MEDICAL AND PATHOLOGICAL INFORMATION

Postmortem examinations revealed that the cause of death for the passengers from the front left and center seats was 'drowning.' The cause of death for the passenger from the rear right center seat was reported as 'cardiac arrest due to near drowning.' The coroner noted no serious injuries on any of the passengers.

SURVIVAL ASPECTS

During the tour flight, two passengers were seated in the two front seats to the left of the pilot, and the other three passengers were seated in rear seats.20 The two surviving passengers, who had been seated in rear seats, reported that they received a safety briefing before departure and that each passenger was wearing a personal flotation device (PFD) in a pouch attached around the waist.

20 The passengers occupied the rear right seat, rear right center seat, and the rear left seat; the rear left center seat was empty.

The passenger from the left rear seat stated that she did not know how to swim and was panicked. She stated that she donned her PFD vest but had trouble remembering the safety briefing and tried to inflate it while inside the helicopter but could not figure out how to do it.21 She stated that she attempted to assist the passenger in the rear right center seat, who was having difficulty because he was tangled with his headset. After she exited the helicopter out the left side and reached the surface, she still could not figure out how to inflate her PFD. The passenger from the right rear seat assisted her by pulling at least one of the inflation handles to inflate her vest for her.

The passenger from the right rear seat stated that he then dove back down to the helicopter to attempt to extricate the passenger from the rear right center seat. When he resurfaced with that passenger, who was having difficulties breathing, he put that passenger s PFD vest over the passenger s head and inflated it for him.22 The pilot stated that he was already completely under water when he released his seatbelt. He stated that, as he made his way out the helicopter s left side, he tried to see or feel for passengers as he exited, but he did not find anyone. He stated that he made his way to the surface then tried to dive back down to the helicopter, but he could not find its door. He then returned to the surface and found one passenger being supported by two others. He stated that he helped one of the passengers don and inflate a life vest and that he donned and inflated his own vest. Recovery personnel found the body of the passenger in the front center seat still secured in the seat by the lap belt and wearing an uninflated PFD vest. The body of the passenger from the front left seat was found floating facedown in the water and wearing a PFD vest. First responders recalled that the passenger s PFD vest appeared inflated, but they did not know if only one or both chambers appeared inflated. At some point during recovery of the victim, the PFD was removed from the body and misplaced; therefore, it was not available for examination to determine its actual inflation configuration.

21 The safety briefing video instructed the passengers to remove their headsets before donning the PFD vests. The video also showed how to use the PFD s inflation handles and the manual inflation tubes, and it instructed the passengers not to inflate their vests until after exiting the helicopter.

22 The survivors attempted to assist the passenger by providing aided breathing and chest compressions beforerescue arrived, but the passenger died later that day.

TESTS AND RESEARCH

Examination and Functional Testing of Recovered Personal Flotation Devices Four of the six PFDs from the accident were recovered for examination;23 all of the recovered PFDs were Hoover Industries model FV-35E, manufactured in accordance with Technical Standard Order (TSO)-C13e. This model PFD features two separate inflation chambers that a user must inflate separately by pulling each chamber s plastic handle. According to the PFD s design, each chamber is equipped with a pressurized, 16-gram, carbon dioxide cylinder that punctures when the handle is pulled, releasing the pressurized gas into the chamber to inflate it fully within 2 seconds. Each chamber is also equipped with an oral inflation tube into which the user can blow to inflate the chamber.

One of the recovered PFDs belonged to the passenger in the front center seat. Examination revealed that neither chamber was inflated and that the plastic inflation handles were not pulled. Testing revealed both chambers inflated when the handles were pulled. The three other recovered PFDs were, on the basis of passenger interviews, those that were used by the pilot and the two surviving passengers, though it was not known which PFD belonged to which occupant. Examination of these vests revealed one had both chambers inflated, and the other two vests each had only one chamber inflated. Examination and testing of one PFD that had only one chamber inflated revealed the other chamber inflated when the handle was pulled.

Examination of the other PFD that had only one chamber inflated revealed that the inflation cylinder for the uninflated section was dimpled in the discharge area but was not punctured. Testing revealed that, after the dimpled cylinder was reinstalled in the PFD, pulling the inflation handle punctured the cylinder, and the chamber inflated.

Water-Immersion Performance Demonstration of Personal Flotation Devices

Heli-USA provided the investigative team with two PFDs: one was a Hoover Industries model FV-35E, and the other was an Eastern Aero Marine model KSE-35HC2L8.24 Heli-USA had recently retired both PFDs from service after about 12 months of use in accordance with the manufacturers recommended inspection interval.25 These PFDs were used for water-immersion demonstrations to examine donning procedures and to compare vest performance with one and both chambers inflated.

23 According to interviews with the survivors, of the two PFDs that were not located, one belonged to thepassenger from the rear right center seat, and the other belonged to the passenger whose body was found floating facedown in the water.

24 The Eastern Aero Marine model KSE-35HC2L8 is also manufactured in accordance with TSO-C13e.

25 Each PFD manufacturer recommends that the PFDs be returned for inspection at specified intervals. On the recommended annual inspection dates, Heli-USA retired the PFDs from service and replaced them with new ones. The Honolulu FSDO requires its air tour operators to maintain the PFDs in accordance with the manufacturers instructions (the requirement is included in Section D104 of each operator s approved operations specifications).

Although Heli-USA s operations specifications were approved by the Las Vegas FSDO, and Section D104 did notspecifically reference PFD maintenance, Heli-USA followed the manufacturer s recommended inspection intervals.

Two test subjects26 entered the water before donning the PFD vests, and each described that the vests were 'relatively easy' to put on but that two hands were required to place the vest over the head while in the water. The subjects found that, with only one vest chamber inflated, each PFD provided flotation for the wearer, and they were able to remain at the surface with their heads above the water. The subjects also found that, with only one chamber inflated, if they simulated unconsciousness and made no attempts to right themselves, it was possible for them to float facedown. With both vest chambers inflated, it was not possible for either subject to float facedown; the PFDs rolled them to a faceup position within seconds. According to TSO-C13e, which specifies that the PFD must right a wearer who is in a facedown position, the buoyant force needed to meet the TSO is determined with both chambers inflated.

During the demonstration, when the subjects first attempted to pull the inflation handles one at a time, the investigator found that one chamber on the Eastern Aero Marine PFD failed to inflate when the handle was pulled. Examination revealed that the threaded cylinder for that chamber was not screwed securely into its housing. When the investigator properly seated the cylinder and then pulled the inflation handle, the chamber inflated.

Following these demonstrations, another Hawaii air tour operator voluntarily examined

13 PFD vests that had been recently retired from service after about 1 year of use.27 Each PFD had 2 inflation cylinders, and the operator reported that 18 of the 26 cylinders were loose in their housings.

ORGANIZATIONAL AND MANAGEMENT INFORMATION

Heli-USA is based in Las Vegas and conducts Part 135 air tours in Las Vegas and on the islands of Kauai and Oahu, Hawaii. At the time of the accident, the company operated 9 helicopters, including the accident helicopter, and employed 20 pilots and 13 mechanics; 3 helicopters, 6 pilots, and 4 mechanics were used for the company s operations in Hawaii.

26 One test subject was 5-feet 5-inches tall and weighed 128 pounds, and the other was 6-feet 3-inches tall and weighed 195 pounds.

27 Such a voluntary inspection by the operator is only feasible for retired-from-service PFDs because in-servicePFDs must remain unopened within their waist pouches to meet FAA airworthiness requirements. The operator had to open the pouches on the retired PFDs to examine the security of the cylinders.

In 1997, Heli-USA began sightseeing operations in Las Vegas under the provisions of 14 CFR Part 91. The company obtained a Part 135 air carrier certificate in March 1999 to conduct on-demand air taxi operations in the contiguous United States and the District of Columbia, and, in 2000, the FAA amended the company s Part 135 operations specifications to allow for operations in Hawaii.

The Las Vegas FSDO issued Heli-USA s Part 135 operating certificate and, as the certificate holding district office, was responsible for all FAA reporting requirements, technical administration requirements, and regulatory oversight of Heli-USA. The Honolulu FSDO was responsible for surveillance of air tour activities within its geographic area; this surveillance included enforcing SFAR 71 rules and Honolulu FSDO-approved SFAR 71 procedures throughout the Hawaiian Islands.

Company Procedures for Weather Information and Adverse Weather

According to Heli-USA s operations specifications, in class G airspace,28 no flight may be conducted on overland transition segments where the flight visibility is less than 3 statute miles, no flight may be conducted on overwater transition segments where the flight visibility is less than 1 statute mile, and no flight may be conducted closer than 300 feet above, below, or horizontally from any cloud. The operations specifications also require that en route helicopter operations be conducted a minimum of 500 feet above raw terrain and no closer than 1,500 feet from any person, structure, vehicle, or vessel.

According to Heli-USA s general operations manual, pilots are required to obtain valid aeronautical weather information from FAA- or NWS-approved sources. The manual also states that, for VFR operations, the pilot may 'use weather information based on your own observations or on those of other acceptable sources29 to supply appropriate observations' if no reports are available from the approved sources.

The general operations manual also provides procedures for encounters with adverse weather and states that pilots should 'avoid flight through or near thunderstorms' and should 'not trust the visual appearance to be a reliable indicator of the turbulence inside a thunderstorm.' The manual states that, when flying a helicopter under VFR, a pilot must maintain visual surface reference sufficient to safely control the helicopter.

Special Federal Aviation Regulation 71 Procedures Regarding Adverse Weather

Heli-USA s Honolulu FSDO-approved SFAR 71 procedures manual contains adverse-weather provisions that enable pilots to deviate from the SFAR 71 minimum altitude requirement to avoid poor weather, if necessary. According to the manual: 28 The accident occurred in class G airspace, which, according to the FAA Aeronautical Information Manual, chapter 3-3-1, is 'uncontrolled' airspace that 'has not been designated as' class A, B, C, D, or E airspace.

29 These sources include television news reports and radio reports.

According to 14 CFR 135.205, the daytime VFR minimum visibility requirement for helicopter operations at or below 1,200 feet agl in class G airspace is 1/2 mile. The requirements of 14 CFR 135.207 state, 'No person may operate a helicopter under VFR unless that person has visual surface reference sufficient to safely control the helicopter.'

ADDITIONAL INFORMATION

Preflight Safety Briefing

According to Heli-USA personnel, the passengers were shown an approximate 4-minute safety video before they boarded the helicopter.30 A review of the video showed that the safety topics included a briefing that demonstrated various aspects of the vest-type PFD, including how to remove it from the waist pouch and place it over the head. The video instructed the passengers to remove their headsets before donning the vests. The video also identified the two red handles to be pulled to inflate the vest and the two oral tubes to blow into in case the vest does not inflate. In addition to the safety video, the passengers received verbal instructions from ground personnel and the pilot when they boarded the helicopter and were asked if they had any questions.

Previous Weather-Related Air Tour Accident on Kauai

During the National Transportation Safety Board s investigation of the September 24, 2004, accident on Kauai involving a Bali Hai Helicopter Tours, Inc., air tour flight that encountered reduced visibility and crashed into a ridgeline, killing the pilot and the four passengers,31 the Safety Board found evidence that the pilot of that helicopter had flown into clouds on previous tours and that he had previously performed ridgeline crossings at low altitudes in areas where the minimum flight altitude, per SFAR 71, was 1,500 feet agl. In addition, some Hawaii air tour pilots interviewed did not fully understand the minimum altitude requirements established by their FAA-approved SFAR 71 deviation authorizations. 30 SFAR 71 requires that, before takeoff, passengers on air tour flights that include any segment beyond the shore must receive a briefing on water ditching procedures, use of required flotation equipment, and emergencyegress from the aircraft in the event of a water landing.

31 National Transportation Safety Board, Weather Encounter and Subsequent Collision into Terrain, Bali Hai

Helicopter Tours, Inc., Bell 206B, N16849, Kalaheo, Hawaii, September 24, 2004, Aviation Accident Report

NTSB/AAR-07/03 (Washington, D.C.: NTSB, 2007).

During that investigation, Safety Board investigators also met with Honolulu FSDO personnel in February 2005 to discuss air tour oversight and surveillance issues. FSDO personnel reported that, from October 1995 to 2003, the FSDO had a dedicated geographic surveillance unit (GSU) that provided direct oversight of all air tour operators in Hawaii and was responsible for ensuring compliance with SFAR 71. The GSU was equipped with surveillance cameras, binoculars, video cameras, and other equipment that the inspectors used to monitor tour operations and ensure that the pilots were complying with cloud and terrain clearance requirements. The GSU also used a number of innovative surveillance methods, such as monitoring air tour activity from remote locations and sending inspectors posing as tourists on revenue flights. According to FSDO personnel, the GSU was highly successful.

That investigation found that, however, by late 2003, the Honolulu FSDO needed to fill operations and airworthiness inspector positions and that the GSU inspectors were reallocated. After the GSU was officially disbanded in May 2004, there were no inspectors dedicated to providing direct surveillance of air tour flights in Hawaii. By the time of the Heli-USA accident, the Honolulu FSDO still did not have a GSU or other means of providing direct surveillance of commercial air tour operations.