The NTSB accident investigation process: My company’s experience A fatal helicopter crash in 2019 forced Safari Aviation to reevaluate nearly every aspect of its operation. By J.C. Murphy On Dec. 26, 2019, a Safari Aviation helicopter went down along the Nā Pali Coast of Kauai, Hawaii. The tragedy claimed the lives of all seven people onboard—the pilot and six passengers. It was a day that forever altered our company and all those connected to it. While the grief and loss were overwhelming, what followed was a long and sobering journey through a full-scale National Transportation Safety Board (NTSB) investigation. The Call No One Wants When an aircraft fails to check in, everyone in ops feels it in their gut. That was the case on Dec. 26, 2019. Our pilot missed a scheduled position report. Weather was marginal. Terrain was unforgiving. Within minutes, we initiated emergency procedures and notified the FAA and the NTSB of the crash. Everything moves quickly after an accident. Within 24 hours of the Nā Pali Coast event, the NTSB had investigators en route to the scene. Meanwhile, we were in crisis mode, scrambling to support our team, communicate with families, and preserve every shred of documentation.’ That’s the first real takeaway: whatever you think you’ll need in the event of an accident, triple it. Records, training files, maintenance logs, duty rosters—everything becomes urgent.” What the NTSB Process Really Feels Like Most aviation professionals are familiar with the NTSB, the federal government agency responsible for investigating all civil aviation accidents in the United States. We know the NTSB’s role, the phases of its investigative process, and the agency’s importance to the industry. But what many don’t fully appreciate until they live through it is what it actually feels like to be on the inside of an NTSB investigation, to sit across the table from investigators, and to open your company’s records, culture, and decisions to intense scrutiny. The general phases of an NTSB investigation are well known and include the initial notification and decision to investigate, on-site fact gathering, analysis of facts, and probable-cause determination. What’s less talked about is what these phases demand from the operator: In the field: The field phase starts quickly. Investigators arrive on-site and begin collecting data. They interview your pilots, maintenance techs, dispatchers, and anyone else tied to the flight—people, many of them grieving, who are still processing what’s happened and now face detailed interviews with federal investigators. Party status: Safari was granted party status in the Nā Pali Coast investigation, which meant we provided technical representatives from our operations and maintenance teams to work alongside the NTSB. This is a serious responsibility. Your reps must be experienced, composed, and cooperative and they must represent your company with total honesty and professionalism. Evidence collection: Expect everything to be reviewed: pilot logs, flight risk assessments, weather briefings, communications records, internal emails, even informal team chats and text messages. The NTSB leaves no stone unturned. This was one of the most sobering aspects of the investigation, revealing to what degree our operation was documented and how quickly assumptions or bad habits can be uncovered in writing. Communications and media: In the aftermath of an accident, one of the hardest things to do is stay silent publicly. The NTSB controls the release of information, so you can’t provide much clarification as the public and the media begin forming opinions. Internally, communication must be tight, honest, and empathetic, especially with families and employees. The Final Report, and What It Told Us The NTSB ultimately found the probable cause of the Nā Pali Coast accident to be continued VFR flight into IMC in mountainous terrain, with contributing factors including deteriorating visibility and inadequate weather decision-making. That was hard to hear. Like many operators in Hawaii, we operate in a unique and often volatile weather environment. We had trained for these scenarios. But the truth was, in this case, our systems failed to support the right decision in the moment. The accident forced us to reevaluate and improve nearly every aspect of our operation by implementing important changes, including: • Stricter weather minimums for high-minimum captains (35 hours with the company)• Required FRATs (flight risk assessment tools) for every flight, no exceptions• Scenario-based weather decision-making training, moving beyond theory to real-life cases• Weather briefings for all flights as part of their flight release• Line operations safety assessment (LOSA) flights• A strengthened safety management system (SMS) that emphasized practical, anonymous reporting and a true just culture. We also realized that what we thought was a safe culture was, in many ways, aspirational. We had to make it real by encouraging open reporting, protecting those who spoke up, and ensuring that corrective action followed reports. Be Ready Before You’re Tested The best time to prepare for an accident investigation is long before one happens. Ask yourself: • Are our documentation systems bulletproof?• Do we have the internal maturity to handle an investigation honestly and transparently?• Can our pilots say no to a flight without fear of reprisal?• Do we really, truly prioritize safety over schedule and revenue? The NTSB is not out to assign blame. They are there to find the truth, and as painful as that process can be, it’s also an opportunity for real improvement on the operator’s part. We didn’t choose to have an accident, but we did choose how to respond to it. We chose transparency. We chose to learn. And we chose to make meaningful changes that will hopefully prevent another tragedy. If sharing our experience can help another operator be better prepared, more self-aware, and more safety focused, then we’ve done something good with something terrible:we’ve honored those we lost by acting boldly, improving relentlessly, and never taking safety for granted. J.C. Murphy is director of operations at Safari Aviation, where he oversees daily flight operations for one of Hawaii’s established tour operators. He will present “Straight Talk: My Experience Working with the NTSB” on Wednesday, Oct. 22 at the 2025 VAI Air Tour Safety Conference in Las Vegas, Nevada.
