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An air tour helicopter crash on Kauai last month that killed three people occurred against a backdrop of conflict among regulators and the tour business over how best to assure safety, including a warning about dangerous practices just a week before the accident.

In a July 3 letter, the National Transportation Safety Board warned the Federal Aviation Administration that some local air tour operators and pilots were drifting toward “risky weather-related operating practices” and flying heavily trafficked sightseeing routes without adequate communication.

The NTSB has criticized the FAA for poor oversight of local air tours and delaying reforms after a crash in 2019 killed seven near Kekaha.

Even as that dispute has played out, the importance of the FAA’s oversight of the air tour business became clearer. A week after the July 11 Kauai crash, recently enacted state legislation requiring more monitoring of air tours by the state Department of Transportation was struck down in the U.S. District Court in Hawaii.

An industry-funded lawsuit successfully argued the FAA had preemptive authority, reinforcing its central role in regulating Hawaii air tours.

The Kauai crash may also raise new questions about the type of helicopter that went down. The Robinson R44 model has been the subject of safety concerns and has a long history of accidents, including mid-air breakups during turbulence.

From 2006 to 2016, the R44 had the highest fatal accident rate among all major helicopter makes, according to the NTSB’s accident database.

The three fatalities on the copter operated by Alii Kauai Air Tours brought the total killed in Hawaii air tour accidents since 2000 to 48.

The letter, from NTSB chair Jennifer Homendy to FAA administrator Michael Whittaker, was the latest NTSB criticism following a fatal crash in 2019 in Kekaha.

That accident five years ago was the result of the pilot’s decision to continue flying in deteriorating weather before losing visibility and crashing into a hillside, the NTSB found. Gaps in communication infrastructure and a lack of safety management at the company, Safari Helicopters, contributed to disaster, the board said. 

During that investigation, NTSB investigators heard testimony about a local culture of “pushing the weather.”

“The biggest thing that we fight here is that old cultural mindset of ‘get it done, just go,’” said Eric Hamp, operations manager from Blue Hawaiian Helicopters.

Homendy’s July 3 letter said the NTSB remains “concerned that there may be a tendency among some companies or individual pilots to develop norms for accepting increasing weather-related risks – until they encounter a situation from which they cannot safely escape.” 

Hawaii operators contacted in the past few weeks pushed back on the idea that there was pressure on the pilots to keep flying no matter what. 

“Pilots get to make the call on weather,” said Casey Riemer from Jack Harter Helicopters. “We will not pressure them, but we will make them justify their decision.”

Curtis Lofstedt from Island Helicopters on Kauai also said his pilots get to decide if conditions are safe to continue flying. 

The owner of Alii Kauai Air Tours, William Zeffiro, declined to comment.

But while the industry presents itself as an effective steward of flight safety standards, observers remain concerned – among them Sen. Brian Schatz, who sits on the congressional committee with oversight of the FAA.

“We clearly have a problem in the state of Hawaii, and people are dying,” he said in an interview.

Rapid Ascent From Waimea Canyon

There were 80 air tour landings per day at Lihue Airport in 2023 — more than half of all landings at the airport and 40% of all the air tour traffic in the state.

Riemer from Jack Harter Helicopters said that nine operators are flying 30 helicopters around Kauai, fewer than 30 years ago. Most of these aircraft are carrying at least two passengers paying a minimum $250 a flight, although most tour options cost more.

Alii Kauai Air Tours promotes its use of Robinson R44 helicopters for its “private and personalized tours” with a maximum of three passengers, including in “doors-off” configuration meant to ensure all-round visibility.

Guy Croydon, a licensed flight instructor, had already piloted the 2009 R44 registered N144KW on three earlier flights along the same route July 11, according to data from the flight tracking website .

The site uses a number of sources to monitor aviation traffic, including radio signals generated from a transponder on the aircraft picked up by computerized tracking stations — .

The ADS-B data from N144KW show it followed a path used by most local operators on a one-hour sightseeing tour that takes in Waimea Canyon and tracks along the Na Pali Coast before a return leg tracks through the Waialeale Crater — the location of a fatal crash in 2003 involving a Jack Harter helicopter.

The 9-mile stretch of the route from Honopu to Haena on Kauai's north coast is a known blackout zone for radio, radar, ADS-B coverage and cell reception.

But enough data was captured to show that on its final flight, N144KW behaved differently than on earlier flights of the day about 18 minutes after takeoff.

The deviation occurred at 12.50 p.m. as Croydon began the climb out of the Waimea Canyon with his two mainland passengers, James and Amy Quintua from Kentucky.

At , the helicopter abruptly ascended for 25 seconds as Croydon tried to clear the rim of the Waimea Canyon. The helicopter ascended at a rate of 1,273 feet-per-minute -- more than double the rate the helicopter flew earlier that day at the same location, the helicopter's ADS-B data shows.

That rate of climb is well above Robinson's published .

A replay of the flight available on Flightradar24 shows Croydon struggling to maintain level flight in that segment. That half-minute was, at the very least, inconsistent with controlled comfortable flying. Croydon had reduced his air speed when he entered the Waimea Canyon the data shows, which Robinson's own manual advises pilots flying R44s to do if they encounter turbulence.

N144KW eventually cleared the western rim by 160 feet before abruptly descending by 700 feet-per-minute. The helicopter and its occupants then went through a five-minute period of turbulence before its ADS-B signal was lost at 12:55 p.m. over the Na Pali-Kona Forest Reserve.

About five minutes later, hikers on the coastal Kalalau Trail felt a "huge" and sudden gust of wind blow over them, they told NTSB investigators. A loud “bang” followed and they turned and “saw the helicopter wreckage free falling into the ocean in two sections, a main fuselage section, and the tail boom section” about a quarter-mile offshore.

The lack of cell tower coverage on that part of the coast meant it was something of a miracle that the text message the hikers sent reached Kauai’s police dispatch at 1:20 p.m. Two ocean safety officers on jet skis who reached the location in about 20 minutes reported an oil slick and recovered the body of Amy Quintua. Kauai's fire and police chiefs acknowledged that communication issues delayed news of the accident and the recovery effort.

The NTSB will determine what role weather played in the accident but its preliminary report mentioned a strong pressure gradient off Kauai’s north shore and gusting easterly winds.

The National Weather Service has confirmed there were also – AIRMETS – in effect for the area July 11. AIRMET Sierra indicated lower cloud ceilings, reduced visibility and "extensive mountain obscuration" and AIRMET Tango warned of surface winds up to 30 mph and low-level turbulence on the lee of mountains due to the strong trade winds.

Both weather warnings take on more significance when considering the helicopter’s rapid ascent out of the valley, the model's safety record and the to avoid flying in turbulence and when surface wind speeds exceed 28 mph.

'Mast Bumping' And Mid-Air Breakups

Robinson R44s like N144KW are relatively affordable helicopters in widespread use, “a proven product” according to Chuck Street, the western U.S. representative of the industry lobby group, Vertical Aviation International.

"There's a lot of them out there, and a lot of successful missions and operations, so I think we have to wait and see what the NTSB has to say about that incident," Street said.

At least 10 other R44s continue operating in Hawaii as of Aug. 1, according to .

But the R44 also has a well-documented history of accidents that are linked to its tendency for “mast bumping.” 

Mast bumping or rocking in Robinson R44s has been linked to multiple accidents including , particularly in low-gravity conditions. These most often occur during turbulence, especially if the pilot makes abrupt or severe changes to the controls. 

Under those conditions, the Robinson’s two-bladed main rotor can seesaw on its tall mast, producing excessive vibrations and, in the worst cases, striking the cabin or tail assembly, case studies show. The NTSB has reported that was likely the cause of near Bluestem, Washington, less than a month before the Kauai accident.

The of an R44 in Alaska brought the issue to a head in the United States and led the NTSB to call on Robinson to track the frequency of mast bumping incidents, alert service centers to the issue and actively look for an engineering solution.

Robinson issued about the dangers of flying its R44 models in high winds especially on the “downwind side of hills, ridges, or tall buildings where turbulence will likely be most severe,” and addresses the problem in its own training materials.

The company has also made design modifications, and last year released an for the tail section of the R44 to address a dangerous tendency for the helicopter to roll right during mast-bumping events.  

A New Tool: Weather Video

One significant safety development has occurred in Hawaii’s air space since the last fatal accident in 2019 -- remote cameras.  

In theory, Croydon would have been able to review near-realtime video images of some of the route transmitted from remote sited at Makaha Ridge and Princeville. 

The camera stations transmit images from four different compass points as well as limited textual weather data like wind speed and temperature. The Makaha Ridge station is 6 miles from the reported crash site and in theory, may have captured footage of the incident that is only available to the public for six hours before the files are written over. A Freedom of Information request by Civil Beat for archived footage is pending.

The FAA began installing a network of the cameras across the state in 2022. There are now 21 and another five will be installed on Kauai, the Big Island, Maui and Molokai. The FAA did not confirm the exact locations.

The cameras have been operating in Alaska for more than a decade but for funding and other reasons took much longer to arrive in Hawaii. The NTSB investigation partly blamed the 2019 Safari Aviation accident that killed seven on the delayed implementation of the weather camera program by the FAA. 

Riemer from Jack Harter Helicopters agrees that the 2019 accident would likely have been prevented if the system had been available, describing it as “the biggest advance in aviation safety that I have seen in my 35 years of involvement with the helicopter industry in Hawaii.”

Then why didn’t the new system help prevent the accident on July 11? 

Lefsted from Island Helicopters said that the four weather cams on Kauai do help pre-flight decision-making, but his company relies on a range of information sources.

The FAA also advises that the images need to be used alongside other weather data, and the camera feeds are on a 10-minute delay so might not be showing rapid weather changes, for example.

It’s not known if Croydon checked weather cam footage as he decided whether to proceed with the 12:30 p.m. tour. But neither camera would have given any indication of the issues in the AIRMET warnings or the conditions in Waimea Canyon where data indicates they encountered turbulence.

The decision to go came down to a judgment call during a few minutes on the Lihue tarmac -- the kind of decision air tour operators in Hawaii continue to make every day. 

What About Safety Culture?

The July 11 accident occurred a week before the U.S. District Court in Hawaii quashed state legislation that would have given the state Department of Transportation additional oversight of air tours. 

A spate of helicopter accidents -- including three in 2019 -- led to calls for more scrutiny of the helicopter flights. Act 311, signed into law in 2022, required operators to file monthly reports on their takeoffs and landings, passenger loads, routes and route variations.  

But in a July 22 decision, Magistrate Judge Kenneth Mansfield placed a , finding that the federal regulatory authority of the FAA legally preempts regulation on the state level.

The industry lobby group brought the suit because it said it did not want to see a “hodgepodge of very different kinds of requirements across the United States,” Street said. A total of 10 helicopter companies, including Safari Helicopters from the 2019 Kekaha crash, put money into the action, according to Riemer. 

“Some helicopter companies take safety seriously and proactively worked to improve it," said state Sen. Chris Lee, who co-sponsored the original legislation.

"But it’s very telling when other bad actors would rather go to court to stop any real discussion about how to keep people safe. It’s absolutely terrible, but I’m honestly not surprised there are another three dead people on Kauai.”

The injunction also puts the spotlight back on the FAA’s ability to effectively monitor the local industry, an issue that the NTSB letter of July 3 addresses.

“We continue to believe that the FAA needs to develop innovative strategies for conducting operational oversight of air tour operations to reduce procedural drift toward risky weather-related operating practices,” the letter states.

That could include regular FAA review of video recorded onboard and flight-tracking data to detect trends in weather-related operating practices, including flight path deviations, the NTSB said. The NTSB has been pushing for an expansion of ADS-B technology here as one of its key safety recommendations.

But that additional review would further stretch the resources of the FAA's Flight Standards District Office in Honolulu. The office has been historically underfunded and understaffed and was at the center of a whistleblower scandal in 2020 over alleged misconduct by its managers. That led to an investigation by the Office of Inspector General at the U.S. Department of Transportation that still hasn’t been resolved.

The FAA recently wrote to the NTSB that it has increased the number of aviation safety inspectors in Hawaii to 15 after allowing them to reside anywhere in the state to help with retention. The FAA, however, would not provide a list of staff at the Honolulu Flight Standards District Office. Civil Beat has filed a FOIA request.

Issues in the office were supposed to be addressed as part of the in May, said Schatz, who sits on the  Commerce, Science and Transportation Committee. But before they would support that bill, Republican members including Ted Cruz knocked out everything that wasn’t sufficiently pro-industry, he said.

“The industry won this round, just to be blunt," Schatz said.

Other measures that largely align with NTSB’s recommendations for the local industry are contained in another bill Schatz hasn’t been able to enact yet. He said the issues in the industry can’t be addressed through the FAA or rule-making, but require new statutory standards. 

After the developments of last month, operators and industry voices like Street and Riemer are rallying behind one new mandate included in the FAA reauthorization intended to encourage a culture of safety in local helicopter companies.

Operators are now required to create a -- essentially policies and procedures that assess and manage organizational risk. The FAA will be responsible for reviewing the policies, which must be completed within the next three years. 

"Anything that helps improve safety is good," Lofstedt said.

But critics say those policies are a low bar and are best suited for larger operations like airlines with layers of staff and multiple departments. Riemer says most operators will be able to comply by modifying .

Acknowledging the renewed scrutiny on the local industry, Vertical Aviation International has convened a in September to "boost air tour safety” and help operators comply with the FAA's safety management system mandate. 

Thursday: Tour companies are fighting efforts to restrict flights over Hawaii Volcanoes National Park. 

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