On Tuesday, the NTSB concluded that the probable cause of the fatal Dec. 26, 2019, crash of a Safari Aviation AStar in Hawaii was “the pilot’s decision to continue flight under visual flight rules (VFR) into instrument meteorological conditions (IMC), which resulted in the collision into terrain.” Safari’s chief pilot and check airman, 69-year-old Paul Matero, died in the crash along with his six air-tour passengers.
According to the NTSB, the Airbus AS350B2 “flew into a mountainous region shrouded in low clouds and fog and wasn’t able to exit the area of limited visibility” along a well-established tour route on the northwest portion of the island of Kauai near the Na Pali coast. The Board noted that the weather pattern that day was “atypical,” with rain and low clouds moving in from the northwest and that three other air tour pilots who saw it elected to divert to avoid it.
The NTSB noted that the weather situation at the time of the crash was complex, with discordant reports in the area of the crash site, 24 miles northwest of Lihue. A witness about 1.5 miles away from the scene in the Koke'e State Park reported hearing the helicopter shortly before the crash at 4:57 p.m. local time and weather conditions of 20-feet forward visibility in rain and fog.
An NTSB investigator said fellow tour pilots described Matero as someone who sometimes pushed weather limits due to his long flight experience on Kauai. In 2019, Safari said Matero had been with the company for 12 years. Matero held a commercial rotorcraft rating issued in 2011 and a second-class FAA physical with limitations for corrective lenses. He was scheduled to retire in early 2020. The accident was his eighth 50-minute aerial tour of the day.
The NTSB noted that, at the time of the crash, Safari did not have a safety management system (SMS) in place, nor were other germane recommendations previously made by the Board to the FAA regarding air tour operations, and Hawaii in particular. Specifically, the NTSB renewed its calls for specialized in-flight weather training for air tour operators in Hawaii; installing active flight tracking systems on air tour helicopters operating in the state; establishing aviation weather cameras in Hawaii and training ground support specialists to effectively use imagery from those cameras when providing weather briefings to pilots; and developing and requiring cue-based training for Hawaii air-tour pilots.
More generally, the Board reiterated its recommendations for mandatory SMS and flight data monitoring at air-tour and air-taxi operators, required installation of crash-resistant flight recorder systems and traffic-alerting in those operator aircraft. It also again called for the voluntary adoption of flight and training technologies to help prevent inadvertent IMC accidents.
“When the NTSB issues safety recommendations, they are data-driven, supported by factual evidence developed from investigations, and are carefully crafted to prevent accidents,” said new NTSB Chair Jennifer Homendy, adding that the accident was “one-hundred percent preventable.”
"There was minimal FAA oversight of the safety of air-tour operations in Hawaii. The FAA should be leading on safety, not ceding their responsibility to the industry that they are charged with regulating," she said.