PPRuNe Forums - View Single Post - N72EX (Kobe Bryant) Crash Reconstruction with new ATC Audio
Old 30th May 2020, 16:41
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JimEli
 
Join Date: Dec 2006
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Originally Posted by [email protected]
Yes, that report is classic saturation trying to deal with real IMC as a single pilot.

What can make it worse is engaging an autopilot that has its own limitations and tends to meander about whatever datum was set - this is especially true of 3 axis APs that have to use cyclic pitch to do things like hold ALT or VSI - they are slow, lagged to reduce control inputs and don't deal with turbulence well.

Unless you have experienced it to the point you were scared, it is difficult to explain how powerful the spatial disorientation illusions can be, convincing you that you are in a turn to the right (for example) when you are actually close to wings level and causing you to push left bank because it 'feels right'.

Constant practice in actual IMC conditions is the only way to prepare you for IIMC - or perhaps try teaching students to fly IMC, that sorts you out when they screw it up
Having SPIFR experience in the 135, and many a hour in the 135 simulator (flying and observing), I surmise the pilot lost control of the aircraft during his reconfiguration for the missed approach.

First, it appears the controller violated ATC procedures by vectoring the aircraft in violation of the recommended distance/angle from the approach gate. This is what precipitated the accident. At his point, I guess the pilot failed to arm the GS, or armed the GS after passing through it. This would explain why the aircraft never descended.

Second, when the pilot realized the AP didn’t capture the GS, he requested a missed approach. However, I believe he may have been in a slightly confused state of mind (unusual position and circumstances). He was then instructed to perform the published missed, which suddenly increased his workload. I would guess he hadn’t familiarized himself with the missed approach instructions, and therefore needed to quickly find/read them. This also helps to explain the unwarranted climb at this time. Most pilots would (eventually) place the FMS into NMS/GPS mode in order to fly this missed procedure, which requires a reconfiguration. I suspect the pilot may have inadvertently disconnected the AP at this point. Disconnecting is an easy mistake, especially if one doesn’t perform the reconfiguration in an orderly fashion. With the sudden, unexpected AP decoupling, and a slightly confused state, I expect the aircraft quickly lost airspeed, stability and the pilot lost control.

An ATC procedural error combined with pilot task saturation and FMS/AP misconfiguration followed by the pilot’s inability to perform an unusual attitude recovery resulted in this crash.

As always, I could be completely wrong.
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