed from investigations, and are carefully crafted to prevent accidents.”

The pilot and all six passengers of a seven-seat Airbus AS350 B2 helicopter were killed when the commercial air tour flight encountered deteriorating weather and crashed in wooded terrain near Kekaha, Hawaii, on Dec. 26, 2019. The helicopter was operated by Safari Aviation, whose 69-year-old chief pilot and check airman was at the controls. Though described by the NTSB as “highly experienced,” he, nevertheless, “flew into a mountainous region shrouded in low clouds and fog and wasn’t able to exit the area of limited visibility before he either lost control of the helicopter or flew into rising terrain he wasn’t able to see.” Conditions were described as “an atypical weather pattern of low clouds and rain [that] began to move onshore from the northwest into areas along the tour route.”

The board expressed frustration with the FAA for not implementing its repeated recommendations that formal safety management systems (SMSs)—defined as “organization-wide program[s] to manage risks and assure the effectiveness of safety controls”—should be mandated for all air taxi and air tour operators.

From its statement: “The NTSB initially recommended the FAA require air taxi and air tour operators to have safety management systems in 2016. Since the FAA refused to take such action, the board reiterated the recommendation for the sixth time.”

Mark Phelps is a senior editor at AVweb. He is an instrument rated private pilot and former owner of a Grumman American AA1B and a V-tail Bonanza.

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  1. This is where regulations come from. The government makes recommendations, private industry doesn’t take it seriously, and the result is a regulation to make private industry comply. A safety management system is not expensive or hard to implement, but many organizations don’t like being self-critical about what they do.

  2. An SMS would have directed the pilot to involve management in the final decision making process. Since it was a chief pilot and check airman who crashed the helicopter, I would like to know how a SMS would have prevented this. As far as I have heard, the FAA doesn’t think much of SMS to begin with. They only made pt121 certificate holders have a SMS because of ICAO. The FAA also knows exactly how much negative feedback (for lack of a better politically correct term) they will get from pt135 and 91K certificate holders on this issue. I know my company president doesn’t want it, and I am not looking forward to dealing with the SMS nonsense again.

    • “As far as I have heard, the FAA doesn’t think much of SMS to begin with.” … “I know my company president doesn’t want it, and I am not looking forward to dealing with the SMS nonsense again.” A reflection on the FAA, your company president and on you, not on the SMS concept.

        • Yes. It’s called “building a safety culture”. If you’re thumbing your nose at the SMS concept, you’re not building a safety culture. And if you’re not building a safety culture, your chief pilot/check airman who should be at the forefront of SMS will flaunt safety at the behest of the president’s bottom line. SMS works but only if everyone from management to line personnel realize it can be their best friend and make it so instead of making it a bureaucratic nightmare.

        • I think you are right about SMS being worthless in this instance. BUT I think the lack of support by you and your company for an SMS program is a reflection of you and your employers desire to skirt safety to keep the operation going. I have worked at 3 135s, 1 had SMS, at that operation the CEO was a pilot on the line with us, he regularly disregarded regs, op specs and company policy to get the job done. Now, I am at my second 121 operation and safety is always first. I think the accident rates between 121 and 135/91 reflect that difference in mentality.

          I was appalled at the decisions made by and supported by management in 135. At one point I was a VP of safety there and they adamant that a FOQA program would only be detrimental, that same operator has had 3 overruns now, and ran over a GPU last year because they preferred to avoid checklist usage.

          • You don’t need some long winded process to have a “safety culture”. My company has never had an accident or injury or fatality. I have never been asked to do something illegal or even unsafe. Nothing kills a management company quicker than a reputation of accidents or abuse of airplanes. My company has a long waiting list of clients wanting us to manage their airplanes. I have every confidence in our maintenance department, not something I could say about one company I flew for that is no longer in business. And the owner has enough sense to pace our growth so the flight and maintenance departments can keep up. My company just implemented an ASAP program.

          • I also worked at a company that had a SMS program. The owner of the company never followed it if it got in the way of business. It amazed me that the DO and chief pilot were willing to deal with that situation very long. I was not, that is one of the reasons I left. Considering the FAA unwillingness to enforce their own legal department’s time and duty regs country wide, why would the NTSB expect the FAA to enforce a SMS program for pt135 and pt91K certificate holders.

  3. Isn’t there already an FAA Rule about not flying into IMC when under VFR? (Although if they were in uncontrolled airspace, then technically, one can fly into IMC – if the aircraft and pilot are both IFR Current. And already a Rule about “Don’t crash and kill yourself and your passengers”?

    Didn’t we see this same scenario in the Kobe Bryant crash?

    I don’t see how another Rule is going to change things.

    As for involving “Management” into the final decision making process, I don’t see how that would change things here. Especially for in-flight decision making in unexpected conditions.

    When I opt to scud-run, it’s always with another pilot onboard and with their consent. So if we really need another Rule for Helicopter Tour Operators, it might be something along the lines of “If there is any chance that the weather will be less than VFR, then a second IFR Rated pilot is required for the flight.”

    (I’m not a helicopter pilot. But my understanding is that, helicopters being less stable than fixed-wing airplanes, they’re not easy to fly in IMC. Having one competent IFR Rated pilot to focus on flying and the other to focus on the moving map sounds a lot safer to me.)

    • I’ll show my ignorance here. The article says a “commercial” air tour flight. And SMS would only be for other than Part 91 Ops. If Part 135, then I’m going to assume that the General Ops Manual didn’t allow flight into IMC.

      If so, then it was another Rule broken. In which case, adding one more Rule won’t make any difference.

  4. Two things to remember about NTSB: (a) NTSB’s only mission is to make recommendations to enhance safety. FAA, on the other hand, acts by making rules, not recommendations. Rulemaking must comply with a handful of laws that require cost-benefit analysis and prioritization. Result: Often NTSB just can’t have what it wants. (b) NTSB hearings are not like court hearings; they’re more like congressional hearings. In court, opposing sides produce evidence, a judge or jury decides what to believe and follows those facts to reach a conclusion; there can be surprises. In an NTSB hearing, as in a congressional one, the conclusion is decided well before the hearing starts; if there are any surprises it means someone on the NTSB staff screwed up. NTSB hearings are dog-and-pony shows intended to persuade the public that the NTSB is right and to pressure the FAA into going along. Watch them as you would congressional hearings and soap operas. Better, read the transcripts. As in soaps, the writing is often better than the acting.

  5. That said, weather cameras and radio relay stations scattered around the Hawaiian islands sound like very good ideas to enhance pilots’ situational awareness and avoid VFR into IMC. FAA is not the only entity, and the federal government not the only unit of government, that can invest in infrastructure. State of Hawaii: You have significant interests in tourism and safety within your borders. Time to step up?

  6. Here we have it–yet ANOTHER discussion of “we need more rules” vs. “rules don’t improve safety.” Put me down for the latter.

    Consider the difference between Part 135 and corporate Part 91 fixed-wing operations. I use this comparison because both are conducted by commercial pilots–weeding out the “low time private pilot” argument. Same aircraft–same pilot qualifications. In corporate operations, Part 91 has far fewer restrictive rules than Part 135–they fly pretty much the same aircraft–yet corporate Part 91 operations have a FAR BETTER safety record than Part 135–putting the lie to “more rules make flying safer.”

    Some would say that Part 135 has a worse safety record than Part 91 “because of management pressure.” In both cases, FAA rules specify the weather and terrain clearance minimums–either you adhere to them or you don’t. MANAGEMENT didn’t fly that aircraft into the ground–the PILOT did it. It is a horrible indictment of our system when a pilot is more afraid of management than they are of being killed in a crash. To improve safety, we don’t need more “cover your butt” rules–we need to adhere to the RULE #!–“Short of war time, there is no reason to make a flight you are not comfortable with”–and RULE #2–“there is no job worth your life.”

    I manage corporate aircraft. I’ve put them on Part 135 certificates, and will never do so again–the additional “busy work”, liability exposure, and additional cost just isn’t worth it. It is a heck of a comment to say that “We have a paid-for and well-equipped turbine aircraft–and pilots that attend professional recurrent training, but is not worth the additional time and expense of conducting Part 135 operations.”

    Do you know any pilots that would rather fly Part 135 than Part 91? NEITHER DO I!

  7. Having worked for an organization who’s “safety” decisions were based on $$ and not safety (like demanding that CFIs take students out in low marginal VFR known icing conditions and being told “You are instrument certified, just depart IFR.” into those conditions), and having seen first-hand the tourism industry in Hawaii, I can completely understand (not condone) what that chopper pilot did. The rules to prevent a crash like this are already in place. Another risk matrix is not going to fix the root cause.

  8. Safety Management System (SMS) does work. SMS is just very poorly explained. If you had a full career in Aviation or any job that requires daily judgement calls you have been practicing SMS.

    Pilots with successful careers have specific ‘Rules to LIVE By’. Those rules may not apply to my personality as much as other rules but, we each follow our personal ‘Rules to Live By’. SMS is just a practice of “Discussing”, “Documenting” and Discussing again The ‘Rules to Live By’ in a manner that they are practiced and shared with the current and future Aviators.

    The accident in this article would have been prevented by the pilot’s acknowledgement that tourist do not want to pay for a sight seeing tour in the clouds. Instead the pilot decided to ignore his most basic ‘Rules to Live By’ and risk everything for a couple bucks. The SMS manual creates the discussion and recognizes the rules Safari Aviation employees WILL follow. The regularly scheduled discussions are similar to an Alcohol Anonymous (AA) meetings (it gets personal). From my experience after about three meetings the newest employee feels involved and a part of the company. ‘Standards’ instead of ‘winging it’ are discussed and comfortably practiced. The goal being: Inclusive Work Environment.

    When you are thinking about your own ‘Rules to Live By’ ask yourself: How could I have sat with that accident pilot and prevented this scenario? If you are asked to create a class syllabus titled: “LONG & Prosperous Aviation Career” for every Aviation Student to take, what would you teach them?

  9. I am a retired aircraft engineer for one of the major GA manufacturers. I have read about future SMS requirements for Part 21 (certification), and have had a hard time figuring out what the program would involve differently than we do/did anyway, except for likely additional paperwork and bureaucracy.

    • With regard to my comment on additional paperwork and bureaucracy, I just tried to read the EASA Comment/Response document for proposed Part 21/145 SMS. It is 1387 pages. Sort of makes my point.

  10. This is a leadership issue. If you have regs, policies, rules, standards etc but the culture just thumbs their noses at it, then you WILL have accidents and fatalities. If you see leadership disregard these, run away. It will catch up to you. We see this every day in the accident reports.

    We need an anonymous whistleblower program, or some other mechanism that would protect the passenger. It’s too late for the families once the copter goes down. Pilots that know their company doesn’t operate in a safe manner but don’t say anything must feel some level of guilt for these accidents.