The NTSB is faulting the pilot for the fatal air tour crash of a Blue Hawaiian Helicopters Airbus EC130B4 that went down in heavy rain and limited visibility on the island of Molokai on Nov. 10, 2011. The crash killed pilot Nathan Cline and his four passengers. However, lawyer Ladd Sanger of the Texas firm of Slack & Davis, who represented the family of Canadian crash victim Stuart Robertson, also alleges that Blue Hawaiian’s pilot training was deficient and that Cline’s checkride of Molokai had been “pencil-whipped.” Blue Hawaiian settled with the Robertsons last March.

The NTSB final report on the accident was released on July 25 this year. It concluded that the accident’s probable cause was “the pilot’s failure to maintain clearance from mountainous terrain while operating in marginal weather conditions, which resulted in the impact of the horizontal stabilizer and lower forward portion of the Fenestron with ground and/or vegetation and led to the separation of the Fenestron and the pilot’s subsequent inability to maintain control. Contributing to the accident was the pilot’s decision to operate into an area surrounded by rising terrain, low and possibly descending cloud bases, rain showers and high wind.”

In its report, the NTSB also noted that “the combined loading from the horizontal stabilizer and the Fenestron’s impact with vegetation and/or terrain caused the stress in the forward flange of the junction frame to exceed its ultimate design strength. The forward flange of the junction frame fractured, which allowed the Fenestron to separate from the tail boom.”

Responding to the NTSB’s findings, Blue Hawaiian Helicopters president Patricia Chevalier said in a prepared statement issued July 24 by parent company Air Methods that “we are studying the report closely and taking the findings to heart to further improve our processes and procedures.”

Chevalier further sent this statement to AIN: “Blue Hawaiian Helicopters was the first company in the United States to be certified under the Tour Operators Program of Safety (Tops). The company conducts more hours of flying than any other air-tour company and has implemented a Safety Management System program in cooperation with the FAA. This safety system goes beyond the requirements of Tops by incorporating safety assurance feedback loops, much like the quality-control systems of ISO 9000.”

Blue Hawaiian operates 44 helicopters. In a written statement given to AIN earlier this year, Air Methods CEO Aaron Todd said, “Air Methods has a strong commitment to safety. Our progress in maturing our FAA-overseen safety management system (SMS) has been successful. In May 2013, seven months before acquiring Blue Hawaiian, we successfully reached the highest and final level (Level 4) of the FAA’s voluntary SMS program: the continuous-improvement stage. Under the SMS umbrella we continue to actively pursue and invest in technology, systems and training well in excess of FAA requirements, all while encouraging a culture of compliance.”

Before the release of the NTSB final report, attorney Sanger told AIN that factors related to inadequate new-hire pilot training and the peculiarities of Hawaii’s microclimate likely were significant causal factors in the accident. The NTSB report is evidence once again suggesting that pilots flying in Hawaii, as they have in Alaska, would benefit from the installation of weather cameras. An FAA spokesman said a final decision on whether to fund installation of said cameras, expected earlier this year, remains pending.

Sanger is reticent about faulting Cline, who was hired by Blue Hawaiian on July 1, 2011, and completed his training in the EC130B4 on July 10, 2011. Before joining the company, he had been flying the Bell 206 and 407 in the Gulf of Mexico for the Bristow Group. Hawaii’s microclimates make it a unique flying environment that requires special training, Sanger told AIN. Blue Hawaiian’s “training program requires a local orientation flight for each island but Blue Hawaiian short-changed Cline’s training and checkout for flight to Molokai. The records indicate he was given local orientation on Molokai and Lanai in the same flight but [the] recorded duration of the flight was not long enough to cover both islands,” Sanger said. Cline’s master training records in the NTSB docket lack information concerning dates and times of specific orientation flights, showing only an initial and recurrent checkride for Maui.

Cline had accrued 4,500 flight hours at the time of the crash, 306 of them in the EC130B4. He held an instrument helicopter rating and had passed a Part 135 competency checkride administered by the FAA’s principal operations inspector (POI) for Blue Hawaiian Helicopters the day before the crash. According to the NTSB, “The checkride included instrument navigation and communications procedures, inadvertent IMC procedures and unusual-attitude recovery. According to the POI, the accident pilot was capable and current in all of his required pilot tasks and training.”

However, under questioning from Sanger in a court deposition, a fellow pilot testified that he personally had observed Cline violating the Hawaii Air Tour Common Procedures Manual (FAA AW13-136A) and missing radio calls as recently as two weeks before the crash.

The accident helicopter was equipped with the Garmin G500H system, including optional helicopter synthetic vision technology (HSVT) system that is shown on the pilot’s primary flight display with visual and audio terrain and obstacle identification and alerting. However, because of a lack of accurate local weather reporting, the G500H can have limited utility in Hawaii. The NTSB accident report noted, “When asked if the pilots had any form of in-flight weather available to them, [Blue Hawaiian chief pilot Darl] Evans replied no. The Garmin 500, which was installed in the accident helicopter, can have weather information downloaded; however, since the system used airport weather reports it does not provide accurate enough weather information for the pilots where they need it most. Evans further mentioned that the company has been trying with the FAA to get weather cameras up along the coastlines of the islands; however, they are having difficulty getting funding. Evans also stressed that the company has limited radio contact with its helicopters because their radios are restricted to line of sight. There is no repeater; therefore, transmitting capabilities are not good.”

Flight Challenges for the Pilot

Sanger said time pressure also might have contributed to the crash. “There are several different routes that you can fly for the Molokai tour.” The crash flight initially was supposed to be a tour of Maui, but the weather there was so poor the Maui flight could not take place, so the tour was changed to Molokai. “Nathan hadn’t flown the Molokai tour very many times and wasn’t properly trained on it,” Sanger said, noting that Cline “had been nine minutes late on the previous tour flight that day on Molokai. At ten minutes Blue Hawaiian’s procedures call for them to initiate search-and-rescue. So he had obviously encountered some difficulty on the previous flight. For the normal route in good weather you go up the right side of the island around a waterfall and then come around the top of the island and pop up over the top of a ridgeline. We believe that is where he encountered bad weather because of witnesses who said the weather up there was an absolute downpour.” Sanger suspects Cline tried to get below the weather and then was caught by a wind shear on the back side of the mountain.

AIN attempted to contact Blue Hawaiian CEO David Chevalier via telephone and e-mail concerning Sanger’s allegations. Chevalier did not respond directly, but forwarded the request to Air Methods, which again provided the June 24 statement without further comment, noting that the accident “remains under investigation.”

Over the years the NTSB has noted the unique challenges of helicopter flying in Hawaii, including terrain, mountain wind and rapidly changing cloud conditions. A spate of fatal heli-tour crashes in Hawaii between 2004 and 2007 brought increased criticism of, and scrutiny on, the industry. The NTSB faulted heli-tour operators for inadequately training new-hire pilots on the particulars of flying in Hawaii. The Safety Board reviewed weather-related accidents since 1994 and found “four involved pilots who were relatively new to air-tour operations in Hawaii, three of whom had been operating for less than two months. The Board cited the pilots’ inexperience in assessing local weather conditions as a contributing factor.

Airbus Helicopters Takes Corrective Action

As noted elsewhere in this article, the NTSB stated that “the combined loading from the horizontal stabilizer and the Fenestron’s impact with vegetation and/or terrain caused the stress in the forward flange of the junction frame to exceed its ultimate design strength. The forward flange of the junction frame fractured, which allowed the Fenestron to separate from the tail boom.”

The accident helicopter was placed into service on April 16, 2010, and had accumulated 2,440.1 hours. The Board stated that “the helicopter was maintained in accordance with an FAA-approved aircraft inspection program (AAIP). The most recent 100-hour inspection was completed on Nov. 8, 2011, at 2,431.4 hours total time since new (TTSN). During this 100-hour inspection, Eurocopter Emergency Alert Service Bulletin # 53A019 (check of the tail boom/Fenestron junction frame for cracks) was complied with, and no defects were noted.”

Airbus Helicopters (AH) provided AIN with a written statement with regard to the original and subsequent bulletins/ADs:

“The company has launched a complete internal investigation to understand the origin of these cracks, which includes measures of stresses in flight on the aircraft, fatigue testing, finite element model stress calculation and so on. AH will implement the appropriate corrective actions based on the outcome of this investigation. In the meantime, the preventive measures requested by AH guarantee the safe operation of the helicopter.”

Those measures include an Emergency Alert Service Bulletin issued on June 9 (revised June 13) and the August 5 FAA AD following reports of two events of crack propagation through the junction frame of the tailboom/Fenestron on EC130B4s. To date, cracks have not been found on the junction frames on any of the newer EC130T2s even though both helicopters use the same tailboom structure. AH reports that 433 EC130B4s and 50 EC130T2s are in service and that the combined fleet has accumulated 1.2 million flight hours.

AH said there are “no links” between the two recent reported incidences of crack propagation and the 2011 Blue Hawaiian accident.

On August 5, 11 days after the NTSB issued its accident report, the FAA published a new airworthiness directive (AD) for EC130B4 and EC130T2 helicopters that requires more stringent inspections for cracks in the FenestronFenestron-to-tailboom junction frame. Failure of the junction frame could result in the loss of the Fenestron and subsequently loss of control of the helicopter. The AD applies to helicopters with 690 or more hours time in service (TIS) and requires, within 10 hours of TIS, “removing the horizontal stabilizer, cleaning the junction frame and dye-penetrant inspecting the junction frame for a crack” in a specified area. It also requires 25-hour inspections, using dye penetrant or a borescope, of another area on the junction frame for cracking. If any cracking is found, the junction frame must be replaced. The previous AD merely required contacting Airbus for approved repair instructions. This one mandates replacement of the junction frame at a cost of $64,250 per helicopter. The new AD took effect on August 20.

Attorney Sanger said there is no evidence that maintenance played a role in the crash. “We looked at maintenance actions thoroughly, including the airworthiness directive on the tail boom, but there was nothing to suggest that their [Blue Hawaiian’s] maintenance on this helicopter was deficient.”