In 2019, a Beech King Air 65-A90 operated by a Hawaii skydiving company crashed with 11 aboard. Everyone died. The NTSB's finding afterward wasn't really about that one aircraft — it pointed to the system around it: the agency said the FAA's regulatory framework was insufficient for overseeing parachute jump operations.
The FAA still hasn't fully implemented those recommendations.
Seven years later, Butler happened. Same industry, similar regulatory gap, a different aircraft. That's not coincidence — it's an unclosed loop.
Here's the pattern worth naming: skydiving operations fly under the same Part 91 rules as any private small-plane owner, as long as flights stay within 25 miles of the departure point. No charter-level maintenance scrutiny.
The Butler aircraft wasn't required to carry a crashworthy flight data recorder, so investigators have also turned to GoPro footage recovered from the wreckage. Jeff Guzzetti — a former NTSB and FAA investigator — put it plainly: "I was surprised that they had determined that the engine was producing power."
"Underneath every simple, obvious story about 'human error,' there is a deeper, more complex story about the organization.."
That's exactly where HFACS points when the sharp-end causes get ruled out one by one. The framework has four tiers: unsafe acts, preconditions, supervision, and organizational influences. Butler's preliminary report has already cleared most of tier one — no obvious pilot error, no mechanical precondition.
That pushes the inquiry toward tiers three and four: an operational tempo of three flights before noon, a regulatory category that exempts the operator from the oversight a charter flight would face, and an industry-wide pattern the NTSB flagged once already, seven years unresolved.
The FAA established a skydiving safety committee this past April — two months before Butler. It hasn't produced anything yet.
Next week, the final part: why "the rules are the same as any small plane owner" is itself the design flaw — and a look at how a very different operating environment, Nepal's Himalayan STOL routes, handles a comparably thin margin for error.