This is my transcription of the findings and probable cause from the NTSB board meeting. I apologize in advance for typos or transcription errors when compared to the actual release.:
Findings:
1) None of the following safety issues were identified for the accident flight. One - Pilot qualification deficiencies or impairment due to medical condition, alcohol, other drugs, or fatigue. Two - Helicopter malfunction or failure, or; Three - Pressure on the pilot from Island Express Helicopters Inc., the air charter broker, or the client, to complete the flight.
2) Although the air traffic controller's failure to report the loss of radar contact and radar communication with the accident flight was inconsistent with air traffic control procedures, this deficiency did not contribute to the accident or affect its survivability.
3) Had the pilot completed an updated flight risk analysis form for the accident flight that considered weather information available at the time the flight departed, the flight would have remained within the company's low risk category but would have required the pilot to seek input from the Director of operations and to provide an alternative plan.
4) At the time the pilot took action to initiate a climb, the helicopter had already begun penetrating clouds and the pilot lost visual reference to the horizon and the ground. The loss of outside visual reference was possibly intermittent at first, but likely complete by the time the flight began to enter the left turn that diverged from his route over U.S. 101.
5) The pilot's poor decision to fly at an excessive airspeed for the weather conditions was inconsistent with adverse weather avoidance training and reduced the time available for him to choose an alternative course of action to avoid entering instrument meteorological conditions.
6) The pilot experienced spatial disorientation while climbing the helicopter in instrument meteorological condition, which led to his loss of helicopter control and the resulting collision with terrain.
7) The pilot's decision to continue the flight into deteriorating weather conditions was likely influenced by a self-induced pressure to fulfill the clients travel needs, his lack of an alternative plan, and his plan continuation bias, which strengthened as the flight neared the destination.
8) Island Express Helicopters Inc's lack of a documented policy and safety assurance evaluations to ensure that its pilots were consistently and correctly completing the flight risk analysis forms hindered the effectiveness of the form as a risk management tool.
9) A fully implemented mandatory safety management system could enhance Island Express Helicopter Inc's ability to manage risks.
10) The use of appropriate simulation devices and scenario-based helicopter pilot training has the potential to improve pilot's abilities to accurately assess weather and make appropriate weather-related decisions.
11) Objective research to evaluate spatial disorientation simulation technologies may help determine which applications are most effective for training pilots to recognize the onset of spatial disorientation and successfully mitigate it.
12) A pilot data monitoring program which can enable an operator to identify and mitigate factors that may influence deviations from established norms and procedures can be particularly beneficial for operators like Island Express Helicopters Inc that conduct single pilot operations and have little opportunity to directly observe their pilots in the operational environment.
13) A crash resistant flight recorder system that records parametric data and cockpit audio and images with a view of the cockpit environment to include as much of the outside view as possible could have provided valuable information about the visual cues associated with the adverse weather and the pilots focus and attention in the cockpit following the flight's entry into instrument meteorological conditions.
Probable Cause:
The National Transportation Safety Board determines that the probable cause of this accident was the pilot's decision to continue flight under visual flight rules into instrument meteorological conditions which resulted in the pilot's spatial disorientation and loss of control. Contributing to the accident was the pilot's likely self-induced pressure and the pilot's plan continuation bias which adversely affected his decision-making, and Island Express Helicopter Inc's. inadequate review and oversight of its safety management process.
Last edited by airplanecrazy; 9th Feb 2021 at 18:50.