NTSB report on helicopter crash that killed Madison mom and daughter takes aim at FAA

WASHINGTON (WMTV) - The National Transportation Safety Board blasted a fellow federal agency for not implementing multiple safety recommendations its investigators had previously made, arguing that not doing so contributed to a 2019 helicopter crash that killed a Madison mother and daughter and five other people.

“The NTSB previously made 11 recommendations to the FAA to prevent accidents like this one, but our recommendations only work when they are implemented,” the NTSB wrote in a statement that accompanied its board meeting Tuesday.

Amy Gannon and her daughter Jocelyn were in the helicopter on Dec. 26, 2019, as part of a sightseeing tour along the Na Pali Coast, in Hawaii, when it went down in a remote, wooded area near Kekaha. The Gannons, the pilot, and four other passengers died in the crash.

Amy was an entrepreneur in Madison community and formerly taught at Edgewood College, where she also served as Interim Dean of the School of Business for two years. The college’s Director of Communications Ed Taylor described her at the time as very dynamic and devoted to empowering women in business. Additionally, she was a co-founder of the consulting firm, Doyenne, in Madison.

Thirteen-year-old Jocelyn had been a middle school student at Hamilton Middle School.

NTSB investigators determined the Safari Aviation pilot flew into a mountainous region that was covered in fog and low clouds. The 69-year-old pilot, whom they noted was highly experienced, was not able to reach clearer skies until he either lost control of the helicopter or it struck rising terrain that had been hidden by the clouds.

The NTSB found that a little less than an hour before the helicopter had departed for the tour low clouds had started to move onto the shore in a weather pattern that investigators described as atypical. They noted that three other pilots who saw the system moving in either diverted their flights or canceled it altogether.

The investigators concluded that the pilot of the helicopter the Gannons were on made the decision to continue flying because he did not have up-to-the-minute information on the weather system, the unusual weather pattern, and he “may have been influenced by the possibility that he inadequately [assessed] the weather conditions in the flight or was overconfident in his abilities.”

The probable cause for the crash was ruled to be a combination of the pilot’s decision to keep flying and the lack of safety management processes by Safari Aviation. In addition, the NTSB listed in its Probable Cause for the crash actions by the FAA that included:

• Delaying the implementation of a Hawaii aviation weather camera program
• Lacking leadership for the development of a cue-based weather training program for Hawaii air tour pilots
• Ineffectively monitoring and overseeing Hawaii air tour operators’ weather-related operating practices.

The NTSB argued having a proper safety management system in place that would manage risks and the effectiveness of safety controls would have likely mitigated the safety factors cited in its report as contributing to the crash.

“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,” the agency stated.

While the NTSB says it has been asking for those changes for approximately six years, another one of its recommendations that investigators say hindered their investigation was made to the FAA nearly a decade ago: onboard recorders. The agency stated the lack of information that those devices could have provided, such as the precise weather conditions and the pilot’s corresponding actions, demonstrate the need for the recorders.

The FAA told NBC15 News that tour operators already can apply for its voluntary Safety Management System program and that the agency “strongly encourages” that they do do. FAA officials have begun the rule-making process that is expected to make it a requirement.

As far as onboard recorders, the FAA stated it does encourage use of ADS-B and flight data recorders and it is exploring whether or not the devices should be mandatory. The agency pointed out that all air ambulances have recorders and large helicopter makers have been including them as standard features for approximately ten years.

The FAA also pointed to a weather camera system that will see 26 cameras installed on three Hawaiian islands, Oahu, the Big Island, and Kauai. Five of the cameras are already installed with the remaining 21 set to be in place by the end of next year.

According to the agency, the locations for the cameras were determined with feedback from local pilots and are based on where they experience sudden weather changes and where accidents have occurred. At least two of the cameras will be located near where the site of the 2019 helicopter crash. Images from the cameras are available at https://weathercams.faa.gov/.

In all, the NTSB made eight new safety recommendations as a result of this crash, while reiterating the need for 11 others. Two other recommendations were split between the Vertical Safety Aviation Team and the Tour Operators Program of Safety.

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