N72EX (Kobe Bryant) Crash Update-

[377 Pete]

Final NTSB report due on 2/9/21
Finding well probably be spatial disorientation in IMC conditions.

Here's a rendering of the final minute of flight based on the granular ADSB data-

https://i.imgur.com/YsiA23k.png

And an update from Blancolirio-

https://www.youtube.com/watch?v=gWBa1mYTLUE

[gulliBell]

I'm not expecting any surprises in the final report.

[airplanecrazy]

I think there may be one surprise. In December, the NTSB posted to the docket the data extracted from the Flight Management System (I only noticed it yesterday). I am not a pilot or aviation professional, but I noted some anomalies:

1) When the FMS was powered on at LGB the day of the crash, its last known position was at the IEX helipad on Catalina Island. Can someone more knowledgeable about FMS operations explain to me how that is possible? Do you have to turn on the FMS separately, or is it normally powered on by switching on the avionics power bus?
2) The NTSB notes: "When the FMS is initialized, it will default to the position stored when power was previously removed or the GPS position, if it is available. This position is presented to the crew on the FMS initialization page, where the crew can accept it, or manually change it before accepting it. Should the crew accept a Reference Position that is significantly different from the actual aircraft position, the FMS will annunciate position uncertain and post difference warning messages after GPS position becomes available. Over time, the Reference Position would converge to true position by using DME and GPS.
3) There are unseen (by the pilot) warning messages in the FMS: "GPS 1 DIFFERENCE 6 NM" "REFPOS and GPSPOS > 6.0 NM". "DEAD RECKONING MODE"
4) When the pilot selects DTO (Direct To) KCMA, the FMS records a present position (PPOS) not on the flight path (this is recorded in the NAV Leg Editing Buffer). I am wondering if the FMS has not yet converged to true position.
5) The CDU at the time of the crash appears to me to be showing errant data (Figure 4-1 in the report). I think it is saying the distance to the destination is closer that it actually is and that the bearing between the displayed PPOS and Destination is incorrect. It would be fantastic if someone with more experience with the UNS FMS can confirm.

If I am interpreting the information correctly, it seems that the above would have added to the pilot confusion and workload. Here is a link to the docket entry: https://data.ntsb.gov/Docket/Document/docBLOB?ID=11662700&FileExtension=pdf&FileName=DCA20MA059FmsReportReleasedRev2-Rel.pdf

[Gordy]

Blancolirio clearly caters to the masses and not aviation experts. He could not even pronounce Ara's name correctly.

[malabo]

FMS especially an old one in the 76B is insignificant for low level VFR operations. Usually the pilot just has an iPad balanced on his lap - though EASA and USCG pilots are known to have them on knee boards. The EGPWS recommendation is just a tired old NTSB hobby horse that they trot out on every investigation, again, of no consequence in this situation.

[Torquetalk]

I think there may be one surprise. In December, the NTSB posted to the docket the data extracted from the Flight Management System (I only noticed it yesterday). I am not a pilot or aviation professional, but I noted some anomalies:

1) When the FMS was powered on at LGB the day of the crash, its last known position was at the IEX helipad on Catalina Island. Can someone more knowledgeable about FMS operations explain to me how that is possible? Do you have to turn on the FMS separately, or is it normally powered on by switching on the avionics power bus?
2) The NTSB notes: "When the FMS is initialized, it will default to the position stored when power was previously removed or the GPS position, if it is available. This position is presented to the crew on the FMS initialization page, where the crew can accept it, or manually change it before accepting it. Should the crew accept a Reference Position that is significantly different from the actual aircraft position, the FMS will annunciate position uncertain and post difference warning messages after GPS position becomes available. Over time, the Reference Position would converge to true position by using DME and GPS.
3) There are unseen (by the pilot) warning messages in the FMS: "GPS 1 DIFFERENCE 6 NM" "REFPOS and GPSPOS > 6.0 NM". "DEAD RECKONING MODE"
4) When the pilot selects DTO (Direct To) KCMA, the FMS records a present position (PPOS) not on the flight path (this is recorded in the NAV Leg Editing Buffer). I am wondering if the FMS has not yet converged to true position.
5) The CDU at the time of the crash appears to me to be showing errant data (Figure 4-1 in the report). I think it is saying the distance to the destination is closer that it actually is and that the bearing between the displayed PPOS and Destination is incorrect. It would be fantastic if someone with more experience with the UNS FMS can confirm.

If I am interpreting the information correctly, it seems that the above would have added to the pilot confusion and workload. Here is a link to the docket entry: https://data.ntsb.gov/Docket/Document/docBLOB?ID=11662700&FileExtension=pdf&FileName=DCA20MA059FmsReportReleasedRev2-Rel.pdf


The FMS (inc this UNS model) will update its position very quickly once it has sight of satellites (out of the hangar) and in receipt of signals from VORs and DME equipment (the aircraft was flying in well-served airspace). It is very unlikely that the UNS did not know exactly where it was. That is usually a pilot problem.

[airplanecrazy]

The FMS (inc this UNS model) will update its position very quickly once it has sight of satellites (out of the hangar) and in receipt of signals from VORs and DME equipment (the aircraft was flying in well-served airspace). It is very unlikely that the UNS did not know exactly where it was. That is usually a pilot problem.

Let me first say that I acknowledge that I am out of my area of expertise, and so this is my amateur speculation. I believe the Reference Position in the NTSB report (l34.25080n 118.76038w) recorded at 17:37:43 does not accurately reflect the actual position of the aircraft at that time. I am wondering if the UNS incorrectly determines position in the following scenario:

1) UNS Powered off in Santa Catalina
2) UNS Powered on at LGB
3) UNS Never receives DME.
From the report:

"DME Stations for shortrange navigation: No DMEs Received"
"Scanned DME Stations: Fifteen DMEs being scanned. None responded."

4) UNS records Reference Position (according to the report "Reference Position is Blended GPS/DME position propagated with GPS velocities")

This is last reported position information as detailed in the report:

System Position (GPS position propagated by heading and true air speed) N 34:08.17861 W118:41.55108 (34.1363101n 118.692518w)
Reference Position (Blended GPS/DME position propagated with GPS velocities) N 34:08.17861 W118:50.54967 (34.1363101n 118.8424945w)
DME Position (Position computed from DME range measurements) N 34:23.21876 W119:13.96316 (34.38697938n 119.2327194w)


As you suspected, the GPS position information is correct (very close to the crash location). However, the Reference and DME Positions are not. I wonder if this corner case is rare because most of the time UNS systems receive DME. I do not have a hypothesis as to why the FMS was not receiving DME data.

[gulliBell]

...In December, the NTSB posted to the docket the data extracted from the Flight Management System (I only noticed it yesterday)...

Red Herring. Furphy. Whatever you care to call it. The pilot was navigating visually in sight of the ground in an area well known to him. He knew exactly where he was until he lost sight of the ground, lost control, and crashed. The FMS had nothing to do with it.

[Torquetalk]

Airplanecrazy,

Gullibell is sure to be right.

As a point of interest, the FMS sums all available sources to determine ppps, and tells you when it doesn‘t have a reliable determination. No or poor DME signal or a discrepancy means the FMS will disregard the unreliable source. No issue.

What might have helped him was regular real IR training and a greater willingness to use the automatics to get him out of trouble once he lost reference. Not pressing on and chomping it whilst scud running, with limited visibility, in a rising ground environment, would have avoided the accident altogether.

[Sikpilot]

The S76 is not a great machine for scud running, ESPECIALLY single pilot. Sitting in the right seat, you cant look over your left shoulder and see out behind you if your trying to turn left. The high Sikorsky console doesn't can also block the horizon. While I never had a problem flying the 76 single pilot, I NEVER did it with VIP passengers. Kobe could afford to put a second pilot up front and as PIC I would have expressed to the customer that a second pilot is mandatory for safety reasons. I can't say I would or would not have taken off that day since I have never flown that route but if I did it would have been with 2 pilots and EVERY helipad between my takeoff point and destination punched in to the GPS ready to be pulled up for an emergency landing due to weather. The PNF would make sure we always had a pad to land at. No one would complain if we dropped on in when they saw Kobe get out, not even the sheriffs helipads. This was a completely avoidable tragedy.

[airplanecrazy]

Airplanecrazy,

Gullibell is sure to be right.

As a point of interest, the FMS sums all available sources to determine ppps, and tells you when it doesn‘t have a reliable determination. No or poor DME signal or a discrepancy means the FMS will disregard the unreliable source. No issue.

What might have helped him was regular real IR training and a greater willingness to use the automatics to get him out of trouble once he lost reference. Not pressing on and chomping it whilst scud running, with limited visibility, in a rising ground environment, would have avoided the accident altogether.

Thanks for your reply. I have reviewed the FMS extraction report again and I still suspect that the FMS is using the wrong position. Either the authors of the report incorrectly decoded the position information, the FMS is confused, or I am confused. The "Active From Waypoint" recorded at 17:37:43 is 34.25080271n 118.7603827w, and that is over 15nm from the actual position at that time of 34.250610n 118.450834w. Furthermore, the aircraft never comes closer than 7nm to that waypoint.

I certainly defer to your experience on whether that possible discrepancy could have had any influence on the outcome. I was hypothesizing that when the pilot entered the steep left turn about 30 seconds before the crash, that something distracted him from watching the primary flight instruments. I was wondering if problems with the NAV radios could have been that distraction, but it sounds like you think that is unlikely. I guess we will see what the NTSB thinks in a couple of weeks. I really appreciate your time!

[gulliBell]

The left turn didn't happen because the FMS was doing something it shouldn't. The left turn happened due to spatial disorientation of a pilot who had never flown in cloud before.

[airplanecrazy]

The left turn didn't happen because the FMS was doing something it shouldn't. The left turn happened due to spatial disorientation of a pilot who had never flown in cloud before.

Thank you for your reply!

[[email protected]]

Add in some potential complacency because he had flown the route before (possibly in similar conditions) and got through OK - plus the commercial pressure to get the job done and personal pressure since he seems to have had a good relationship with his pax.

All adds up to an accident waiting to happen that wouldn't have been prevented by TAWS which would have been constantly alerting at low level anyway.

Plan properly and know when to say no.

[TowerDog]

Interesting article on the final flight and crash in the March 2021 Vanity Fair Magazine.
(Yes, I know it is not March yet and I know V.F. Is not an aviation magazine, but sometimes they shine with well researched articles, this one seems to fall in that category)

[gulliBell]

Yes, the Vanity Fair Magazine story was well written. I found this comment compelling "If he handled it right, no one would ever know what he’d done." But, handle it wrong he did, and everybody found out. As an aside, $1800/hr for an S76B sounds on the cheap side to me.

[MikeNYC]

As an aside, $1800/hr for an S76B sounds on the cheap side to me.
Possible that Bryant purchased block time of 50-100h/year for that rate?

[gulliBell]

That's a 204L4 or AS350 charter rate. They would be lucky to break even at that rate for a 76B. $5000/hr would be a more realistic number. Give clients a 10% discount for block hours. Obviously having a prang really screws up the economics.

[Arnie Madsen]

I think Kobe owned the S76 and then the charter service took it over .... maybe he got a special hourly rate within the deal.

[albatross]

I guess nobody uses the old “Climb, Confess,Comply” rule anymore.

[OvertHawk]

I guess nobody uses the old “Climb, Confess,Comply” rule anymore.

You have to have control of your aircraft for that to work.:sad:

[TowerDog]

I guess nobody uses the old “Climb, Confess,Comply” rule anymore.

He started the Climb thingy, without using the autopilot and slowly but surely lost control and banked to the left until the climb turned into a descent then a crash into the hillside. :sad:

[nomorehelosforme]

The Daily Mail has printed their pennies worth.

https://www.dailymail.co.uk/news/article-9240215/U-S-safety-board-meet-Kobe-Bryant-fatal-helicopter-crash.htmlKobe Bryant pilot 'didn't know which way was up' after ignoring weather warnings and federal safety standards to fly NBA legend, his daughter and seven others through thick fog - as officials prepare to deliver crash verdict

[NutLoose]

https://www.msn.com/en-us/news/us/ntsb-reveals-likely-cause-of-helicopter-crash-that-killed-kobe-bryant/ar-BB1dxqrr

A helicopter pilot's "spatial disorientation" played a key role in the crash that killed (https://www.nbcnews.com/news/us-news/no-survivors-los-angeles-area-helicopter-crash-n1123406) basketball legend Kobe Bryant, his daughter and several friends last year, federal authorities said Tuesday.

[airplanecrazy]

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.

[[email protected]]

Or - if you lack the ability through lack of training or recency to enter IMC and recover to a safe height for an instrument recovery, don't fly in poor weather.

[FH1100 Pilot]

Define "poor," Crab

[gulliBell]

"Poor", I suggest, defined as being weather which is below VMC.

[roscoe1]

I've suggested it before with not much agreement from folks but how about making SVFR unavailable as an option for 135 VFR only operations? I feel it would do more to prevent pilots who might be inclined to keep a special VFR clearance in their back pocket from pushing a formal, or more importantly, an informal risk analysis that points toward discression being the better part of valor and not flying. If you think this puts a straitjacket on the stick wiggler, anyone at any time is fully free to declaire an emergency for inadvertant IMC to do the right thing and "land the damn helicopter". If the wx situation was reasonable for the flight and the IMC was really not expected, an emergency declaration would be nothing more than a bit of paperwork or a phone call and would instantly garner any help ATC might be able to offer. Safe landing, handshakes all around, everybody goes home. It offers companies a chance to walk the talk about risk analyis and safety in general.

[[email protected]]

FH1100 - as Gullibell suggests - also marginal weather that if it worsens on a slightly, would require reversion to IFR to remain legal. No-one can guarantee the weather so prudence should be the name of the game.

If you only have a plan A when you launch into marginal weather, you probably shouldn't launch.

I heard a supposedly professional pilot state to ATC the other day that he would cruise at 4000' en route, would be classed as VFR yet would be IMC??? I knew where he was going and the cloudbase was solid below 2000'

[Two's in]

I am intrigued by the ding against the operator for not "... correctly completing the flight risk analysis forms."

The benefits of using them is obvious, but it lurches dangerously close to assuming that everything you encounter while in the air can be planned or anticipated. Surely the most effective flight safety device for being able handle the unexpected is called Captaincy?

That said, in this particular case you didn't need a flight risk analysis form, you only needed a TAF and METAR.

[Arnie Madsen]

I keep thinking that one of the gremlins was when he was switched to a different ATC ... the first one had guided him to skirt Van Nuys .... circle for 12 minutes or so .... then up to the highway and turn left toward destination.

Right around the time he was approaching the foggy valley crossing he had been switched to a different tower and had to tell them where he was and where he was heading .... right when he was intensely focused on what was in front of him .

Call it a minor distraction or whatever .... but our brains lose focus when we communicate by phone or radio while driving or flying.

[212man]

https://helihub.com/2021/02/10/hai-statement-on-kobe-bryant-ntsb-hearing/?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+HelihubNews+%28HeliHub.com+%C2%BB+Daily +News+Update%29

[[email protected]]

Right around the time he was approaching the foggy valley crossing he had been switched to a different tower and had to tell them where he was and where he was heading .... right when he was intensely focused on what was in front of him .

Call it a minor distraction or whatever .... but our brains lose focus when we communicate by phone or radio while driving or flying.
That's when, in a well equipped twin, you use the upper mode functions of the AP to offload you - if you are too low and fast to do that then you have already made significant errors of judgement such that the HAI's Land and LIVE advice is the best solution.

Head down changing freq/squawk at low level is not clever - another reason that twin pilot Ops for this sort of work are better.

[FH1100 Pilot]

If helicopters only flew when it was nice and clear and VFR, then not many helicopters would ever fly. The fact is, we fly in bad...some might call it "poor" weather. As pilots, our *first* responsibility is to not crash. Obviously, Ara did not adhere to that one.

When Ara went I-IMC, maybe he thought he could just climb up above the low deck or layer and continue on VFR. Whatever was the actual circumstances, he surely lost control of the ship quickly. That happens. We've all been there. If we're posting on this forum, it means that for some reason we did not lose control and die. (In 35 years of flying, I've been there twice.)

The NTSB also dinged Ara for his speed. I've said this from the beginning: You can't go charging along at the speed of heat when you're down low in crappy weather. You've *got* to slow down so you don't blunder inadvertently into a cloud or fog bank. Obviously, Ara failed there.

It's just not sufficient to say, "The weather was bad that day; he never should have flown."

[[email protected]]

I agree FH1100 - but it seems plenty of people still need to learn how to fly in poor (crappy) weather safely.

[nomorehelosforme]

And sadly this won’t be the last thread on here that has all the similar outcomes and reasons why it all went wrong!

[megan]

plenty of people still need to learn how to fly in poor (crappy) weatherSadly crab we only get to learn that by doing, when and how to pull out has never been content of any course, other than reading others misfortunes.

[[email protected]]

With the changeable weather we have in the UK, learning to fly in poor weather is just the norm - otherwise you would never get airborne:)

However, you don't need a course to follow the basic principles - Go Down, Slow Down, Land or Turn Back.

[Mutley1013]

Crab is bang on and is part of every course I have been on and there is plenty of literature and real life incidents to learn from for people to stay current with the danger. The life shortening effect of going into cloud in a heli were drilled into me from early doors training back in the '90's - (civilian VFR only). When I'm asked, "how to get out of cloud?", the reponse is always, "don't get in the cloud".

Over the years there have been a few occasions when my poor planning and focus on getting the flight done has forced me to take corrective action. In all cases, going down, slowing down and turning back. I've not had to unplanned land yet, but I would if I needed to to save my arse!

I know there are parts of the world where the speed of (or unpredictable) weather change and terrain may rule out landing, but if flying in those regions, being IFR certified\current would seem a logical life saver.

[Gordy]

when and how to pull out has never been content of any course, other than reading others misfortunes.

It is part of basic indoc for Part 135 flying and also part of annual recurrent training for ALL part 135 operators----mandated by FAR's.

[megan]

Perhaps my view is coloured by the fact that we as military were taught to fly helos on instruments from the get go, H-34 at the start and unstabilised Huey after getting wings. Flying offshore in the 1970's in the 205 we had to resort to instruments on a regular basis.

[Robbiee]

I agree FH1100 - but it seems plenty of people still need to learn how to fly in poor (crappy) weather safely.

After my experience, I'd rather just have the balls to say ****it and land before I reach the crappy weather. No one could pay me enough to fly through that **** again!

[[email protected]]

If you are allowed to push the limits - ie operating special VFR because the weather isn't good enough for VFR - should you not be instrument rated and current? Seems an accident waiting to happen if you let people scud run (legally) who have no plan B.

What actual IIMC training is required in the US? Does it involve a screened cockpit or 'foggles' or, heaven forbid, actual experience of flying in cloud? If it is just a VFR 'let's pretend' exercise it is about a s useful as a chocolate fireguard.

I know regulation is detested in the US but it seemst his crash was allowed to happen because part 135 regs let a non- IFR pilot fly single pilot in skoshie weather with fare-paying pax without the skills to recover in the event of IIMC.

[gulliBell]

Crab. The chocolate fireguard is all that's required.

[wrench1]

because part 135 regs let a non- IFR pilot fly single pilot in skoshie weather with fare-paying pax without the skills to recover in the event of IIMC.
FYI: Not quite. As mentioned above, Part 135 does require competency in those skills to maneuver out of IIMC for all 135 rotorcraft ops to include a recurrent requirement. Plus those IIMC procedures are usually listed in the operator GOMs as well.

[[email protected]]

As mentioned above, Part 135 does require competency in those skills to maneuver out of IIMC for all 135 rotorcraft ops to include a recurrent requirement. But how is that policy documented and policed to ensure a level of quality assessment rather than a box-ticking process?

Having a piece of paper that says you can recover from IIMC is all very well (clearly not in this case sadly) but unless you have been tested in an environment (real or simulated) that replicates IIMC it is simply paper-safety ie no use at all.

It is quite easy to replicate a DVE situation at night over unlit terrain or by day over the sea with hazy conditions, you don't actually have to go into cloud - but that is the real acid test.

[wrench1]

[[email protected];10989353]But how is that policy documented and policed to ensure a level of quality assessment rather than a box-ticking process?/QUOTE]
The requirement is part of the FAA approved 135 Training program and requires a demonstrated level of proficiency at an initial and recurrent basis with the associated 135 training record.

but unless you have been tested in an environment (real or simulated) that replicates IIMC it is simply paper-safety ie no use at all. It is quite easy to replicate a DVE situation at night over unlit terrain or by day over the sea with hazy conditions, you don't actually have to go into cloud - but that is the real acid test.
How it is demonstrated is based on the the approved program and how the aircraft are equipped. Most use aircraft in simulated conditions but some operators have started moving into simulators for some of the requirements. However some don't pass either. We had a couple at the old day job that upgraded to a different airframe but couldn't get out of the clouds during the training. They both went back to the original rides until they got more training and eventually successfully upgraded again.

What I always found ironic was that even with the same identical training the percentage of offshore ops having adverse IIMC incidents was much lower than the EMS ops. Seems the ops with the higher operational control oversight have better luck at IIMC than those without like this flight.

[[email protected]]

So Ara will have had a training document detailing the circumstances and outcome of his recurrent IIMC training then - yet for a real it went for a ball of chalk.

Is there any mandated use of 3 or 4 axis AP systems in that IIMC recovery or is it all flown manfully without having to demonstrate proficiency with the kit in your aircraft?

[aa777888]

I can't honestly say I read every word, but this particular flight appears to have been 100% in compliance with all regulatory requirements, and in many cases exceeded those requirements by quite a bit, including the presence of a safety management program, a pilot with IFR and IFR instructor qualifications and required Part 135 training all in order, an aircraft with an operating 4 axis autopilot, etc., etc.

Refer to: https://data.ntsb.gov/Docket/Document/docBLOB?ID=9742056&FileExtension=pdf&FileName=Ops-HP%20Factual%20Report-Rel.pdf
And also: https://www.ntsb.gov/news/events/Documents/2021-BMG-DCA20MA059-BMG-abstract.pdf

Leaving aside the fact that good enough is never good enough for the NTSB, it was good enough by current US regulations, indeed better than good enough.

There are at least a dozen shoulda/woulda/coulda's that might have avoided this event. All of them associated with pilot judgement and not regulatory deficiencies. Don't go/slow down/turn back/air file IFR (illegally but live to tell the tale)/etc. and all already discussed in this topic, and the most egregious of which appears to be the failure to slow down. But at the end of the day, the one that sticks out like a sore thumb to me is why, in lowering visibility, with such a wonderfully equipped aircraft, was the autopilot not engaged in some reasonable mode as soon as visibility became a concern, before it became zero? As a VFR only helicopter pilot who has never flown a helicopter with an autopilot (but has used autopilots in other contexts), am I missing something? Overreliance on automation is always a favorite topic. Do we observe an under-reliance in this particular case?

[gulliBell]

...Is there any mandated use of 3 or 4 axis AP systems in that IIMC recovery or is it all flown manfully without having to demonstrate proficiency with the kit in your aircraft?

If I recall correctly what was mentioned somewhere else, the accident pilot hadn't done any IFR training in the S76.

[wrench1]

So Ara will have had a training document detailing the circumstances and outcome of his recurrent IIMC training then - yet for a real it went for a ball of chalk.
Yes. Plus the available record goes back several years.
Is there any mandated use of 3 or 4 axis AP systems in that IIMC recovery or is it all flown manfully without having to demonstrate proficiency with the kit in your aircraft?
If I recall the Island IIMC procedure included manual and AP recovery but not 100% sure. The link below will take you to the Docket which has the actual Island IIMC procedure, training records, and a bunch of other info which should answer your questions that are outside of my skill set.
https://data.ntsb.gov/Docket?NTSBNumber=DCA20MA059

[malabo]

Many of us flew hard day/night winter/summer IFR in old 76A models that only had a hat trim for a couple of attitude retention AP. And that was a step up from FT only 222UT that was certified single-pilot IFR, and from 212's that no stab at all and yet we did our IFR rides in them. It is all skill and scan, training, practise, experience. Annual low viz training (1/2 mile clear of cloud) required for all operators here. Avoid going IMC, but no biggie to deal with it if it happens. I've said before in this one, Ara seemed fully competent handling the reduced (but still legal VFR) weather in the LA basin that day. The fact that the police were parked is a red herring, their job wasn't to deliver a passenger. I never "got" the why of the airspeeds Ara was hauling, unless it was customer pressure to "make it to the game", same as pressing on. But it was his turf and his call. Losing visual reference was the end for him, regardless of all the outs the aircraft offered and would not have changed with any of the NTSB recommendations. One training session a year and the occasional check ride, especially done in simulated conditions, does not ensure competence 6 months or 11 months later. One more rich guy with a mickey-duck attitude to a profession.

[aa777888]

From the first reference I posted above, Page 9:

2.5.5 Emergency training

Title 14 CFR 135.293 required pilots to undergo an evaluation for IIMC recovery and stated the following in part:

(c) Each competency check given in a rotorcraft must include a demonstration of the pilot's ability to maneuver the rotorcraft solely by reference to instruments. The check must determine the pilot's ability to safely maneuver the rotorcraft into visual meteorological conditions following an inadvertent encounter with instrument meteorological conditions.

Island Express’s Training Manual, Revision 15, Section F, S-76 Maneuvers, listed loss of anti-torque effectiveness, anti-torque failure, and settling with power. Revision 16 dated March 6, 2020, added brownout, whiteout, and or flatlight conditions, unusual attitude recovery, and inadvertent entry to IMC.

The accident pilot was evaluated on unusual attitude recovery and/or inadvertent entry to IMC on:

S-76 Part 135.293 proficiency check June 21, 2019
S-76 EuroSafety International check May 8, 2019
S-76 Part 135.293 proficiency check August 20, 2018
S-76 EuroSafety International check May 18, 2018
S-76 Part 135.293 proficiency check August 18, 2017
S-76 EuroSafety International check May 12, 2017
S-76 Part 135.293 proficiency check January 28, 2016
S-76 Part 135.293 proficiency check December 9, 2014
AS-350 Part 135.293 proficiency check July 31, 2019

A review of training records revealed the accident pilot met the new hire, recurrent ground, air, and check airman, ground and air, and emergency training requirements. A records review did not reveal non-compliance or deficiencies noted by the evaluators.

[[email protected]]

I can't copy and paste part of the Island Express documents but En Route Qualifications procedures states in para 2 that 'IEH, INC pilot will never take and aircraft into IMC weather conditions, nor into weather that in their opinion will deteriorate into IMC conditions' - well that clearly wasn't complied with.

It later states the IEH flight minima for local area, controlled and uncontrolled airspace as 'Between 500' and 1000' agl but not below 300' agl and with a minimum in flight visibility of not less than 1 nm.' - another non-compliance.

there is another paragraph about landing or diverting in the event of weather not permitting flight at those altitudes or in that visibility.

The link is the one Wrench 1 has put in his post and the Island Helicopters documents look satisfactory on the face of it since they have weather limits, training procedures for IIMC and unusual attitudes - including a paragraph about use of automation and particularly the use of the go-around button.

So if all that was followed and Ara was tested adequately and not found wanting - how did he not either make the simple decision to land or divert as specified in the ops manual or recover successfully from IIMC which he put himself into?

Either he had a particularly off day or he was habitually pushing weather limits below the Ops manual and had not been properly tested on his ability to recover from UAs or IIMC in anything other than benign, VMC conditions.

[JimEli]

From the first reference I posted above, Page 9:

2.5.5 Emergency training

Title 14 CFR 135.293 required pilots to undergo an evaluation for IIMC recovery and stated the following in part:

(c) Each competency check given in a rotorcraft must include a demonstration of the pilot's ability to maneuver the rotorcraft solely by reference to instruments. The check must determine the pilot's ability to safely maneuver the rotorcraft into visual meteorological conditions following an inadvertent encounter with instrument meteorological conditions.

Island Express’s Training Manual, Revision 15, Section F, S-76 Maneuvers, listed loss of anti-torque effectiveness, anti-torque failure, and settling with power. Revision 16 dated March 6, 2020, added brownout, whiteout, and or flatlight conditions, unusual attitude recovery, and inadvertent entry to IMC.

The accident pilot was evaluated on unusual attitude recovery and/or inadvertent entry to IMC on:

S-76 Part 135.293 proficiency check June 21, 2019
S-76 EuroSafety International check May 8, 2019
S-76 Part 135.293 proficiency check August 20, 2018
S-76 EuroSafety International check May 18, 2018
S-76 Part 135.293 proficiency check August 18, 2017
S-76 EuroSafety International check May 12, 2017
S-76 Part 135.293 proficiency check January 28, 2016
S-76 Part 135.293 proficiency check December 9, 2014
AS-350 Part 135.293 proficiency check July 31, 2019

A review of training records revealed the accident pilot met the new hire, recurrent ground, air, and check airman, ground and air, and emergency training requirements. A records review did not reveal non-compliance or deficiencies noted by the evaluators.

Since March 6, 2020 is after the accident, what exactly was he trained and tested on? And the FARs initiated mandatory checking on the maneuvers and procedures in paragraph (c) when taking a competency check after April 22, 2015.

[megan]

So if all that was followed and Ara was tested adequately and not found wanting - how did he not either make the simple decision to land or divert as specified in the ops manual or recover successfully from IIMC which he put himself into?crab, the answer to that question can be found in the NTSB statement,The report discussed during Tuesday’s meeting highlighted Island Express Helicopters Inc.’s inadequate review and oversight of its safety management processes. Island Express Helicopters Inc.’s lack of a documented policy and safety assurance evaluations to ensure its pilots were consistently and correctly completing the flight risk analysis forms, hindered the effectiveness of the form as a risk management tool. The NTSB concluded a fully implemented, mandatory safety management system could enhance Island Express Helicopter Inc.’s ability to manage risks.The following New York Times article doesn't paint a very good picture of the company's safety ethos. You can have all the rules in the world, but if a company feels no need to comply, and by implication requires its pilots to circumvent the rules in order to get the job done, there is little point in taking the pilot him/herself to task. The FAA oversight may be questionable as well, with the company asking for a different inspector to be assigned because the current one was too safety minded according to the article.By Mike Baker, James Glanz and Sarah Mervosh

Published Feb. 6, 2020Updated Feb. 7, 2020

LOS ANGELES — In the years before the helicopter crash that killed the basketball legend Kobe Bryant and eight other people, the company operating the aircraft, Island Express Helicopters, had a series of disputes over its safety practices, according to federal accident reports and a former federal safety inspector.

The tensions first came to the attention of federal investigators in 2008, when a fatal accident involving an Island Express helicopter revealed disagreements that had been playing out for years behind the scenes. A Federal Aviation Administration operations inspector assigned to oversee the company, then under a previous owner, had been pushing for more stringent safety practices, according to federal records. The company’s president at the time pushed back, asking the F.A.A. to assign a different inspector.

The inspector, Gary Lackey, who agreed to step aside, said he was concerned that the company seemed unwilling to spend the money necessary to improve safety beyond what was minimally required.
“Everything that involves safety usually involves money also,” Mr. Lackey, who is now retired, said in an interview. “I think they were trying to cut corners.”Before the tragedy involving Mr. Bryant, Island Express had four crashes since 1985 that damaged or destroyed helicopters, all under the company’s previous management, according to records.

Tensions over the company’s safety culture simmered even after the 2008 crash as the company came under new management several years later, according to people involved in the discussions.

The F.A.A. recorded an additional “incident” in the summer of 2018, when two Island Express helicopters were started up too close to one another, causing significant damage to the blades on both aircraft.

As recently as 2017, Kurt Deetz, a pilot and former safety manager at Island Express, resigned from his safety responsibilities, he said, over “differences of opinion” about how the company’s safety management system should be run.

It is not known what caused last month’s crash. Officials with the National Transportation Safety Board said they are looking at a range of potential issues, ranging from weather to mechanical problems. A key question is whether the Island Express pilot attempted to fly into thickening clouds and fog; N.T.S.B. investigators have asked for the public’s help in gathering photographs of weather conditions near the scene of the crash.

Island Express’s general counsel, Teri Elizabeth Neville, declined to comment in detail until after investigators release their findings on the crash. In a telephone interview this week, Ms. Neville said she was not aware of disputes with safety officials and noted that the company’s four crashes happened before the current management took over. She declined to say when that was, but state records and the company’s website suggest it was in 2012 or 2013.

Mr. Lackey, who was the F.A.A.’s point person for Island Express off and on during his 17 years at the agency, said the tensions between him and the company’s management began sometime around 2005, and N.T.S.B. records show that he issued warning letters to the company.

The records also show that the company’s former owner, John Moore, pushed back against Mr. Lackey’s efforts — in particular, his recommendations to tighten safety procedures on refueling, operating rotors when passengers were boarding, and operations at a helipad in San Pedro, Calif., that Mr. Lackey felt were unsafe. The company also protested when Mr. Lackey failed a pilot on a proficiency check.

Discussions over flying in bad weather came up with all helicopter companies, Mr. Lackey said. Though federal regulations allow helicopter flights in relatively low visibility, given their ability to fly very slowly when necessary, Mr. Lackey said he urged charter operators to consider the risks of doing so and advised them in such cases to land the aircraft and wait for the weather to clear.

He was aware that companies had to balance safety with the need to complete the jobs they were hired to do, he said, and those that did not deliver their customers on time might find their clients going to another operator.

Island Express was one of the few companies to go to Mr. Lackey’s managers to challenge his oversight, he said. After a series of clashes, the F.A.A. in 2008 assigned a new principal operations inspector for the company, records show.
“When John came in and said he wanted a new P.O.I., I said, ‘Fine, you can have somebody else,’” Mr. Lackey said, referring to Mr. Moore. Mr. Lackey said he felt the new person would also be vigilant about safety and that it was an opportunity to reset what had become a contentious relationship.In a statement, the F.A.A. said it could not comment on an individual case, but that it was not uncommon to periodically rotate inspectors to new assignments. “All aviation safety inspectors are qualified to perform the oversight work they are assigned,” the statement said.

Mr. Lackey said he was assigned once again to oversee Island Express in subsequent years and found that Mr. Moore seemed more willing to accept F.A.A. safety requests. The relationship improved, Mr. Lackey said, until new owners and managers took over at Island Express.

After that, Mr. Lackey said, some of the old conflicts began to re-emerge. Once again, the company argued for a different inspector, but this time, Mr. Lackey said, he did not recall a change taking place in response to the request.

Accident and aviation experts said that tensions between aircraft companies and local F.A.A. inspectors are not uncommon. But short of gross incompetence on the part of the inspector, they said, it is highly unusual for an inspector to be replaced at the suggestion of a regulated company. In his interview with N.T.S.B. investigators after the 2008 crash, Mr. Moore did not raise any issues about Mr. Lackey’s competence, acknowledging that the inspector “knows his stuff.”

Jeff Guzzetti, a former N.T.S.B. and F.A.A. accident investigator, said that “a personality clash between an operator and an inspector” is not uncommon.

“It’s less frequent that an operator would hold sway over the F.A.A.,” he said. “It would have to be something that rises to the level of getting the attention of upper F.A.A. management to say, ‘Let’s get this inspector off and get another inspector.’”
Mr. Moore did not respond to a message seeking comment.Mr. Deetz, the former safety manager who also flew Mr. Bryant as a pilot for Island Express, said that proactively managing safety within the company had been part of his job.

He said he established safety protocols for the company and convened a quarterly meeting with pilots and maintenance employees to discuss safety issues. But he said it was the company’s owners who usually dealt directly with the F.A.A., and he was unaware of any disputes with federal regulators during his time at the company.

Mr. Deetz declined to elaborate on the specific dispute with company management that prompted him to resign from his position as safety manager sometime in 2017. “It all goes back to culture,” he said. “There is window-dressing safety, and there is real, actual, get-your-hands-dirty safety culture.”

He later left the company altogether to take a pilot position with a competitor and now flies air ambulances in Arizona.

Most of the company’s previous crashes — a total of four since it was founded in 1982 — involved mechanical failures, federal records show.

In the 2008 accident, a turbine engine blade failed during an approach to Catalina Island near Los Angeles, leading to a rapid plunge and a crash into the ground that killed three people and injured three others.

In 1999, in the same area, a helicopter with seven people on board crashed and slid down a hill, striking some trees and rolling over after an engine failure caused by a loose pneumatic fitting. The crash resulted in mostly minor injuries.
In 1989, another incident with minor injuries occurred when an engine failed over the ocean because of a worn fuel pump assembly. The pilot was able to set the craft down with the help of emergency floats.In 1985, an Island Express helicopter collided with another helicopter, an accident that investigators found was probably a result of “the inadequate visual lookout of both pilots.” One person was killed and 11 others were injured.

In the most recent incident, in 2018, two of the company’s Sikorsky S-76 helicopters were parked next to each other at Long Beach Airport for a photo shoot. When pilots started the engines, the drooping rotors straightened, and their blades began colliding. All six blades were damaged, an F.A.A. report says, “and Island Express Helicopters altered their parking plan to no longer park two S-76 aircraft next to each other.”

Mr. Guzzetti, the former federal accident investigator, said the 2018 incident was of more concern than it might initially appear. “This one is recent and it’s operational,” he said. “It’s an indicator of inadequate safety culture.”

But John Cox, an accident investigator and the head of Safety Operating Systems, an aviation consulting firm, said it was hard to determine any pattern in the company’s overall record. The previous crashes, he said, occurred over a long time period and many of them involved equipment failures, not operational ones.

“It could be construed as a red flag to have this many accidents for the same operator,” Mr. Cox said. “But you have to look more deeply as to when those accidents happened, over what period of time.”https://www.nytimes.com/2020/02/06/us/kobe-bryant-island-express-helicopters.html

[Gordy]

Mr. Deetz declined to elaborate on the specific dispute

I wonder why.... Actually I know....seek the truth....

[[email protected]]

I think the IEH accident history is a red herring, a series of unconnected failures that don't imply a safety culture issue.

But, the incident where 2 S 76s ended up damaged smacks of complacency, poor awareness and poor piloting - if you can get something as simple as a photo shoot so wrong that is concerning.

Whatever Mr Deetz's issues with the company, they seem largely irrelevant to the Bryant crash and are probably a personality issue of the '6 of one and half a dozen of the other' variety.

What cannot be ignored is that Ara did not comply with the IEH Ops manual which is quite clear on both the weather limits for flight and the actions to be taken in the event of weather deterioration.

If his attitude to the Ops manual was like this habitually, one must question his attitude to other professional aspects of flight such as the UA and IIMC training - was there a cosy relationship in IEH where boxes were ticked to meet the regulations but no actual testing was conducted - a 'handshake currency check' if you will.

Are there sufficient numbers of helicopter guys in the NTSB who understand the difference between the inherent stability of a FW and the inherent instability of RW, especially where IIMC is concerned?

[megan]

I wonder why.... Actually I know....seek the truthSince you know Gordy, what is the truth? We seek the truth.

[aa777888]

Since March 6, 2020 is after the accident, what exactly was he trained and tested on? And the FARs initiated mandatory checking on the maneuvers and procedures in paragraph (c) when taking a competency check after April 22, 2015.
His training records can be reviewed at this link: https://data.ntsb.gov/Docket/Document/docBLOB?ID=9728818&FileExtension=pdf&FileName=Attachement%202_Redacted-Rel.pdf

[airplanecrazy]

The link is the one Wrench 1 has put in his post and the Island Helicopters documents look satisfactory on the face of it since they have weather limits, training procedures for IIMC and unusual attitudes - including a paragraph about use of automation and particularly the use of the go-around button.
.

Out of curiosity, on the SPZ-7000 DAFCS, what does the pilot have to do to activate the go-around button? Does the AP1 or AP2 button need to be pushed first? Does the FD2 button and/or CPL button need to be pressed before the go-around button?

[rotorspeed]

Crab

As ever, very good take on all of this. But did Ara really not have a current IR? And I guess even if he did, an issue would be his IMC currency. Pretty extraordinary to be flying an S76 without surely?

And does anyone know what the weather was like at the intended destination? And how would Ara have known that - was there a nearby airfield with met reporting? How much further did he have to run? One of the biggest risk areas of ops to private sites in poor weather is uncertainty of weather there. Reports from particularly non pilots are to be given little weight in my experience.

But fundamentally I do groan at yet another stupid accident that should never have happened. All the form filling out and box ticking issues are just peripheral - there was just grossly incompetent pilot judgement here I’m afraid. If it was the usual low time PPL in an R44 scenario it wouldn’t have surprised too much, but a charter operator with a celeb in a S76....

[airplanecrazy]

As ever, very good take on all of this. But did Ara really not have a current IR? And I guess even if he did, an issue would be his IMC currency. Pretty extraordinary to be flying an S76 without surely?



None of the pilot's proficiency check records published by the NTSB (since 2014) show FAR 135.297 Pilot in command: Instrument proficiency check. https://data.ntsb.gov/Docket/Document/docBLOB?ID=9728818&FileExtension=pdf&FileName=Attachement%202_Redacted-Rel.pdf


And does anyone know what the weather was like at the intended destination? And how would Ara have known that - was there a nearby airfield with met reporting? How much further did he have to run? One of the biggest risk areas of ops to private sites in poor weather is uncertainty of weather there. Reports from particularly non pilots are to be given little weight in my experience.
.

Weather reports from airports (CMA destination airport, VNY closest airport to crash site):

At 0851 PST, (prior to departure) VNY reported a calm wind, visibility of two and a half statute miles, haze, ceiling overcast at 1,100 feet agl,
At 0905 PST (just prior to departure), CMA reported a wind from 080° at 7 knots, visibility of 4 statute miles, haze, ceiling overcast at 1,600 feet agl,
At 0951 PST, (about 5 minutes after the crash) VNY reported a calm wind, visibility of two and a half statute miles, haze, ceiling overcast at 1,300 feet agl,
At 0955 PST (about 10 minutes after the crash), CMA reported a wind from 030° at 3 knots, visibility of 4 statute miles, haze, ceiling overcast at 1,700 feet agl,

During the NTSB Board meeting the investigators said that at the time of departure the forecast flight conditions were within company specified limits, but that the visibility less than 3 miles at VNY should have resulted in the pilot consulting with the Director of operations and the SVFR should have required an alternative plan.

I'll add that in looking at the NTSB provided ADS-B data, which includes GEO altitude, I can see that the pilot was squeezed to ~300' AGL going over the U.S. 101 pass near Mureau Rd (this pass is the highest point on his planned route). After the pass, the helicopter maintains ~300' AGL for a few seconds as the road (and the helicopter) descend ~150', then the pilot climbs to "get above the layers". I hypothesize that the pilot's plan was to get over the pass and descend underneath the cloud base to complete the flight scud running, but that conditions on the other side of the pass were not what he expected. A witness told the NTSB: "The cloud that the aircraft entered and disappeared into was a thick wall that extended as low as about ten feet above ground and upward beyond visibility. This low cloud started at about the Juan Bautista de Anza East Trailhead, heading west. This trailhead starts at the end of Calabasas Rd. When I first spotted the aircraft, the clouds were relatively higher than the cloud I watched it disappear into. I couldn't guess the altitude of the higher cloud line but it was lower than a police helicopter would fly when closely circling a person on foot over a residential neighborhood in West Hills, CA. It appeared that the aircraft was flying at a level which had visibility until it entered the cloud wall."

[Gordy]

None of the pilot's proficiency check records published by the NTSB (since 2014) show FAR 135.297 Pilot in command: Instrument proficiency check.

This check is only completed if the aircraft/pilot are flying on a 135 IFR program which they were not. The company was Part 135 VFR only. The inadvertent IMC portion of the 135.293 and .299 was completed each year.

[airplanecrazy]

This check is only completed if the aircraft/pilot are flying on a 135 IFR program which they were not. The company was Part 135 VFR only. The inadvertent IMC portion of the 135.293 and .299 was completed each year.
Sorry, I can see how my response could be misleading. I did not mean to imply that he didn't meet all the regs, just meant to answer rotorspeed's question "But did Ara really not have a current IR?"

[JimEli]

His training records can be reviewed at this link: https://data.ntsb.gov/Docket/Document/docBLOB?ID=9728818&FileExtension=pdf&FileName=Attachement%202_Redacted-Rel.pdfTrust me, I am very familiar with all of the NTSB docket information (see this long-winded post for background: https://www.pprune.org/rotorheads/632833-n72ex-kobe-bryant-crash-reconstruction-new-atc-audio-4.html#post10871271).

However, the point is, IEH added the tasks for unusual attitude recovery, and inadvertent entry to IMC to their training manual AFTER the accident, an egregious oversight by both IEH and the FAA POI, a violation of FAA policy and possibly FAR.

So, how did they train/evaluate these tasks in the S-76? Did the procedure address airspeed management, autopilot, diversion, abort, landing or emergency IFR? Because of the oversight, we don’t know. At best, they used a generic procedure, and at worst the instructors/evaluators did whatever they pleased. Or, did they even didn’t do it, absent published tasks?

Without a specific delineated procedure, maybe the accident pilot was attempting to perform exactly what his GOM (at the time) instructed him to do, “pilots will never take an aircraft into IMC…” As best he could.

All we know is the forms have a checked box on them.

[gulliBell]

...Without a specific delineated procedure, maybe the accident pilot was attempting to perform exactly what his GOM (at the time) instructed him to do, “pilots will never take an aircraft into IMC…” As best he could.

As "best he could"..." “pilots will never take an aircraft into IMC" we know he did make a decision to enter a climb in IMC to find VMC on top. So the "best he could" part of that theory probably doesn't apply when there was a “pilots will never take an aircraft into IMC" option to land or turn around.

[FH1100 Pilot]

All of this speculation is pretty moot. There are things we cannot know about this accident, and things that we will *never* know. We do know that Ara was Instrument-rated and took annual 135 checkrides which most likely included some hood work. *EVERY* VFR 135 ride I've ever taken (and I've taken a bunch) included a UA recovery. So he was - at very least - qualified to fly under IFR even if he was not current and legal (approved) to do so. How many people on internet boards like this one claim that a pilot is not a pilot with an Instrument Rating, as if that imbues one with some magical skill set that just might come in handy in a situation like this? (Obviously, that's bogus.)

But keying on that... We can surmise that Ara had a somewhat "casual" relationship with weather. If it is true that he flew over the Pacific, over a cloud deck to get offshore and then descended (probably IMC) to get under the marine layer and come back into the beach VFR, then we can also surmise that he was able to maintain some semblance of control over a helicopter by reference to the instruments only. But that's just a guess.

So what happened here? What went wrong so quickly? Was there a distraction or two just as the view outside went completely white? We're pretty sure that right after he punched-in, he called up ATC to report that he was climbing to 4,000', figuring that the guy he was talking to was familiar with who and where he was. Not so! They'd had a controller change and now the guy he was talking to didn't know Ara from Adam. This new controller had to go through the whole process of getting him radar identified, something the other controller presumably wouldn't have had to do. So now Ara has got to look down and put in a squawk. And while he was down there, he probably re-centered the GPS to Camarillo. I would *guess* that right then, Kobe keyed the intercom and said something like, "Hey, uhhh, Ara? Are we okay here, buddy? All I see outside is...nothing." And while those things were happening, the helicopter was banking over to the left, undetected because "someone" took his eyes off the attitude indicator and the helicopter did what helicopters do when you're not paying attention.

Unusual Attitude recovery practice is great. We all should get some. Trouble is, when it happens for real, when you're already down to just a couple of hundred feet above the rising terrain when you punch-in, your chances of getting the wings level, stopping the descent and getting a climb going before smashing into something are pretty...how shall we say...zero. So Ara maybe didn't have any "real world" UA practice lately. Big deal, what would it have helped in that case? Once he got into the UA, it was game-over.

Some of us seem to think that flying a helicopter and not crashing is SOOOO EASY! Any idiot can do it. The truth is that sometimes circumstances conspire and combine against us and a bunch of crap happens at exactly the wrong time, and maybe we're not operating at 100% that day for whatever reason.. Maybe on any other day, Ara would've initiated the straight-ahead climb to get above the layer and he would've popped out on top, perhaps as he'd done once or twice before. No harm, no foul, no one would have to know...and he'd continue on with the flight like nothing happened.

[gulliBell]

..So Ara maybe didn't have any "real world" UA practice lately. Big deal, what would it have helped in that case?

Pressing HDG mode on the flight director was all that was required to keep wings level and redirect some attention to other tasks. Doing so would have helped enormously.

[roscoe1]

My take is that this is simpler than people are making out. " Circumstances conspire and combine" is not reality. Conditions only exist. They have no consicousness or means of combining against you. We allow them to " conspire" by ignoring them individually and forgetting what the one job of a pilot is. That is to fly the aircraft to the point of a safe landing. Ignore Kobe if he calls on the ics when you're busy. In fact isolate the passengers if you like, if they are chatty when you are sweating. No need to dial in that squawk code if you are busy actually flying. It can all wait, it isn't going to save your butt. If you've ever lapsed from your task of driving a car due to a phone call, text or something that just draws your eye off the road then you must know this is no different. He obviously had the training and ability to revert to basic instrument flight ( had the rating and had UA recovery training) but chose not to focus on that. What he apparently did not have was the judgement to see that in a little while all would be forgiven if he landed short, in a vacant parking lot and called cabs for the passengers. I suspect that his thoughts during the flight, until g forces were not computing, was " I can get through this" , not " I need to be on the ground right now, if not a few minutes ago".

The words I rember most clearly from my ( airplane) instrument instructor were " Quit fu*king with the radio and just fly".

[FH1100 Pilot]

Indeed, Roscoe and gulliBell, all of those things are what Ara *should* have done. Sadly, apparently he did not do any of them. We are left to forever wonder why.

[industry insider]

Airplane Crazy
Out of curiosity, on the SPZ-7000 DAFCS, what does the pilot have to do to activate the go-around button? Does the AP1 or AP2 button need to be pushed first? Does the FD2 button and/or CPL button need to be pressed before the go-around button?

I am a bit rusty on the SPZ 7000 but if my memory works, the GA button was on the collective around your thumb area. To initiate a GA, the aircraft had to be already coupled and the collective was not coupled so an increase in power had to be initiated by a pull on the lever, the GA function would essentially manage speed.

[megan]

But did Ara really not have a current IR? And I guess even if he did, an issue would be his IMC currency. Pretty extraordinary to be flying an S76 without surely?It was a VFR only operation, so no need for him to have an instrument rating, even though it was a fully equipped 76 he was driving. The only thing I can find in the docket is mention of 75 hours instrument on a document dated 3rd July 2019 (a little over six months prior to the accident) He had received his instrument rating in October 2007 with simulated instrument listed at 68.2 hours in a R-44, a number of check flights in the 76 record instrument elements checked including ILS & VOR approaches. On the face of it then he had done 6.8 hours, probably simulated and likely in the 76, so when he found himself in actual condition on the accident flight it is likely it was the first time ever. Little wonder then that he came to grief given lack of both currency and exposure to real IMC. Never found simulated IMC in the 76 realistic, you always had a view of the outside somewhere.We are left to forever wonder whyNot in my mind, given what I've written above the result is about what I'd expect.

[gulliBell]

If he'd done 6.8 hours IF training in a 76 he should have worked out that you should not be hands flying it in IMC, and certainly not hands flying it in SAS mode with the force trim off. For the life of me I can't see how you can get in a UA in a 76 unless you were flying in SAS and totally not paying attention. Teaching UA's in the 76 on annual recurrent training was never done in SAS, always in ATT with the force trim on. I'd like to know what mode he was flying in to have lost control.

[gulliBell]

...I am a bit rusty on the SPZ 7000 but if my memory works...

An S76B has a SPZ 7000?

[gulliBell]

...the GA function would essentially manage speed.

Umm, not quite. The GA button cancels all other modes, maintains wings level, and commands a rate of climb of 750 fpm. The key point about this behavior is, if you don't have the power required to climb at 750 fpm, in trying to maintain that ROC the autopilot will slowly increase nose up pitch. As the nose is slowly pitched up the airspeed deceases slowly. If you fail to notice this, eventually the aircraft will get your attention with a sudden nose up pitch just before it falls out of the sky with zero airspeed. I've seen this happen during recurrent training, far too many times.

[[email protected]]

Whilst Ara certainly does seem to have been 'current' in terms of his 135 checkrides and UA/IIMC training - I am left wondering how demanding those UA/IIMC manoeuvres were that he had to pass.

The IEH Ops manual defines a UA as +/- 10 kts of intended IAS or +/- 10% of normal cruise power (unless I am reading it all wrong) so very little adjustment required to correct either of those.

By comparison, the 2 standard UAs for Brit Mil IRTs are 'Low speed autorotative turn at not more than 30 deg AoB and High speed descending turn at not more than 30 deg AoB' - both of these should be recovered with minimum height loss and with a specified minimum base height and recovery height to simulate being below safety alt.

My point is that if you don't train properly for a hazardous situation, you are far less likely to recover from it if it does present itself.

Do the part 135 UAs and IIMC checks come even close to replicating real disorientation? If not, is it because the checkers don't have any more actual IMC time than the check airmen and have no idea what it is really like?

Real disorientation is f***ing scary - as Robbiee has discovered - and only good, realistic training or a very big handful of luck will save you.

[212man]

An S76B has a SPZ 7000?
what were you thinking it has? I thought it was standard and some even gave 7600.

[megan]

Ara got his A model 135 rating on 12th September 2014 and B rating 12th August 2017. What IF time he had in either model i don't know, but with no IF time since completion of training in October 2007 that means he had between seven and ten years between drinks, whatever you had learnt about IF in training would be long forgotten, assuming the 6.8 hours were in the B over the period of 31 months is not going to get you one tenth of the way up to speed.If he'd done 6.8 hours IF training in a 76 he should have worked out that you should not be hands flying it in IMC, and certainly not hands flying it in SAS mode with the force trim off. For the life of me I can't see how you can get in a UA in a 76 unless you were flying in SAS and totally not paying attention.Being special VFR winding his way along a freeway at low level my bet he would be in SAS and force trim off, when confronted with IMC he likely lost it maybe searching for the requisite buttons as you describe would be needed Gulli, muscle memory would have him floundering, and understandably so, use it or lose it.

An insight to the company ethos may be gained in the docket with interview with one of the pilots.

https://data.ntsb.gov/Docket?NTSBNumber=DCA20MA059

Down load "3 OPERATIONAL FACTORS AND HUMAN PERFORMANCE GROUP INTERVIEW OFFICIAL TRANSCRIPTS" and open the "Deetz" PDF file.

[[email protected]]

It's an interesting interview and probably describes many small operations where commercial pressure inevitably impacts operational decisions - much like a lot of HEMS operations in the US I would expect. Don't fly, don't get paid - but crashing is a lot more expensive.

[airplanecrazy]

Umm, not quite. The GA button cancels all other modes, maintains wings level, and commands a rate of climb of 750 fpm. The key point about this behavior is, if you don't have the power required to climb at 750 fpm, in trying to maintain that ROC the autopilot will slowly increase nose up pitch. As the nose is slowly pitched up the airspeed deceases slowly. If you fail to notice this, eventually the aircraft will get your attention with a sudden nose up pitch just before it falls out of the sky with zero airspeed. I've seen this happen during recurrent training, far too many times.
Is the behavior you describe specific to particular SPZ-7000 installations? The SPZ-7000 DAFCS Pilot's manual for the S76 says: "The go-around mode may be engaged by pressing the button on the mode selector or by depressing the go-around switch on the collective. When engaged this mode will cancel all other modes that are engaged. Upon engagement the collective will be commanded to obtain 75 knots or more while the roll axis will return the aircraft to a level roll attitude and will maintain the current aircraft magnetic heading. The pitch axis will be commanded to a positive rate-of-climb of 750 fpm."

[gulliBell]

It behaves as you describe there. However, where many pilots become unstuck is in an OEI go-around. The autopilot does not know you only have one engine available, and you probably don't have enough power (via the collective) to automatically maintain 75 knots. The autopilot will still always pitch for 750 fpm. The end result, if left uncorrected, is the sudden nose up pitch, zero airspeed and falling out of the sky tail first. In a GA let the pilot control the power, and let the autopilot take care of climb rate. For whatever reason doing it this way more often results in better pilot monitoring of the situation and less falling out of the sky tail first.

[airplanecrazy]

It behaves as you describe there. However, where many pilots become unstuck is in an OEI go-around. The autopilot does not know you only have one engine available, and you probably don't have enough power (via the collective) to automatically maintain 75 knots. The autopilot will still always pitch for 750 fpm. The end result, if left uncorrected, is the sudden nose up pitch, zero airspeed and falling out of the sky tail first. In a GA let the pilot control the power, and let the autopilot take care of climb rate. For whatever reason doing it this way more often results in better pilot monitoring of the situation and less falling out of the sky tail first.
That makes perfect sense. Thanks!

[megan]

The end result, if left uncorrected, is the sudden nose up pitch, zero airspeed and falling out of the sky tail first. In a GA let the pilot control the power, and let the autopilot take care of climb rateFor climbing I never used VS mode because you could find yourself running out of airspeed and falling tail first, only use VS for descent, for climb use IAS. It's going to be a life saver if you're heavy, single engine and you're inattentive, as some FW accident reports spell out even with all engines running using VS for climb they ended up stalling and incurred buffet induced structural damage - bits falling off the airframe.

[gulliBell]

For climbing I never used VS mode because you could find yourself running out of airspeed and falling tail first, only use VS for descent, for climb use IAS. .

Exactly. But you have a thorough understanding of the system and know exactly what you are doing. The problem arises with pilots who only push the GA button once per year on their annual competency check without knowing exactly what it does, and does not, do. Quite often on those check rides the recurrent trainee gets an engine failure about 3 seconds after they push the GA button on a missed precision approach. The confusion and calamity with the pushing of auto-pilot buttons after that can so easily lead to mayhem and the falling out of the sky tail first. I find successful outcomes are more likely if the pilot just leaves the auto-pilot mode as it is, and manually adjust the power to droop the main rotor speed to 100%. And then leave it there. That is easy, and will see the aircraft safely climbing wings level. Whilst changing the auto-pilot mode from VS to IAS as suggested by megan is very good advice, the execution of that in practice can be very problematic and quickly lead to an unfortunate outcome.

[[email protected]]

The only problem with VS in a descent (not qualified on 76 but other similar aircraft) is that without adequate monitoring of the collective and what power you have set, the AP can reduce speed sufficiently to put you into VRS. That is if you are in 3-axis mode.

[JimEli]

Did the NTSB miss some blame in this accident? Could it have been prevented if the FAA had performed their duties? The FAA was specifically tasked to check for these apparent missing tasks, which seem to have be added with an update to IEH's training manual on March 6, 2020?

Part 135 Helicopter Training and Qualification Program Review and Competency Check Requirements (https://www.faa.gov/documentLibrary/media/Notice/N_8900.437.pdf)
National Policy Effective Date: 9/22/17, Cancellation Date: 9/22/18
“The objective of the program review is to identify and correct part 135 helicopter training and qualification programs that do not include the required training and checking on (1) procedures for helicopter handling in flat-light, whiteout, and brownout conditions and (2) recovery from inadvertent instrument meteorological conditions (IIMC). In addition, this notice provides guidance to ASIs conducting § 135.293(a) helicopter written or oral tests or § 135.293(b) helicopter competency checks.”

As pilots, the FAA holds our feet to the fire, yet this seems egregious on their part...

[ShyTorque]

Pressing HDG mode on the flight director was all that was required to keep wings level and redirect some attention to other tasks. Doing so would have helped enormously.

Only if the aircraft heading was the same as the heading bug. Otherwise the aircraft would enter a rate one turn onto the bug heading.

[wrench1]

which seem to have be added with an update to IEH's training manual on March 6, 2020?...
FYI: This issue was discussed during the preliminary investigation stages. Island outsourced their 135 training who provided the required 135 IIMC, etc training procedures and records. As I recall the main issue was that the procedures used had to be also listed in the Island training as well which they revised in March after it was brought up during the investigation. Also keep in mind, Island passed a number of audits to include Chevron where no training short comings were noted. I can't readily find the document that discussed this March revision but it is out there.

[havick]

Only if the aircraft heading was the same as the heading bug. Otherwise the aircraft would enter a rate one turn onto the bug heading.

This exact reason is why I got funny looks when I flew jets after helicopters and the other pilot thought I was overly OCD centering the HDG bug.

[megan]

The only problem with VS in a descent (not qualified on 76 but other similar aircraft) is that without adequate monitoring of the collective and what power you have set, the AP can reduce speed sufficiently to put you into VRS. That is if you are in 3-axis mode.Very true crab, hence why procedures have to be tailored to your operation. In 12,000 hours on the 76 never once used the GA function, we were a VMC operation (cough, cough), never once flew an IMC approach in anger.

[JimEli]

FYI: This issue was discussed during the preliminary investigation stages. Island outsourced their 135 training who provided the required 135 IIMC, etc training procedures and records. As I recall the main issue was that the procedures used had to be also listed in the Island training as well which they revised in March after it was brought up during the investigation. Also keep in mind, Island passed a number of audits to include Chevron where no training short comings were noted. I can't readily find the document that discussed this March revision but it is out there.In the docket interview with the FAA POI, he characterized the contract training as not part of the operator’s approved training program, stating, “it was never something where, you know, I either approved, accepted, or required it, or, you know, anything to that effect.”
And I would suggest rereading the interview with the FAA POI. Especially when they get to the part about the missing procedures. You know, the point where his appointed representation cuts in to clarify things....

[wrench1]

In the docket interview with the FAA POI, he characterized the contract training as not part of the operator’s approved training program, stating, “it was never something where, you know, I either approved, accepted, or required it, or, you know, anything to that effect.”
And I would suggest rereading the interview with the FAA POI. Especially when they get to the part about the missing procedures. You know, the point where his appointed representation cuts in to clarify things....
And? Don’t quite follow where you’re going with this. Are you saying the FAA missed the inclusion of IIMC procedures in Islands Training manual over a 14 year period and as such Ara didn’t have the proper IIMC training which caused the accident?

Keep in mind, IIMC training wasn't required until a few years after the Island Training Manual was approved and they used a Part 142 provider for most of their required training in that same time frame. But as I mentioned earlier, this has been discussed by the investigators and when the IIMC procedure was found missing in the Island manual (not the Part 142 manual) Island revised their manual to correct the error.

[JimEli]

And? Don’t quite follow where you’re going with this. Are you saying the FAA missed the inclusion of IIMC procedures in Islands Training manual over a 14 year period and as such Ara didn’t have the proper IIMC training which caused the accident?

Keep in mind, IIMC training wasn't required until a few years after the Island Training Manual was approved and they used a Part 142 provider for most of their required training in that same time frame. But as I mentioned earlier, this has been discussed by the investigators and when the IIMC procedure was found missing in the Island manual (not the Part 142 manual) Island revised their manual to correct the error.

No. I'm saying the FAA POI was tasked w/i 60 days of 9/22/17, to "conduct a focused review of the helicopter training and qualification programs for their assigned certificate holders to identify whether the programs include the required training and testing on procedures for aircraft handling in flat-light, whiteout, and brownout conditions and training and checking on recovery from IIMC." It is doubtful this was accomplished, because we know they didn't discover the missing procedures until after the accident.

[wrench1]

No. I'm saying the FAA POI was tasked w/i 60 days of 9/22/17, to "conduct a focused review of the helicopter training and qualification programs for their assigned certificate holders to identify whether the programs include the required training and testing on procedures for aircraft handling in flat-light, whiteout, and brownout conditions and training and checking on recovery from IIMC." It is doubtful this was accomplished, because we know they didn't discover the missing procedures until after the accident.
So you are of the opinion that if the POI conducted that policy review on Euro Safety’s training program, whom Island contracted their training requirements to per 135.324, this would not meet the intent of the 60 day 2017 Policy memo?

[Gordy]

No. I'm saying the FAA POI was tasked w/i 60 days of 9/22/17, to "conduct a focused review of the helicopter training and qualification programs for their assigned certificate holders to identify whether the programs include the required training and testing on procedures for aircraft handling in flat-light, whiteout, and brownout conditions and training and checking on recovery from IIMC." It is doubtful this was accomplished, because we know they didn't discover the missing procedures until after the accident.

It was accomplished satisfactorily, otherwise it would have been noted as a deficiency.

So you are of the opinion that if the POI conducted that policy review on Euro Safety’s training program, whom Island contracted their training requirements to per 135.324, this would not meet the intent of the 60 day 2017 Policy memo?

Island did NOT contract their 135 training to Eurosafety. The Eurosafety training was in addition to the FAA required training as stated by the POI “it was never something where, you know, I either approved, accepted, or required it, or, you know, anything to that effect.”

[wrench1]

Island did NOT contract their 135 training to Eurosafety..”
I'll defer to your local knowledge, but there were several discussions/documents during the initial part of the investigation that did show a contractual agreement with Euro Safety for training. How those discussions turned out I do not know. If I find the documents I'll post them.

[airplanecrazy]

I'll defer to your local knowledge, but there were several discussions/documents during the initial part of the investigation that did show a contractual agreement with Euro Safety for training. How those discussions turned out I do not know. If I find the documents I'll post them.

Not to insert myself into your debate, but I recalled this section of the "OPERATIONAL FACTORS/HUMAN PERFORMANCE" report https://data.ntsb.gov/Docket/Document/docBLOB?ID=9742056&FileExtension=pdf&FileName=Ops-HP%20Factual%20Report-Rel.pdf:

"2.5.4 Additional ground and flight training
According to the director of operations, Island Express contracted with EuroSafety International (EuroSafety) to provide ground and flight training along with flight examinations for the company pilots to prepare for annual FAA proficiency checks. This training was not a part of Island Express’s FAA-approved training program. EuroSafety used company helicopters for the flight training and examinations. According to the EuroSafety S-76 flight instructor, EuroSafety offered an S-76 refresher program that consisted of 2 to 3 days ground training and 2 to 3 flights, depending on the experience of the pilots. EuroSafety did not use an S-76 simulator for training or evaluations. The flight instructor stated that he provided ground training and flight training on inadvertent instrument meteorological conditions (IIMC) avoidance and recovery, to prepare the pilot for FAA check rides that may include those evaluations. A review of Island Express training records revealed the accident pilot’s last EuroSafety training and evaluation occurred on May 8, 2019."

[Gordy]

Not to insert myself into your debate, but I recalled this section of the "OPERATIONAL FACTORS/HUMAN PERFORMANCE" report https://data.ntsb.gov/Docket/Document/docBLOB?ID=9742056&FileExtension=pdf&FileName=Ops-HP%20Factual%20Report-Rel.pdf:

"2.5.4 Additional ground and flight training
According to the director of operations, Island Express contracted with EuroSafety International (EuroSafety) to provide ground and flight training along with flight examinations for the company pilots to prepare for annual FAA proficiency checks. This training was not a part of Island Express’s FAA-approved training program. EuroSafety used company helicopters for the flight training and examinations. According to the EuroSafety S-76 flight instructor, EuroSafety offered an S-76 refresher program that consisted of 2 to 3 days ground training and 2 to 3 flights, depending on the experience of the pilots. EuroSafety did not use an S-76 simulator for training or evaluations. The flight instructor stated that he provided ground training and flight training on inadvertent instrument meteorological conditions (IIMC) avoidance and recovery, to prepare the pilot for FAA check rides that may include those evaluations. A review of Island Express training records revealed the accident pilot’s last EuroSafety training and evaluation occurred on May 8, 2019."
Correct.....

[[email protected]]

It still seems to me that, however legal and FAA approved it might be, training for IIMC in an environment where visual cues are still available (foggles) compared to proper simulator or best of all, actual cloud - is just paper-safety and could go a long way to explaining why there are so many IIMC accidents amongst professional pilots.

I finished a NVG sortie last night by pulling up into cloud and flying an ILS - I was thinking at the time that only years of proper training and constant practice have allowed me to do that that in complete confidence and safety - finding yourself in that environment when you haven't been properly prepared is just relying on luck.

[JimEli]

Now that we have finished bumbling our way through some of that, it seems illogical to me, for the POI, after being tasked to perform a focused review of IIMC training and checking, that he would miss the fact that the procedures didn’t exist. This is especially remarkable, given the fact that the POI had also conducted the 2 previous 293/299 checks with the accident pilot. Read the interview (Doty), it’s almost comical in the evasion to actually answer anything with any specificity.

How can the FAA expect a pilot to perform or check airmen to evaluate a maneuver that has no direction, description or standard? Absent proof otherwise, I find it nearly impossible not to put some blame on the FAA.

[malabo]

Rules and reality. Crab nailed it, no sub for actually flying when you can't see the ground. And regular. And knowing what the autopilot does in what modes and what can save and what can kill you. Teaching IFR if they could see the ground through one square inch of chin bubble they were visual. A quick test: in cloud turn both AP's off (yes, even on a 139) and see if they can hold an airspeed and heading. Whether or not the paper box tick was done in "simulated" conditions is academic. As in regulatory compliance, but doesn't keep anybody alive.

[FH1100 Pilot]

Guys, all this talk of UA recovery and I-IMC training is all very well and good. But it's also very moot - just senseless jibber-jabber. Does any real helicopter pilot think that Ara could've recovered 72EX from that UA once he went inadvertent so close to the ground? Come on, man. It's...silly to even suggest that he could. Once that ship began its uncommanded (and probably undetected) left roll it was game-over.

Add to that the fact that in VFR Part-135 operations in the U.S. pilots are not even required to have an Instrument Rating, much less be familiar with how an autopilot works. Strip away all of the B.S., and Ara might as well have been a VFR line charter pilot in a 206 who "inadvertently" punched into a cloud and lost it. Wasn't the first; won't be the last.

[Robbiee]

Guys, all this talk of UA recovery and I-IMC training is all very well and good. But it's also very moot - just senseless jibber-jabber. Does any real helicopter pilot think that Ara could've recovered 72EX from that UA once he went inadvertent so close to the ground? Come on, man. It's...silly to even suggest that he could. Once that ship began its uncommanded (and probably undetected) left roll it was game-over.

Add to that the fact that in VFR Part-135 operations in the U.S. pilots are not even required to have an Instrument Rating, much less be familiar with how an autopilot works. Strip away all of the B.S., and Ara might as well have been a VFR line charter pilot in a 206 who "inadvertently" punched into a cloud and lost it. Wasn't the first; won't be the last.

Hmm,...so all those times I had to open my eyes and do the old, "bank/pitch/power" thing while struggling to hold back puke, was for not?

I guess its kinda like the way we always practiced the old "settling with power" recovery,...I mean come on,...when have I ever (in the real world) flown at 3,000' AGL (let alone) then suddenly decided to pull it into a hover?
:yuk:,...:(

[Bell_ringer]

A recovery is an intentional action once you have realised your mistake or can identify the problem.
If you are determined to push on, or are disoriented and think you are wings level, all the recovery training in the world would be pointless.

Training only helps people who intend applying it.

This vfr flight should never have left the ground, that’s not something that seems to have been in the checklist or training.

[[email protected]]

Does any real helicopter pilot think that Ara could've recovered 72EX from that UA once he went inadvertent so close to the ground?

Yes, I do.

Roll the wings level concentrating all your attention on the AI/AH and bring the nose up to a climbing attitude then apply full power and check balance - it's a basic technique that works every time. WASP - Wings level, select the pitch Attitude to adjust the Speed and then add Power.

If your speed is high when you recognise the UA then zoom climbing can gain you a healthy height very quickly.

I have IF aborted from low level in turns - and it works.

Even better if you have prepared properly and have your AP up and running and local navaids already selected but the MOST important thing is to get safely away from the ground and above safety alt.

On my recent sortie I initiated the climb in SAS mode but, once established in the climb, selected ATT mode and selected HDG and, once level, ALT. Using HDG to steer towards the ILS I then coupled ILS once close to the localiser. Easy peasy if you know your AP and have thought about the process first.

There were plenty of times during the sortie that Ara could have prevented the tragedy but even as he entered the cloud, the route to safety was absolutely available to him.

Do we know how many hours of real IMC the pilots who provided the training for IEH have between them? Anyone can all themselves an instrument pilot but there is only one acid test.

[Bell_ringer]

Crab, its easy as an IF pilot to point out how you identified your situation and corrected it while using automation and being on instruments.

That is meaningless to anyone flying visually and who has no idea where the wings are.
There is no caution on the panel that highlights an impending sense of doom.

By the time someone realises they are in the dwang it is too late.
Prevention is better than cure.

[[email protected]]

True, but this was a previously instrument rated pilot with a whole bunch of hours in an IFR twin - not some newbie in a Robbie

If you are flying around without an attitude indicator/artificial horizon, then get one fitted, it might just save your life.

I only mentioned what I did in terms of the pull up because I was asked to detail it in order to highlight how proper use of automation makes things so easy.

[helonorth]

I have a feeling he started the turn in marginal VMC and then went inadvertent shortly thereafter. You will get the leans immediately and have to force yourself to believe the instruments as the turn now becomes your "straight and level". It takes A LOT of will to force yourself to commit to what the the attitude indicator is telling you. I experienced this first hand many years ago. I transitioned to instruments, took my eyes off them momentarily and was right back in the turn. Would have sworn on my mother I was level. Got things right again, started a climb and popped out on top. I was only at about 400' when the fun started, Quite a bit of pressure to know if you screw this up, you're dead. It's a shame all he had to do was hit the heading bug and ALT and then start a climb. If the heading bug wasn't centered, center it. The force trim probably would have saved him, too but I'm thinking most of his flying was hand flying without it. Too bad he didn't have more training.

[FH1100 Pilot]

The trouble with this fascinating accident is that there are so many things we don't and just cannot know. We *do* know that Ara was scooting along at a pretty good clip in fairly bad weather, which is incautious. His course along his route of flight was full of heading changes both large and small, and I strongly suspect that his eyes were outside the cockpit, not constantly centering the heading bug on the HSI. When he reported to ATC that he was climbing to 4,000, I assume that his intention was to continue toward Camarillo on top of whatever scud layer he just encountered. I doubt that he was intentionally making a 180. But again, who knows? My guess​​​​​ as a pilot is that Ara had not considered the possibility of performing a 180, because if he had, he probably would not have been cruising along at 140 knots. I think he really thought he could make it to Camarillo VFR.

When Ara cleared out of Van Nuys' airspace, he reported that he was in "VFR conditions" at 1500 feet. Well...maybe. (Van Nuys was only reporting 2.5 vis.) We can presume that he was just under the overcast. As he got into the foothills around Calabasas, the ground was coming up, squeezing him into a narrow slot. He obviously ran into the low fog/cloud deck just as he got to the intersection of Route 101 and Las Virgenes Road. The 101 cuts through a pass right there. If Ara was down low over the road, then he would have had hills rising up on both sides of him, the tops of which were likely obscured by clouds/fog. At some point he must have punched-in, because he reported to SoCal Approach that he was climbing to 4000 feet. Now we *know* he had to be IMC. And that's where it all came apart. The S-76 reached an altitude of 2370 feet and began a descending, ever-steepening left turn. It impacted a hill at 1100 feet MSL, slightly below the peak. I doubt that he would have had any visual reference until a millisecond or so prior to impact. I maintain that Ara's eyes were probably not on the AI, and when (or if) they ever returned to the panel, it was way too late to do anything.

Maybe some of you super-heroes could've pulled off that save (depending on at what point you realized it was all going pear-shaped). But for the rest of us mere mortal pilots, I think it would've been a real - and probably unsuccessful - challenge to get the thing wings-level and climbing before smashing into something solid...like Earth.

[megan]

Maybe some of you super-heroes could've pulled off that save (depending on at what point you realized it was all going pear-shaped). But for the rest of us mere mortal pilots, I think it would've been a real - and probably unsuccessful - challenge to get the thing wings-level and climbing before smashing into something solid...like EarthDoesn't require a super hero, it just requires a pilot that is instrument trained and who is current, Ara had the first but not the latter, so the result is not surprising. Any number of folk posting here could have extricated themselves from the situation he faced in complete safety, because they have the requisite skills and recency, though that is not to say they too have the ability to turn a silk purse into a pigs ear.

It's interesting that the NTSB findings in the abstract says,None of the following safety issues were identified for the accident flight: (1) pilot qualification deficienciesI'd have thought some reference might have been made to his lack of IMC recency though he had a rating, could have saved the day perhaps.

https://www.ntsb.gov/news/events/Documents/2021-BMG-DCA20MA059-BMG-abstract.pdf

[Bell_ringer]

I only mentioned what I did in terms of the pull up because I was asked to detail it in order to highlight how proper use of automation makes things so easy.

What I don't get, is after a long string of poor calls, he decided it was best to rather try climb up through the mess without any automation.
How does that factor into their upset/IIMC training?

Not sure about US regs, but many authorities require SPIF to use a 3-axis auto pilot.
So why is it, in such a capable ship, that there seems to have been so little training to use it?

The FAA minion squirmed his way through the interview, shrugging his shoulders at most questions. His contribution seems to have been little short of a box-ticker.
It becomes more apparent with every high-profile crash, that behind the scenes is a limp-wristed authority, whose value is providing ballast and bureaucracy and doesn't improve safety.

[[email protected]]

Completely agree Bellringer - just looking at this one plus the 139 crashes in UK and the Bahamas - all crew ticked all the regulatory boxes but took perfectly serviceable aircraft in marginal weather conditions and flew them into the ground/sea, killing themselves and their pax.

What is wrong with the training and checking that lets pilots make such bad decisions and then not have the skills to recover them?

Many of the professional exams required for licencing are ridiculously complex and poorly written with little practical application in modern aviation and it seems like there is a lot of box-ticking going on out there in simulator world because no-one wants to lose clients and the regulatory system is just a satis/unsatis box with little qualitative assessment required.

[RatherBeFlying]

​I maintain that Ara's eyes were probably not on the AI, and when (or if) they ever returned to the panel, it was way too late to do anything.​​​​​​Just what I've been thinking for a long time.

​​

[Fareastdriver]

When I was in basic training on the Provost T1, the radial engined original, my instructor during the instrument training stage used to give me UAs in a fully developed spin. Having a vacuum powered AH that toppled at 60 degrees of bank you were reliant on the T/S and altimeter.

Seemed to get out of it OK.

[helonorth]

When I was in basic training on the Provost T1, the radial engined original, my instructor during the instrument training stage used to give me UAs in a fully developed spin. Having a vacuum powered AH that toppled at 60 degrees of bank you were reliant on the T/S and altimeter.

Seemed to get out of it OK.
I assure you, it's one thing to go inadvertent by yourself when it's the real deal and quite another to be in training, expecting it and having an instructor sitting right next to you.

[[email protected]]

I think FED has more than enough real-world experience of IMC, I believe his point was that you don't necessarily need an AI/AH to recover from a UA - however that was in a FW not RW.

[Robbiee]

That Russian guy who used to post videos of flying his R44 in the clouds proved you can do anything in IMC.

,...as long as its planned out well in advance.

[ApolloHeli]

That Russian guy who used to post videos of flying his R44 in the clouds proved you can do anything in IMC.

,...as long as its planned out well in advance.

Until he crashed and died IIMC.

[Robbiee]

Until he crashed and died IIMC.

Exactly...

[[email protected]]

I think it was Mike Tyson who said 'Everyone has a plan, right up until they get punched in the face' - well IIMC is the aviation equivalent of getting punched in the face.

[helonorth]

I think FED has more than enough real-world experience of IMC, I believe his point was that you don't necessarily need an AI/AH to recover from a UA - however that was in a FW not RW.
I would imagine he has plenty of experience which makes it all the more surprising he would say something that ridiculous.

[Airbubba]

NTSB Final Accident Report issued.

https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR2101.pdf

[John R81]

Makes very sobering reading. And the conclusion:

"3.2 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 Helicopters Inc.’s inadequate review and oversight of its safety management processes."

[Robbiee]

Makes very sobering reading. And the conclusion:

"3.2 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 Helicopters Inc.’s inadequate review and oversight of its safety management processes."

Nothing sobering about the conclusion though, just the textbook step by step list of how to get into IIMC and what happens next.

[netstruggler]

From the report Executive Summary

Weather conditions reported to the pilot by air traffic controllers during the flight included an overcast ceiling at
1,100 ft agl, visibility of 2.5 miles with haze, and cloud tops at 2,400 ft msl.
...
The helicopter reached an altitude of about 2,370 ft msl (about 1,600 ft agl) at 0945:15,
then it began to descend rapidly in a left turn to the ground.

Not so far from getting away with it...

[airplanecrazy]

NTSB Final Accident Report issued.

https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR2101.pdf

I'm a little surprised that there was no mention of TAWS and the investigators' conclusion that it wouldn't have helped in this situation. Some armchair pundits thought that it would have helped, and I thought perhaps the NTSB might have disabused pilots of that notion. Here is the lead investigator from the NTSB board meeting talking about TAWS.: NTSB Board Meeting (https://www.youtube.com/watch?t=2234&v=f9ZkIDVEunA&feature=youtu.be)

[havick]

I'm a little surprised that there was no mention of TAWS and the investigators' conclusion that it wouldn't have helped in this situation. Some armchair pundits thought that it would have helped, and I thought perhaps the NTSB might have disabused pilots of that notion. Here is the lead investigator from the NTSB board meeting talking about TAWS.: NTSB Board Meeting (https://www.youtube.com/watch?t=2234&v=f9ZkIDVEunA&feature=youtu.be)

HTAWS would only have helped if the pilot knew how to keep the aircraft the right way up in the first place.

[gulliBell]

HTAWS wouldn't have changed the outcome, be 100% sure about that. A second pilot is what was required, or better decision making from the first pilot.

[donner89]

HTAWS wouldn't have changed the outcome, be 100% sure about that. A second pilot is what was required, or better decision making from the first pilot.

Spot on Gulli, assumption being a competent pilot (crew) taking appropriate action to an EGPWS command. The pilot was sadly not IFR proficient or current and apparently not proficient in acft system management. HTAWS/EGPWS would not have helped in this situation.

[[email protected]]

Not so far from getting away with it... And therein lies the problem - pilots thinking they can get away with it, chancing their arm with no credible plan B.

[rotorspeed]

Gulli

Can’t agree ref second pilot being needed I’m afraid - two AW139 accidents in Norfolk UK and Grand Cay Bahamas prove that. What was needed was a pilot that knew and respected his limitations.

[gulliBell]

Yeah, I know. I've seen so many second pilots arriving at the scene of the accident on recurrent sim checks, sitting on their hands saying and doing nothing whilst the other pilot drives it into the dirt upside down. A second pilot might have saved the day here, or might not.

[FH1100 Pilot]

What bothers me so much about this accident is that it wasn't just some goober 135-pilot in a VFR-only Bell 206 who punched-in and lost it. No, it was the *Chief Goober*...an Instrument Rated Chief Goober...in an all-singing, all-dancing S-76, a helicopter fully capable of IFR flight with a big ol' attitude indicator positioned right in front of him...unlike the aforementioned 206 in which the flight instrument group are skewed off to the left. And yet this Chief Goober punched-in and then somehow lost control while in the process of climbing through a relatively thin layer/deck. (We can assume that he knew that it was a thin layer - I mean, there were probably enough breaks for him to have seen up through it. And so climbing up on top and continuing on VFR to Camarillo was probably his exact plan.)

Two pilots might have helped! Oh really? Tell that to the passengers of that two-pilot AW-139 that crashed in the Bahamas when those two goobers couldn't even make a (basically) ITO at night.

Or how's about back in 2019 when that Instrument Rated girl in the EMS 407 that snowy day in Ohio, U.S. who arrived at the base before sunrise and jumped into the ship with it already running, and then blasted off without doing a proper (and required) weather check or risk-assessment..

And those are just three. There are others - I'm sure you can come up with some right off the top of your head. So here's the thing: What does this say about us as a group? To me, it says that we're pretty crappy pilots when it comes to decision-making and skills. We need to stop thinking that we're all heroes and that none of these accidents would ever happen to us, because we're so much better than them dead goobers.

And then maybe there'd be a few less dead goobers.

[finalchecksplease]

Two pilots might have helped! Oh really? Tell that to the passengers of that two-pilot AW-139 that crashed in the Bahamas when those two goobers couldn't even make a (basically) ITO at night.



IMHO two experienced pilots, trained in multicrew VFR & IFR operations, would have made this accident less likely because the workload could be shared and they could have used the aircraft to its full capability when ending up in IMC. The Bahamas accident wasn't a proper "two crew" setup and the Norfolk pilots weren't very experienced & properly trained in two crew operations or using the aircraft to it's full capability so you can't conclude out of these accidents that 2 pilots couldn't make a difference.

[RVDT]

IMHO two experienced pilots, trained in multicrew VFR & IFR operations, would have made this accident less likely because the workload could be shared and they could have used the aircraft to its full capability when ending up in IMC

?????? Would probably have been IFR in the first place so your point is..................?

[finalchecksplease]

?????? Would probably have been IFR in the first place so your point is..................?

When I was flying for a VVIP, quite a while back, I flew IFR when required but would always try to drop off my boss at his destination, weather permitting. So there were times after breaking off IFR, I flew very marginal VFR to achieve this but always had an out by climbing up and fly back to the nearest suitable IFR destination. I haven't looked at this trip specifically so not saying it is the case here, being California there probably is an airport with a suitable approach a 15 min drive of their destination but that wasn't always the case for me, more like a 1.5 hr drive at one of his holiday homes for instance.
Looking back at that, with now a lot of two crew experience, I know that it would have been a lot safer to have another trained pilot with me. And what is another pilot salary in the grand scheme of things for a multi millionaire?

[JulieAndrews]

and therein lies the problem - I wonder how many HNW individuals are under the illusion that they have 2 properly-trained (MCC/CRM/Sim/checklists/Sops/Ops Manuals etc) pilots up front? They see the gold bars and assume we, the industry, would not be allowed to just stick a costume on anyone in the front

[Fareastdriver]

This one had two pilots; directly employed.

https://www.pprune.org/rotorheads/535936-aw139-g-lbal-helicopter-crash-gillingham-norfolk.html?highlight=helicopter+crash+norfolk

[finalchecksplease]

This one had two pilots; directly employed.

https://www.pprune.org/rotorheads/535936-aw139-g-lbal-helicopter-crash-gillingham-norfolk.html?highlight=helicopter+crash+norfolk

Yes two pilots but from the accident report:"Both pilots maintained single-pilot qualifications to operate the helicopter; they were not trained or tested as a crew of two. The helicopter was operated privately, therefore no flight crew duty limitations applied."

The Bahama's AW139 also had two pilots up front but unless they have received proper training to operate as two crew having two pilots in the cockpit can be more of a hinderance than helpful.

From personal experience coming from a SPIFR to a MP setup does requires training & adjustment before you can operate efficiently two crew.

[Wide Mouth Frog]

Yes two pilots but from the accident report:"Both pilots maintained single-pilot qualifications to operate the helicopter; they were not trained or tested as a crew of two. The helicopter was operated privately, therefore no flight crew duty limitations applied."

The Bahama's AW139 also had two pilots up front but unless they have received proper training to operate as two crew having two pilots in the cockpit can be more of a hinderance than helpful.

From personal experience coming from a SPIFR to a MP setup does requires training & adjustment before you can operate efficiently two crew.
And don't forget poor old Rescue 116 which was two employed, fully multicrew trained pilots, and it looks rather as if the two crew mullarkey actually prevented them responding to the situation with sufficient urgency. What Kobe needed in this flight was a properly trained IFR operation, single, two, or multicrew doesn't much matter.

[gulliBell]

....or a pilot who thought it a better idea, having already decided it wasn't a better idea to turn around, to press one button and let George do the IMC flying bit for 30 seconds. For the life of me I can't think why he didn't do that. Anyway, we're repeating the same ground again.

[megan]

There is not a pilot alive today who may not be tomorrow as the result of a cock up. Even those considered the best come to grief, Chuck Yeager punched out of an F-104 and came within inches of losing his life having lost control through poor instrument flying skills, Bob Hoover refuelled with AVTUR instead of AVGAS and had a double engine failure on take off, survived but air frame never saw air again. Another crew member in the cockpit? L-1011 crashed in the Everglades while the crew were dealing with a failed U/C light, two 747's rolled inverted on take off and crashed because the PF's attitude indicator had failed. No one has yet bred an infallible human.What Kobe needed in this flight was a properly trained IFR operation, single, two, or multicrew doesn't much matter.No one could disagree with that.

I'm intrigued that the report makes no mention of the state of SAS, force trim, auto pilot modes etc, even to state that the status of switch positions or lit captions could not be determined. Rather germane to the accident in my mind.

[Gordy]

having already decided it wasn't a better idea to turn around,

So, I throw this out there that no-one has brought up yet....... What if........ He started the climb, was talking to Kobe on intercom, then decided to turn around. Then and only then lost it during the entry into the turn. He had performed this maneuver many times. (Climb followed by left descending turn).

[[email protected]]

So he starts the climb into IMC and then decides to turn round and chat to the pax - that turns poor piloting into aviation negligence - you really want that as his epitaph?

[Gordy]

So he starts the climb into IMC and then decides to turn round and chat to the pax - that turns poor piloting into aviation negligence - you really want that as his epitaph?
Nope, the aircraft has an intercom system. Whether he was talking on it or not, the possibility is there that he started the turn before getting disorientated and then lost it as he rolled into the turn---this scenario is plausible.

[[email protected]]

So he started the turn OK and then lost it in the turn? or lost it as he rolled into the turn? which is it? Either way trying to turn IMC and descend when instead you can climb with wings level is a very poor choice.

[Gordy]

So he started the turn OK and then lost it in the turn? or lost it as he rolled into the turn? which is it? Either way trying to turn IMC and descend when instead you can climb with wings level is a very poor choice.
Either one---my point being 4 or 5 posts ago was that this statement may not be true: "having already decided it wasn't a better idea to turn around". I believe he made the decision to turn around, albeit too late. I believe the initiation of the turn was deliberate, where he "lost it" after that is irrelevant.

[212man]

Either one---my point being 4 or 5 posts ago was that this statement may not be true: "having already decided it wasn't a better idea to turn around". I believe he made the decision to turn around, albeit too late. I believe the initiation of the turn was deliberate, where he "lost it" after that is irrelevant.
Hard to rationalise, as you either turn back whilst still visual, or you commit to going IMC then recovering through a recognised IFR procedure. Not, go IMC, then turn back and descend into VMC from where you just came from. But, I'm speaking as an IFR pilot with a different perspective of being in real IMC than maybe he had. Albeit I have also carried out low level pull ups into IMC (that were contingency, and with charts and frequencies on my knee, ready) from marginal VMC (and also put downs!)

[gulliBell]

So, I throw this out there that no-one has brought up yet....... What if........ He started the climb, was talking to Kobe on intercom, then decided to turn around. Then and only then lost it during the entry into the turn. He had performed this maneuver many times. (Climb followed by left descending turn).
No way. I don't believe for a second the pilot knew he was turning, because he sure didn't know he was descending.

[airplanecrazy]

I'm intrigued that the report makes no mention of the state of SAS, force trim, auto pilot modes etc, even to state that the status of switch positions or lit captions could not be determined. Rather germane to the accident in my mind.

Good point, it does seem odd that those items were not mentioned in the report. I know from the docket that most of the indicator bulbs in the aircraft were missing or damaged. Here are the DAFCS indicators which I think could reasonably be determined:

Autopilot Controller
HOV: Light was likely off
FD1: Light was likely off

Flight Director Mode Selector
ALT PRE : ARM and CAP Lights were likely off
VOR APR: ARM and CAP Lights were likely off
GA: Light was likely off

I see no mention of the switch positions.

https://data.ntsb.gov/Docket/Document/docBLOB?ID=11602271&FileExtension=pdf&FileName=20-043%20Factual%20Final-Rel.pdf

[avionik]

Nope, the aircraft has an intercom system. Whether he was talking on it or not, the possibility is there that he started the turn before getting disorientated and then lost it as he rolled into the turn---this scenario is plausible.
It's absolutely not.

youtu.be/ooqNFf6t-iY?t=2391

[swisshelipilot]

So, I throw this out there that no-one has brought up yet....... What if........ He started the climb, was talking to Kobe on intercom, then decided to turn around. Then and only then lost it during the entry into the turn. He had performed this maneuver many times. (Climb followed by left descending turn).
The pilot told ATC he's climbing to 4000ft....

[gulliBell]

...I know from the docket that most of the indicator bulbs in the aircraft were missing or damaged...

Just one indicator bulb missing is hard to stomach, that most were missing (if that is true) is blatantly unforgivable. The bulbs are easy to change and there is no excuse for them to be missing, even for a VFR flight.

[airplanecrazy]

Just one indicator bulb missing is hard to stomach, that most were missing (if that is true) is blatantly unforgivable. The bulbs are easy to change and there is no excuse for them to be missing, even for a VFR flight.
Sorry, I didn’t mean to imply that the bulbs were missing at the start of the flight, but I think they were missing or destroyed as a result of the crash.

https://cimg0.ibsrv.net/gimg/pprune.org-vbulletin/629x533/panel_0c80676f9f4c9908540ef7b3af00045bde5b1939.png

[megan]

Half hour discussion on the accident led by AVweb's Paul Bertorelli with HAI CEO Jim Viola and NTSB Vice-Chairman Bruce Landsberg.

https://www.youtube.com/watch?v=N_lzmKsQ3PU


He had performed this maneuver many times. (Climb followed by left descending turn)Going IMC and escaping from same?

[[email protected]]

Clutching at straws I'm afraid Gordy - and frankly, since you have a vested interest, I'm surprised you have commented at all on this accident.

[FH1100 Pilot]

Either one---my point being 4 or 5 posts ago was that this statement may not be true: "having already decided it wasn't a better idea to turn around". I believe he made the decision to turn around, albeit too late. I believe the initiation of the turn was deliberate, where he "lost it" after that is irrelevant.
Gordy, I have to admit that I did not consider the "deliberate 180" scenario. And with all due respect, I don't think that's what Ara was trying to do. He told the SoCal Approach controller that he was climbing to 4,000 feet. Heck, he was only about 7 nm SW of Van Nuys. If his intention was to return to Van Nuys, I believe he would've done his 180 and called Van Nuys Tower, not tell SoCal that he was climbing. I really think that Ara's intention was to continue on to Camarillo, as "VFR" as possible. After all, from anecdotal stories we've heard about him, he doesn't seem like he was the most stringent follower of FAR's.

On the other hand, I can't believe that Ara was hand-flying the S-76 at 140 knots or so with *no* SAS or AFCS or whatever you guys have in the Sikorsky. That doesn't make sense. So, how the ship tried to go inverted is a head-scratcher. At that speed, a little aft cyclic would've had them climbing fast right up to the top of the layer, which was reported to be not all that thick. I mean, it's not like he was climbing up into a solid overcast.

[RatherBeFlying]

Possibly the pilot believed the SAS or AFCS was engaged when it wasn't?

[Bell_ringer]

Why is it so difficult to believe that the pilot’s over-estimation of his abilities, nurtured by a poor culture that valued celebrity above safety and ignored by shoddy oversight is what caused this terrible accident?
There is no amount of automation or “what ifs” that will undo that combination.
There is nothing mysterious about this or any other LOC accident.

[[email protected]]

The weather in the SW of UK today was very similar to what Ara had to deal with - a marine layer of cloud at 4 - 500' agl with poor visibility beneath, less than 1.5SM.

I took the opportunity to shoot some video on a training sortie to show those without the real world experience what such conditions look like - you can decide for yourselves whether 140 kts is a suitable speed for the conditions or if a 180 turn is a realistic option if you enter cloud.

A second video reiterates how easy a descending left hand spiral descent is to recover from - if you use the correct technique. No use of AP modes or GA, just basic but competent instrument skills from a colleague.

As soon as the videos upload I will add links to this post.


https://vimeo.com/518806704

https://vimeo.com/518881997

[212man]

Possibly the pilot believed the SAS or AFCS was engaged when it wasn't?

Believe me, you don’t fly an S76 at 140kts with no stabilisation and not know it!

On the other hand, plenty of pilots seem to take a perfectly good AFCS, with attitude hold, and put it in SAS mode with the force trim turned off when flying VFR!

[megan]

On the other hand, plenty of pilots seem to take a perfectly good AFCS, with attitude hold, and put it in SAS mode with the force trim turned off when flying VFRAs did I during periods of maneuvering, auto functions & trim punched off on downwind for landing. In Ara's case that would have been the mode I would have been flying, with the automatics set to take over should they be required. We were a VMC operation that did plenty of scud running, and dare I say plenty of far less than legal low level IMC at 300 - 500', as Gulli can attest.

[donner89]

As did I during periods of maneuvering, auto functions & trim punched off on downwind for landing. In Ara's case that would have been the mode I would have been flying, with the automatics set to take over should they be required. We were a VMC operation that did plenty of scud running, and dare I say plenty of far less than legal low level IMC at 300 - 500', as Gulli can attest.

In the report of the Bahamas accident It was noted that the FTR was held in throughout the take off. A well lit environment to complete darkness.
I would hypothesize that if Ara was following a road then he was in ATT or SAS mode and using the FTR to make inputs, almost certainly not coupled. Encountering deteriorating viz he depressed the FTR to initiate a climb, a combination of poor instrument scan and task saturation caused him to tense and hold the FTR allowing an unusual attitude to develop.

It is not called the button of death in IMC conditions for nothing. How many times have we seen this occur in the sim?

[gulliBell]

...How many times have we seen this occur in the sim?

Exactly, and I could never work out why the FTR was the button of death. So much so it became SOP to insist the trainees fly in ATT mode with hands off the controls and using only the trim switch (or heading bug when coupled) for manouevering the aircraft. That lead to far less incidents of turning upside down and punching holes in the ground. I could readily understand the accident pilot flying it into the ground if his prior training did not insist the aircraft be flown in IMC in this way.

[GROSSER]

The S76B with the SPZ7000 will not couple the Flight Director in SAS mode - only ATT Mode with LNAV/VNAV choices displayed on the top of the PFD.

[gulliBell]

My point is, he should not have been flying in SAS mode, and it seems possible he might have been.

[industry insider]

My point is, he should not have been flying in SAS mode, and it seems possible he might have been.

And an SPZ 7000 equipped S-76 in SAS mode alone is less stable that an AFCS Hamilton Standard Phase II in my experience.

[helimutt]

Possibly the pilot believed the SAS or AFCS was engaged when it wasn't?

Im fairly certain that anyone who flies an S76 will tell you, flying with the AFCS disengaged is most definitely noticeable. You'd have to be unconscious to not notice a disengaged AFCS.

[airplanecrazy]

The weather in the SW of UK today was very similar to what Ara had to deal with - a marine layer of cloud at 4 - 500' agl with poor visibility beneath, less than 1.5SM.

I took the opportunity to shoot some video on a training sortie to show those without the real world experience what such conditions look like - you can decide for yourselves whether 140 kts is a suitable speed for the conditions or if a 180 turn is a realistic option if you enter cloud.

A second video reiterates how easy a descending left hand spiral descent is to recover from - if you use the correct technique. No use of AP modes or GA, just basic but competent instrument skills from a colleague.

As soon as the videos upload I will add links to this post.


https://vimeo.com/518806704

https://vimeo.com/518881997

i am not a pilot, but is it fair to say that without automation the UA is recoverable ONLY IF the pilot is doing an instrument scan? I would be interested in seeing a similar UA video where the PF is doing something like looking up information in Foreflight on their IPAD and hasn't committed to instruments. I would also be interested in knowing whether you felt any sensation of turning or descending when you recorded the UA recovery video, and whether you felt the rapid descent in your ears. I have done some preliminary analysis that suggests that the N72EX pilot felt 1G straight into the bottom of the seat for much of the descent (see the YouTube video description for details):

https://youtu.be/xI1UqFvNYIU.
I know you already saw it, but I feel that my video reconstruction (https://www.youtube.com/watch?v=M_Dpm144KXo&feature=youtu.be) of the crash that I published last May has aged well in light of the NTSB final report and your videos.

[212man]

Im fairly certain that anyone who flies an S76 will tell you, flying with the AFCS disengaged is most definitely noticeable. You'd have to be unconscious to not notice a disengaged AFCS.

I think I said that immediately after the post in question.

Frankly, when we are having a conversation about the FTR being called the "button of death" we are exhibiting how amateurish an industry we seem to have evolved into. I think one of the reasons we have so many automation issues is because many pilots don't even understand the basics about AFCS and SAS, let alone upper modes. I wonder if some of the attitudes (no pun intended) are based on having zero fixed wing time? I'm sure that any pilot that has initially learned to fly on FW (especially with a gnarly old QFI smacking him around the helmet when out of trim!) first will have a different view and approach to the use of the trim function.

[212man]

https://vimeo.com/518806704

Crab - a PAR I assume, as lots of red flags and frozen needles!

i am not a pilot, but is it fair to say that without automation the UA is recoverable ONLY IF you are doing an instrument scan?

Yes....

[Robbiee]

https://vimeo.com/518806704



Its easy to look at a training exercise and agree with what the corrective action should be. Thing is, in the real world, the brain that decides to go scudd running is the brain that is not running on all cylinders, so you cannot expect it to make rational decisions.

I was wearing my "Land and Live" cap when I went IIMC so,...

[donner89]

Im fairly certain that anyone who flies an S76 will tell you, flying with the AFCS disengaged is most definitely noticeable. You'd have to be unconscious to not notice a disengaged AFCS.

But, and here comes the what if.....He was in SAS instead of ATT and when things started going pear shaped he tried to couple and may have added a further distraction trying to figure out why the AFCS would not couple up.
While that scenario is speculation, I have observed crews in the sim trying to engage upper modes in the 412 after take off and before punching in only to realize they missed a step. Between 2 of them they figure it out

[212man]

But, and here comes the what if.....He was in SAS instead of ATT and when things started going pear shaped he tried to couple and may have added a further distraction trying to figure out why the AFCS would not couple up.
While that scenario is speculation, I have observed crews in the sim trying to engage upper modes in the 412 after take off and before punching in only to realize they missed a step. Between 2 of them they figure it out

But why are they in SAS in the first place? When you push the the FTR you are in SAS anyway.

[[email protected]]

Airplane crazy - the UA recovery can be done with or without AP and force trim but not without looking at the instruments.

The whole process of learning to instrument fly is about building an effective scan, being logical in correcting errors and most of all believing your instruments.

You do have sensations of descent, roll, pitch yaw etc but when you are in cloud, the feedback loop to confirm these sensations - your visual picture of the outside world - is missing and must be replaced by the use of the instruments.

Robbiee - the whole point of the exercise is to highlight that even if you are not firing on all cylinders when you set off to scud-run - you can recover the IIMC nightmare if you have been trained to and then use the correct techniques. I have used the same process for deliberate entry into IMC and IIMC in some stressful SAR scenarios - it works. And it works in everything from an unstabilised Gazelle through to a 139.

You don't have to be an IFR rated pilot to learn the basics of instrument flight - it could save your life one day.

212man - yes, EGDR rw11:ok: - I completely agree with your comment about poor understanding of AP modes, whether it be SAS vs ATT or upper FD modes

[Robbiee]

Robbiee - the whole point of the exercise is to highlight that even if you are not firing on all cylinders when you set off to scud-run - you can recover the IIMC nightmare if you have been trained to and then use the correct techniques. I have used the same process for deliberate entry into IMC and IIMC in some stressful SAR scenarios - it works. And it works in everything from an unstabilised Gazelle through to a 139.


Well my point is that, "get the job done itis" has a way of overriding training, experience, all those fancy toys you put in your aircraft, and whatever is left of what we used to call common sense.

I have absolutely no idea how to prevent these types of accidents.

[[email protected]]

Everyone has moments when the need to get the job done or need to get home impinges on their decision making and there are few pilots who haven't taken a chance during their flying careers - you won't ever prevent that - but at least you can arm them with the training and skills to get themselves out of the poo when it goes wrong.

This case, along with the two 139 crashes mentioned earlier are exactly a case of poor decision making coupled to a lack of training to recover when those poor decisions overtook them.

In all 3 cases, basic instrument flying skills would have saved them IF they had been applied.

[havick]

But, and here comes the what if.....He was in SAS instead of ATT and when things started going pear shaped he tried to couple and may have added a further distraction trying to figure out why the AFCS would not couple up.
While that scenario is speculation, I have observed crews in the sim trying to engage upper modes in the 412 after take off and before punching in only to realize they missed a step. Between 2 of them they figure it out

Yep in ATT mode with the force trim release switch open. Everything looks like it’s coupled with command bars up but alas the aircraft is still in a modified sas mode.

[Robbiee]

Everyone has moments when the need to get the job done or need to get home impinges on their decision making and there are few pilots who haven't taken a chance during their flying careers - you won't ever prevent that - but at least you can arm them with the training and skills to get themselves out of the poo when it goes wrong.

This case, along with the two 139 crashes mentioned earlier are exactly a case of poor decision making coupled to a lack of training to recover when those poor decisions overtook them.

In all 3 cases, basic instrument flying skills would have saved them IF they had been applied.

Are you saying that these pilots were not trained in how to deal with IIMC?,...because even a lowly Robby pilot like myself has been trained in basic instrument flying skills, unusual attitude recovery, and the idea that climbing is a better recovery technique than the good old 180.

Thing is, once you start down that path of irrational decision making, the thought to simply climb out of it may not even cross your mind,...despite you being trained to do so. At least that's how it was for me.

[gulliBell]

Which, as I say, the problem is the pilot having this unknown urge feeling he must be touching the flight controls. Don't touch the controls. Just use the trim switch, as it was designed to be used, and things are far less likely to turn pear shaped. Teaching recurrent trainees in the simulator we don't even practice flying in SAS.

[gulliBell]

... and the idea that climbing is a better recovery technique than the good old 180.

I'm in the camp that the pilot did not know he was turning, or descending. I think his plan was to climb straight wings level but he was overwhelmed when suddenly finding himself IMC, alone up front, and not having configured the aircraft appropriately for what he wanted to do. Others here suspect he made a decision to turn but he lost it.

[Robbiee]

I'm in the camp that the pilot did not know he was turning, or descending. I think his plan was to climb straight wings level but he was overwhelmed when suddenly finding himself IMC, alone up front, and not having configured the aircraft appropriately for what he wanted to do. Others here suspect he made a decision to turn but he lost it.

I can't speak for this guy, but for myself, I kinda froze up. I was staring at the artificial horizon trying to turn slightly left, while watching the guage get bluer and bluer, yet unable to get the signal from my eyes to my hand to push the stick forward. It was only the sound if the low rpm horn that unfroze me just in time to recover from the vertical decent that also brought me out of the clouds and the sheer luck that I had enough altitude to dump the collective and dive the nose to recover.

[megan]

Not knowing the complexities of operating in LAX airspace what route would an IFR flight plan for John Wayne Orange County to Caramillo. The destination was well above alternate minima.


https://cimg6.ibsrv.net/gimg/pprune.org-vbulletin/1544x841/untitled1_b2579623a8f6580ed05dbdff89505fff9cd2d960.png
https://cimg7.ibsrv.net/gimg/pprune.org-vbulletin/784x905/untitled0_281b1df06e90c2af95ec192fb30e974d7f18b7d6.png

[[email protected]]

Are you saying that these pilots were not trained in how to deal with IIMC?, More that the recency of that training has a big effect - instrument flying is a perishable skill, it has been said on here many times before.

Many pilots prepare for a planned instrument flight diligently but far fewer are ready for when an anticipated or intended VFR flight suddenly switches to IFR.

The quality and recency of your training allows to you 'switch on' your IF head and concentrate on the AI.

I've been flying for 39 years and your first time in cloud for a while can still unsettle you for a few minutes as your brain struggles with the lack of visual cues - that is where the training kicks in.

I still challenge myself and often fly IMC with no AP just to keep my skills sharp - even then I can make errors and get the 'leans'.

What chance do you have if you never see cloud, never practice an IMC abort for real and never prepare a plan B for IMC just in case when the weather is poor - that is reflected in the accidents we keep seeing.

[212man]

Which, as I say, the problem is the pilot having this unknown urge feeling he must be touching the flight controls. Don't touch the controls. Just use the trim switch, as it was designed to be used, and things are far less likely to turn pear shaped. Teaching recurrent trainees in the simulator we don't even practice flying in SAS.
Exactly - forward a bit, back a bit, left a bit, right a bit - all adds up to zero, so don't move it in the first place!

[megan]

Which, as I say, the problem is the pilot having this unknown urge feeling he must be touching the flight controls. Don't touch the controls. Just use the trim switch, as it was designed to be used, and things are far less likely to turn pear shaped. Teaching recurrent trainees in the simulator we don't even practice flying in SASSo what skills do they have to handle an AP1 & AP2 failure where no automatic stabilisation capability exists, it's in the emergency checklist. In the current age of automatics a lot of airline aircrew are bleating about both the loss of handling skills and the airlines not permitting the exercise of those skills. Children of the magenta line they deprecatingly call it, has the absolute reliance on auto come to the helo world? Folk of my generation learnt helo IMC in the UH-1 series with nothing to keep you the right way up except a scan, and we flew actual instrument, even in the offshore in a 205 or bare basic VFR 212.

[Robbiee]

More that the recency of that training has a big effect - instrument flying is a perishable skill, it has been said on here many times before.

Many pilots prepare for a planned instrument flight diligently but far fewer are ready for when an anticipated or intended VFR flight suddenly switches to IFR.

The quality and recency of your training allows to you 'switch on' your IF head and concentrate on the AI.

I've been flying for 39 years and your first time in cloud for a while can still unsettle you for a few minutes as your brain struggles with the lack of visual cues - that is where the training kicks in.

I still challenge myself and often fly IMC with no AP just to keep my skills sharp - even then I can make errors and get the 'leans'.

What chance do you have if you never see cloud, never practice an IMC abort for real and never prepare a plan B for IMC just in case when the weather is poor - that is reflected in the accidents we keep seeing.

Four months after I had been shooting approaches to checkride standards I decided to do a flight under the hood. I spent so much time struggling just to maintain level flight that I couldn't even work the radios (and to think the FAA only requires recency every six months!),...so yeah, I get the whole "deteriorating skills" thing.

Problem is, how do you get pilots to go up under the hood frequently enough to stay proficient?,...and how can we ever get that "real life" experience in a cloud when so many of us are flying VFR only aircraft?

I still believe though, that even proficiency is useless if your thought process is already set on scudd-running.

[Fareastdriver]

If you can't stand the heat; keep out of the kitchen.

Don't go IMC unless you are up to scratch.

I've been flying for 39 years get some time in,

As an example of how things are going I was doing a line check with a training captain on a 332L. He told me that he wanted to see my autopilot out flying and then asked me how and in which order to turn the channels off. I'll bang them all off; was my reply which I did with the cyclic cutout. The aircraft lurched, slightly, once as I placed the cyclic and trim in such a way that I was pushing forward and left to maintain level flight, - the passengers didn't notice.

He spent the next fifteen minutes occupied with looking out of the window in disbelief and turning the gain up and down on the autopilot panel to confirm that the autopilot was in fact out.

Ten minutes later the weather and traffic necessitated an ILS. I started the brief to be interrupted by him inasmuch as I was to re-engage the autopilot. I objected on the basis that if the autopilot had folded during the flight it wasn't going to fix itself for an ILS. No argument; I HAD to re-engage the autopilot. He was the captain so I did what I was told.

I can only assume that he did not have the confidence to take over with the autopilot disconnected in IMC.

That is the new standard of supervisory captains.

[[email protected]]

Thanks FED:):ok:

Robbiee - I agree, the problem is convincing those who pay for their own flying that spending more on instrument currency is worthwhile - it is a difficult thing to sell , like much of safety in aviation.

But if pilots are unwilling to keep their own skills up - I suspect you are unusual in your valiant attempts to do so - they can't be surprised when something like IIMC bites them in the ass.

I know I am ridiculously lucky to have had all that military training and mandated currency and recency requirements - and still do - but I wouldn't take my car around a race track at the edge of it's performance without some instruction first.

[Robbiee]

Thanks FED:):ok:
but I wouldn't take my car around a race track at the edge of it's performance without some instruction first.

Oh,...you're definitely not American! :}

[Flying Bull]

Crab and Robbiee are right - flying in IMC is a skill, which needs training to stay current.
Evenso I hold an actual IFR rating I get to seldom the opportunity to do so.
Lately I had to swap helicopters - one airport in the sun, the other ceiling just above minimum - the foggy area just being about a thousand feet thick.
Even with all systems running and a steady approach established well before entry of the cloud it was a weird feeling and I was happy, that I only had to monitor the autopilot/instruments and not to shoot the approach by hand - even more without stabilisation!
On the last VFR - Checkride was a part: Unusal Attitude Recovery
This time I had to establish on heading and altitude with the FTR Button pressed - and then to close my eyes and to continue on that heading and altitude just by feel.
After a minute the checker said - Recover - I was in a climbing turn to the left with about 30° of bank and hat the feeling of a nice straight and level flight.
On debrief the checker said, that after about 10 seconds I started the climb - and then slowly started the turn.
If you are not current - avoid by all means going IMC!!!
What might helps is defining minimums (visibility/heights/speeds) if you reach or have to reduce to either one - turn around and land, no further pushing or excuses (was a tree or so)

[[email protected]]

Oh,...you're definitely not American! https://www.pprune.org/images/smilies/badteeth.gif I should have added "and not expect to crash" :)

[donner89]

Exactly - forward a bit, back a bit, left a bit, right a bit - all adds up to zero, so don't move it in the first place!

You obviously are married!!

[gulliBell]

So what skills do they have to handle an AP1 & AP2 failure where no automatic stabilisation capability exists, it's in the emergency checklist..

We never do that in the simulator with trainees. I don't ever recall an AP being failed, let alone both, to expose the trainees to this malfunction. The instructors have to be able to do it, but not the customers. The only time flight happens with the AP's off is when the pilot trainee forgets to turn them on before take-off, which can be interesting. It's tough enough getting all the basic stuff done within the time allocated let alone having a bit of fun with the AP's off.

[megan]

I don't ever recall an AP being failed, let alone bothWe did have an event once when a bird strike forced both throttles out of the gate and dropped both generators. Pax had fresh poultry delivered to their laps.It's tough enough getting all the basic stuff done within the time allocated let alone having a bit of fun with the AP's off.A perennial problem with the regulatory box ticking nature of sim rides.

[[email protected]]

If you can't fly the machine AP out, you shouldn't be flying it at all.

[Flying Bull]

If you can't fly the machine AP out, you shouldn't be flying it at all.

AP out - depending on the helicopter - is an emergency
(not talking Robbies here ;-) )
and should be treated as such - declared and distractions reduced as much as possible.
Don‘t come with the old days...
Different helicopters, different IFR style
i started IFR with the Lynx, mainly to fly safe over water with an Instrument scan when there were no visible Horizon- with the occasional SRA, PAR or ILS on the places, where you knew the numbers and settings by heart.
Switched to civil helicopters with IFR on the Bo105 - no Autopilot- could be flown when in Trim by just shifting the body weight - but quite a ride in turbulance.
still, from NDB to VOR for Approach
Then BK117 - this time with a 3 axis Autopilot.
One Approach on the Check was always AP reduced/off - either due to the checker or just misbehaving on its own, when you didn’t reduce speed bevore the Final decent point and the AP couldn‘t cope with the changes.
But things have changed since then
Autopilots have four axis by now, the number of NDB and VOR decreases and its mostly GPS points by now.
The skill required now is to set up your screens and procedures, checking they are working as intended and less on the flying side. Properly set up the AP can do it better than any pilot ...
Add to that, that normal helicopter operation is VFR (if you’re not flying VIP for a living) with an occasional IFR flight.
With that set you should set up a risk analyses for your flights.
The risk of an AP failure is now close to 0 - and even so, flying a helicopter with AP of is a skill which should be trained from time to time, it is nothing which needs to be incorporated into check rides on a regular basis.
It is an (major) emergency and should be dealt with accordingly.
Bye the way, the manufacturer of the helicopter I fly emphasized lately, that the helicopter should be flown using the Autopilot as Standard procedure- hands on, except for lift off and landing - should be avoided...

[gulliBell]

...the manufacturer of the helicopter I fly emphasized lately, that the helicopter should be flown using the Autopilot as Standard procedure- hands on, except for lift off and landing - should be avoided...

Exactly. But trying to convince pilots of that is the tricky part.

[[email protected]]

The risk of an AP failure is now close to 0 - and even so, flying a helicopter with AP of is a skill which should be trained from time to time, it is nothing which needs to be incorporated into check rides on a regular basis. so you agree that you shouldn't be flying it if you can't control it AP out?

I didn't say it had to be in a check ride - many are done in simulators which don't accurately reproduce the handling characteristics of the aircraft anyway.

[Flying Bull]

so you agree that you shouldn't be flying it if you can't control it AP out?

I didn't say it had to be in a check ride - many are done in simulators which don't accurately reproduce the handling characteristics of the aircraft anyway.

yepp, i can agree to that.
But always put it into the whole picture.
Putting extra stress on flying AP off - like doing holdings in IMC ie isn’t the way.
But you should be able to get the helicopter back home and down without the Autopilot - and treat that whole procedure as the the emergency as it is put down in section three of the Handbook (according to helicopter type)
On EC 155 ie, easy to fly helicopter with systems on - even an untrained person could be talked through to an landing - what a difference stabilization off.
Easy overcontrolled, if not used to, astonishing how fast nearly five tons can change attitudes from one side to the other and back...
In the FM - run on landing is recommended then...
By now, the section in the FM about the Autopilot, its functions and buttons is thicker than the whole Emergency Part for the Lynx in days I flew it...
And the risk, pushing a button and wondering what the helicopter is doing as a consequence thereafter is actually higher than a failure of the AP itself...
Flying really changed from hands on to managing a flight.
If done correctly it’s really relaxing. You can stay well ahead of the aircraft, monitoring it and pushing in the values you need, having time to look ahead what’s coming next, while the helicopter flies the path you programmed, including climbs, turns and decents

[[email protected]]

Completely agree FB - the AP is only a computer and it will try to do exactly what you ask it to - the problem is that pilots often don't understand what it is they have asked it to do or how it will respond when they do.

The Lynx was great fun AP out, all display manoeuvres were flown that way because of the rapid control response.

[Fareastdriver]

Let the FMS handle it. Nothing can go wrong-go wrong-go wrong.

Other wiz kid pilots on this site have called me an old dinosaur. Maybe I am but when I was trained to fly we flew it to its limits and the overriding lesson thumped into me was that I WAS THE MASTER. The aeroplane did what it was told.

This attitude brought on a protective attitude so that in my long, 49 years, career, I had this rapport with those in whose cockpit I was privileged to occupy. Mechanical sympathy is the engineers term and I had plenty of that so I could stick my neck out and read how my steed was coping.

I must have been successful because I never had an unexpected problem. (They wouldn't have dared.)

Lucky? No. As soon as I started one I would know if it was unhappy and this feeling lead me to an enjoyable and easy career.

[[email protected]]

Use the force Luke:) - but you are right FED - it works. Mechanical sympathy and an understanding of what you are asking the machine to do are key.

[Fareastdriver]

We have wandered too far from this thread so I will close up now.

[212man]

Ref the FTR discussion - the following is from the recently published TSB Canada report into the S92 LOC incident offshore (https://www.tsb.gc.ca/eng/rapports-reports/aviation/2019/a19a0055/a19a0055.html). It tends to support what many of us have said/known......

In tests conducted by the RCAF, helicopter pilots who used ATT mode while minimizing the use of the trim release had far better control in a DVE than pilots who attempted to fly with the trim release button depressed. Pilots who flew with the trim release button depressed “often failed to interpret residual pitch or roll rates (or vertical velocities) due to the reduced cues and aircraft control suffered resulting in ineffective approaches or in the worst case ground impact.”

The RCAF’s CH146 Griffon Standard Manoeuvre Manual states that using the force trim will assist in maintaining a steadier hover and aircraft attitude during night and/or during overwater operations.

Additionally, the RCAF’s Air Mobility CH149 Cormorant Operations manual warns against using the cyclic trim release button, and states the following: In low visual cueing environments (IMC, night, boat hoist, etc.), the pilot should attempt to maintain attitude retention by avoiding the use of the cyclic Trim Release button. Small and precise attitude changes can be made using the cyclic beep trim switch only. Alternatively, the pilot can easily move the cyclic in the manoeuvre mode then use the beep trim to relieve control forces, resulting in faster trim rates.66

[Torquetalk]

Turns executed with the beep trim switch may be controlled and safe, but the odds are that the pilot, flying visually day-in day-out, would have pressed the FTR switch to make turns. Do we even know if he used any of the upper modes as part of his daily flying practice? The lack of real cloud and IFR flying would be poor preparation for switching to upper AFCS modes when surprised and under stress. And alone.

[gulliBell]

There was a comment posted much earlier here somewhere, from somebody who knows the check pilot that did the accident pilot's competency checks, and he was almost sure that the pilot would have been flying in SAS. Because that is the way he was used to flying it. Which would explain why things went pear shaped so quickly after entering some real clouds.

[Torquetalk]

Think you raised the question a while back as to how reliable the upper modes of the AFCS might have been if not used or properly maintained GB. I find it hard to visualize not using them in the S76B, as it is a lot easier to fly with a mode or two in than entirely by hand. The PBA changes the attitude set up if you do that (which in itself needs monitoring or it can bite you in the butt at night/IMC). Even chopping around LA, I would have thought ALT and IAS would make life easier too.

And not using all of that aircraft capability is a shame that only pales compared to the needless loss of life.j

[Cyclic Hotline]

https://insurancenewsnet.com/innarticle/insurer-says-it-wont-cover-flight-operator-in-kobe-bryant-lawsuitsInsurer Says It Won’t Cover Flight Operator In Kobe Bryant Lawsuits https://insurancenewsnet.com/wp-content/uploads/2021/05/GettyImages-520999564.jpg

Kobe Bryant #24 of the Los Angeles Lakers poses for a photo in front of the helicopter he took to his last game against the Utah Jazz on April 13, 2016 at Staples Center in Los Angeles, Calif. (Photo by Andrew D. Bernstein/NBAE via Getty Images) By John Hilton (https://insurancenewsnet.com/author/jhiltoninsurancenewsnet-com)

A California insurer claimed its coverage does not include the type of helicopter that crashed on Jan. 26, 2020, killing basketball legend Kobe Bryant and eight others.

OC Helicopters was covered by an aircraft insurance policy issued by Endurance Assurance Corp. at the time of the accident. The policy contains a single limit of $10 million for bodily injury and property damage, Endurance acknowledged in a lawsuit filed last week in the Central District of California.

OC Helicopters is among the defendants named in four lawsuits filed by Vanessa Bryant, Kobe Bryant's widow, and families of other victims. Endurance defended OC Helicopters to date, and its lawsuit asks the court for reimbursement of money spent.

The Endurance claim is simple: the Sikorsky S76B helicopter was not qualified for coverage under the policy it issued OC Helicopters. The policy had a clause for aircraft it operated but did not own. Helicopters do not fall under that clause, Endurance said.

"Because the Sikorsky is a rotorwing aircraft, it does not fall within the scope of the Non-Owned Aircraft Liability coverage provided by the Policy," the Endurance lawsuit states. "The Policy, therefore, does not provide coverage for the claims alleged against OC Helicopters in the Liability Actions."
https://insurancenewsnet.com/wp-content/uploads/2021/04/IMCA_728x90_2021-05-1.jpg (https://insurancenewsnet.com/wp-content/uploads/2021/04/IMCA_728x90_2021-05-1.jpg)Kobe Bryant, 41, retired in 2016 as one of the greatest NBA players of all time. The Bryants' 13-year-old daughter, Gianna, was also killed in the crash.

There has been plenty of blame to go around following the early morning crash in Calabasas, Calif.

Bryant’s widow blamed the pilot. She and families of other victims also sued the companies that owned and operated the helicopter. The brother of the pilot didn’t blame Bryant but said he knew the risks of flying. The helicopter companies said the weather was an act of God and blamed air traffic controllers.

The nine passengers were flying from Orange County to a youth basketball tournament at Bryant's Mamba Sports Academy in Ventura County when the helicopter encountered thick fog in the San Fernando Valley north of Los Angeles.

Pilot Ara Zobayan climbed sharply and had nearly broken through the clouds when the Sikorsky S-76 helicopter banked abruptly and plunged into the Calabasas hills below, killing all nine aboard instantly before flames engulfed the wreckage.

There was no sign of mechanical failure, and it was believed to be an accident, the National Transportation Safety Board has said.

InsuranceNewsNet Senior Editor John Hilton has covered business and other beats in more than 20 years of daily journalism. John may be reached at [email protected]. Follow him on Twitter @INNJohnH.

[gulliBell]

I can't see the insurer getting that argument to fly. Pilot's wreck aircraft for all sorts of reasons, running out of fuel, flying into mountains buried in cloud, etc etc, and the insurer's still pay out claims even for those accidents attributed to gross pilot negligence. For an insurer to try and wriggle out of a liability for the excuse offered here does seem a bit out of the ordinary.

[Gordy]

I can't see the insurer getting that argument to fly. Pilot's wreck aircraft for all sorts of reasons, running out of fuel, flying into mountains buried in cloud, etc etc, and the insurer's still pay out claims even for those accidents attributed to gross pilot negligence. For an insurer to try and wriggle out of a liability for the excuse offered here does seem a bit out of the ordinary.
OC Helicopters was not the aircraft operator...they were an "agent".

[gulliBell]

Either way, plenty of work generated here for the lawyers.

[megan]

How does OC get a mention? The aircraft was owned by Island Express and the pilot employed by same. The only mention OC gets in the report.According to the broker’s operations manager, the accident client initially approached her company because he liked its work ethic, but she said that OC Helicopters did not have a helicopter big enough to suit his needs, so she began looking for an operator for himWhy are gun sights on OC? Lawyers scatter gun approach?

[Bell_ringer]

OC was an operator, they just didn't have a large enough aircraft for this contract so they farmed the work out to Island.
Not sure exactly how that plays out under US law.
It doesn't seem like an agent role. The transcripts are quite specific about the arrangements between the various parties.
It makes complete sense why they would be named in a case, as they clearly weren't operating as a proxy, they had an active role in choosing who the pilots were and so had a duty of care to ensure the service they were selling was safe.

[wrench1]

OC was an operator, they just didn't have a large enough aircraft for this contract so they farmed the work out to Island. Not sure exactly how that plays out under US law.
From a regulatory side, OC claims they did not have operational control over the flight which is the deciding factor regardless who arranged the flight. OC states they only acted as a charter broker which is quite common in the business. Given OC did have its own 135 certificate and was an aircraft charter operator could be why they were included in the original court filing. And since a defendant's insurance company is usually listed as a separate entity in the court filing it seems to be a smart move on Endurance's part and may have a good chance of succeeding. Then with the policy payout taken off the table, OC may petition to be removed as well. Unfortunately when looking for "standards of care" in a civil proceeding who ever has money available will be included in that search. Had OC been just a standalone aircraft charter broker (which is not regulated) I doubt seriously they would have been included in the original filing as a charter broker is no different than a travel agent and they usually don't get directly sued if the flight they sold a ticket on crashes.

[Maoraigh1]

"The policy had a clause for aircraft it operated but did not own. Helicopters do not fall under that clause, Endurance said."
Was there a clause excluding rotary wing, or are they claiming rotary wing are not aircraft? If the latter, the FAA definitions have the answer.

[Bell_ringer]

"The policy had a clause for aircraft it operated but did not own. Helicopters do not fall under that clause, Endurance said."
Was there a clause excluding rotary wing, or are they claiming rotary wing are not aircraft? If the latter, the FAA definitions have the answer.

I suspect this is because they are claiming they chartered the aircraft and did not operate it. The rest is probably just poor journalism.

[wrench1]

"The policy had a clause for aircraft it operated but did not own...."
I believe the exclusion is on aircraft/helicopters they did not own were not covered. The S76 was owned and operated by Island Express not OC. There is also a report indicating OC only owned/operated single engine aircraft/helicopters which is what the insurance only covered.

[megan]

Insurer Seeks Removal from Kobe Bryant Crash LawsuitOC Helicopter insurer Endurance claims a $10 million policy does not cover rotorcraft.Mark Huber
|
May 2021The insurer of a key defendant in a tsunami of litigation engulfing the January 2020 crash of a Sikorsky S-76B that killed basketball legend Kobe Bryant (https://www.bjtonline.com/business-jet-news/helicopter-crash-kills-basketball-legend-kobe-bryant)and eight others filed suit earlier this month, seeking to be removed from the proceedings. Sompo International Holdings unit Endurance Assurance filed the suit in U.S. District Court, claiming the $10 million non-owned policy it issued to OC Helicopters, which booked the flight for Bryant and his party, does not cover helicopters. Island Express Helicopters owned and operated the accident helicopter.

Endurance had been defending OC in the crash lawsuits brought by Bryant’s widow and others subject to “reservation for rights” but now seeks reimbursement for those costs. The defense employed by OC to date has been that it did not have “operational control” of the crash flight. In September, the company issued a formal statement on the crash, saying in part, “we adamantly deny any responsibility for the accident.”

In February, the NTSB found that the probable cause of the crash was “the pilot's decision to continue flight under visual flight rules into instrument meteorological conditions (IMC), which resulted in the pilot’s spatial orientation and loss of control.”

The filing by Endurance is the latest insurance cloud hanging over the crash. As early as February 2020, industry experts charged that the $50 million insurance coverage carried by Island Express Helicopters was inadequate, considering the passenger capacity of the S-76. In response to suits against it, Island Express has filed a cross-claim against the U.S. government charging that the air traffic controllers handling the flight failed to provide adequate service. Earlier this month, U.S. District Judge Fernando Olguin denied the government’s motion to dismiss that claim and ruled it could proceed to discovery. In its final report on the accident, the NTSB found that the actions of the controllers did not contribute to the crashhttps://www.bjtonline.com/business-jet-news/insurer-seeks-removal-from-kobe-bryant-crash-lawsuit?utm_hsid=28375690&utm_campaign=Waypoints&utm_medium=email&_hsmi=128440395&_hsenc=p2ANqtz-9DsBOLMrcXTfefQsYkeGpRknFb9Rhv2e-ewTz-ySbR3kW30HTxRyP-dd7eAt44xNCqQWXwY73Tj4f9zg4el0p8A3YesQ&utm_content=2&utm_source=hs_email

[gulliBell]

"..a tsunami of litigation..."

They got that bit right.

[SASless]

Weasels looking for a way into a Hen House in my opinion.

Combined with a competition to see who can claim to have the least to do with what happened that sad day.

[Torquetalk]

Weasels looking for a way into a Hen House in my opinion.

Combined with a competition to see who can claim to have the least to do with what happened that sad day.

Welcome back SASless! Your ears must have been burning.

[havick]

In response to suits against it, Island Express has filed a cross-claim against the U.S. government charging that the air traffic controllers handling the flight failed to provide adequate service.

That’s an interesting but futile move.

[SASless]

The legal liability of Air Traffic Controllers in the United States is a complicated issue but the final analysis is going to focus upon whether the actions by the Controller(s) violated their duty of care as set forth by Federal Law and FAA Directives.

The primary function of ATC is to prevent collisions between aircraft and collisions between aircraft and vehicles and other obstacles within the operating area (airport confines) and terrain.

Those responsibilities vary from VFR and IFR and the type airspace involved.

In this particular case....the accident aircraft was being operated VFR not IFR.

At no time did any ATC Controller issue a clearance specifying a minimum flight level to be maintained.

All Clearances given instructed the Pilot to operate within Visual Contact with the Surface and outside of Cloud.

The Pilot is the final authority re control of the aircraft and is compelled to comply with ATC Clearances except for Emergency Situations.

Under FAR Part 135, that responsibility is shared by the Operator's employee who is tasked to oversee Flight Operations but the final authority is the Pilot.

There was no emergency...there was no assigned Flight Level...and other than requiring the aircraft to remain clear of certain Control Zones and out of cloud.....there was no route of flight clearance issued by ATC.

The Pilot did communicate with ATC about planned flight paths and did receive replies from ATCconfirming receipt of that information.

The Operator needs a better Lawyer....one that understands reality and Federal Aviation Law.

Attempting to sue the Government and any ATC Controller is just a waste of time and paperwork.

[nomorehelosforme]

Yes, welcome back SAS, guess the Country Club next to your house had enough of your excuses that you had to stay there for Covid lockdown and had to remind you lockdown was over a while ago and gently escorted you off the premises ....

[megan]

Like others here I'd love Island Express to spell out exactly what service the ATC failed to provide. Good to see you back SAS providing us with your sorely missed wisdom. :ok:

[[email protected]]

Isn't this the way of law in the US? File and counter file to muddy the waters and try to abdicate responsibility?

[jeepys]

[[email protected];11048971]Isn't this the way of law in the US? File and counter file to muddy the waters and try to abdicate responsibility?[/QUOT

Unfortunately Crab, we're going the same way here. Keep suing until you get the answer you want.

[SASless]

Megan,

This is just a news report and not the actual filing by the Operator's Lawyer but it gives some insight into the Operator's allegations against the two ATC Controllers.


https://www.msn.com/en-us/news/us/helicopter-operator-linked-to-kobe-bryant-crash-sues-two-faa-air-traffic-controllers/ar-BB18mGoF

[torqueshow]

Difficult to see how the end result would have been different had ATC provided better flight following.

[SASless]

Commonsense alone instructs us that if you are flying below terrain in a valley....Radar is not going to see you even if you have a Transponder operating.

The Controller knew he was going to lose Radar Contact with the aircraft due to the altitude it was maintaining and the route it was following.

ATC is not required to provide additional services to VFR traffic when their Control Zone is IFR....their job is to provide services to IFR Traffic.

The one exception is when they have a Special VFR flight operating INSIDE their Control Zone under a Special VFR Clearance.

As to their radio transmissions to the Accident Aircraft....they could be ignored by the Pilot if he was becoming overloaded by the deteriorating weather.

What is that old rule....."Aviate, Navigate, Communicate"....in that sequence.

[megan]

My impressions and take, those with FAA experience may pick it to pieces.

With respect to the controllers the formal report says,The controller advised the pilot that radar and radio contact with the flight would likely soon be lost and instructed the pilot to “squawk VFR” (set the helicopter’s transponder code to 1200) and contact the CMA tower once closer to the airport, and the pilot acknowledgedThe report even provides the reference as a footnote,The VFR transponder code of 1200 is used for aircraft that are operating under VFR without ATC radar advisory service (FAA 2019b, 5-2-4). See section 1.5 for more information.Being told to "SQUAWK VFR" or "SQUAWK 1200" is indication that the radar service being provided is now terminated, it doesn't require the "RADAR SERVICE TERMINATED" call in these circumstances 5-1-13b.Radar service is automatically terminated and the aircraft needs not be advised of termination when: 1. An aircraft cancels its IFR flight plan, except within Class B airspace, Class C airspace, TRSA, or where basic radar service is providedIt seems to me the pilot didn't understand the implications of squawk 1200 in that radar advisories were no longer a provided service.What is that old rule....."Aviate, Navigate, Communicate"....in that sequenceWhen you're up to your neck in alligators ignore ATC until you get to the third point of the rule, you might give a "standby", not scrambling about the cockpit looking for the ident button, the old story of "am I up here because you're down there, or are you down there because I'm up here" is relevant. Aircrew at times are cowed by the term "controller".

[gulliBell]

I agree with all of that, except for the pilot not understanding the implications of squawk 1200. He knew. What he didn't know was he was in a descending left turn and impact with terrain was imminent. It was the aviate bit he got wrong. Unfortunately.

[SASless]

"The controller instructed the pilot to “squawk VFR” (set the helicopter’s transponder code to 1200) and contact the CMA tower once closer to the airport, and the pilot acknowledged."

I edited the wording to simplify the exchange between the first ATC Controller at SCT (Southern California Terminal Radar) and the Pilot.

The deleted part of the edit provides the Controller noting Radar Coverage for the aircraft was not going to be available due to the low height above ground the aircraft was flying (400-600 feet AGL).

That wording clearly connotes Flight Following was terminated....the Pilot was to set his Transponder to a standard VFR Code (1200) and to contact ATC when he was closer to Camarillo Airspace.

The Controller at that point was finished with any handling of the Accident Aircraft and a change of Controllers occurred (no mention of the Accident Aircraft was made during the handover of the position ).

What is complicated about that?

In effect that lessened the burden on the Pilot as now he did not have to talk to anyone....as there was not a hand off to another ATC unit.

Unless he wanted to enter Controlled Airspace....he had no requirement to talk to anyone.

He could have continued on as he did....and even done the IMC climb to on top of the cloud layer without having to make a call until established on top....then reported to the appropriate ATC unit what had happened.

Reading the Accident Report....The Pilot did not speak to ATC until four minutes later when he initiated the exchange with the second Controller when he announced his decision to climb IMC to VFR On Top.

The Controller (having no knowledge of the aircrafts position, track, or intentions) asked the Pilot to "Ident" and asked him his position and got a response from the Pilot confirming the requests and offered his location and confirmed his climbing to clear air.

Within seconds the flight path turned left and a descent was begun with the aircraft impacting the ground.

Why would the Operator think ATC played a role in this and should be held liable in Court?

Doing a straight ahed climb in a fully instrumented S-76B....of just over a thousand feet should not be that difficult.

But as we know....it was for some reason and Spatial Disorientation is being blamed when we know full well it was other factors that set up the environment for that to happen.

I am disappointed in the NTSB Final Conclusion as to the Cause of the Accident....it goes far deeper than one guy getting the whirlies and losing control of the aircraft.



https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR2101.pdf

[aa777888]

Why would the Operator think ATC played a role in this and should be held liable in Court?I think this has been covered in the topic already. There's no way the operator truly thinks that, not in a million years. The operator and their lawyers are just waging what some would call "lawfare".

And don't forget that if any of this goes to a jury trial the likelihood of any aviation professional be empaneled as a juror is very, very small. Thus ultimately it will almost certainly be non-aviators passing judgement on the case.

[Bell_ringer]

And don't forget that if any of this goes to a jury trial the likelihood of any aviation professional be empaneled as a juror is very, very small.

At least there’s still a chance of a few Robbie drivers:E

[Fareastdriver]

At least there’s still a chance of a few Robbie drivers

It doesn't matter how much experience the jury may have . They can only use the evidence put before them.

[aa777888]

It doesn't matter how much experience the jury may have . They can only use the evidence put before them.
You do not understand the US legal (note I do not write "justice") system.

[[email protected]]

Anyone with any aviation knowledge would likely be filtered out by the defence during jury selection.

[megan]

I agree with all of that, except for the pilot not understanding the implications of squawk 1200. He knew.That may very well be in doubt, forget whether this came from the report or docket.The second SCT controller said that, when he received his first radio communication from the accident pilot (when the pilot advised that he was starting a climb to go above the layers), the pilot spoke as if the flight were receiving ATC radar advisory services (which it was not). To identify the flight, the controller requested that the pilot “ident,” observed the flight’s location and 1200 transponder code, and asked the pilot for information about his intentions. During this exchange, the controller lost radar contact and radio communication with the flight. According to the controller, he was not providing flight-following service to the flight at the time he lost contact with it because he had not received enough information from the pilot to complete the flight’s entry into the system. He said he did not report losing radio communication and radar contact with the flight because such losses were routine with low-flying aircraft in that area due to spotty radio and radar coverage in the mountains.I am disappointed in the NTSB Final Conclusion as to the Cause of the Accident....it goes far deeper than one guy getting the whirlies and losing control of the aircraftWould you care to expand SAS so we all may learn, I thought the probable cause was a fair summation. We can rabbit on about vestibular illusions and the like, but the focal point is he was not supposed to put himself in a situation where those illusions might arise, it's a typical VMC into IMC accident, with rookie mistakes apparent, such as failing to slow down, was arrival time for drop off important, far, far better to be late than dead on time.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-makingLove a plagarised quote - The irony about flying in fog is that the weather nearly always clears up and sunny by the time they put you in a body bagAnyone with any aviation knowledge would likely be filtered out by the defence during jury selectionThat's when one side or the other brings out its "expert witness", sometimes a contradiction in terms.

[wrench1]

Anyone with any aviation knowledge would likely be filtered out by the defence during jury selection.
Not necessarily. Have seen pilots and mechanics on aviation juries. It all boils down to how the plaintiff wants to sell their version of "duty of care," how sharp the defense side is, and who the jury want to believe. Keep in mind, how the plaintiff defines "duty of care" is not bound by any aviation regulation or in some cases common sense. For example, Part 135 Pilot A doesn't follow various items on a checklist. Pilot A takes off with T/R servo switch in OFF position. Pilot A loses control, hits light pole, and crashes, killing most. Plaintiff convinced jury the helicopter OEM designed a faulty fuel storage system and was awarded $100M. Nothing against Pilot A. And there are many other similar examples both operations and maintenance based. Given the Kobe accident has a wide public following I wouldn't expect less if this does go to trial which I'm sure the ace legal team Kobe's widow has put together is pushing for.

[SASless]

Megan,

"The second SCT controller said that, when he received his first radio communication from the accident pilot (when the pilot advised that he was starting a climb to go above the layers), the pilot spoke as if the flight were receiving ATC radar advisory services (which it was not). "

The first Controller denied the pilot's request for Radar Flight following telling the Pilot the reason was that he would be losing Radar and Comms with him due to his low height above ground and directed the Pilot to Squawk VFR (1200) on his Transponder.

That Controller told the Pilot to contact ATC when he was closer to Camarillo Airport....but did not specify which ATC Unit to contact.

The Pilot appears to have continued to monitor SCT ATC and upon entering IIMC and electing to climb to VMC conditions.....the Pilot informed SCT of that.

The second Controller having no information about the Aircraft....initiated the standard identification process.....seconds later it was all over with no response from the Pilot or the Transponder.

The bold text in the quote is pure supposition by whoever is being quoted and is not borne out by any information, data transfer, or recorded communication that would indicate that being a fact.

I see the listing of Spatial Disorientation as being the Primary Probable Cause also to be speculation not borne out by any direct confirmation.

It is probably the final cause but it was not proven to be "the" probable cause.

Did the NTSB actually rule out all other possibilities as the cause of this crash?

[megan]

Thanks SAS, woods and trees come to mind.

[FH1100 Pilot]

While it may not have had any direct bearing on the crash, it's worth noting that Ara had no idea that he was talking to a new controller. Look at it from his point of view. He'd been in contact with SCT, and they cut him loose. Just a short time later, he calls them back, most likely assuming he's talking to the same controller who knows who he is and where he is. Ara reports that he's climbing (maybe momentarily task-saturated now that he's IMC), and now the dang controller treats him like a first-callup and goes through the whole radar-ID thing! I'm sure it was one of those WTF moments for Ara. Now he has to reach down and put in a squawk - at the very worst time to be performing that act.

[[email protected]]

Yet he still cracked on at very high speed in poor conditions - nothing the controllers could have done about failure to aviate.

[gulliBell]

...Now he has to reach down and put in a squawk - at the very worst time to be performing that act.
If George was doing the flying at the time as it should have been, to look down and press the squawk button would have been the most trivial task to complete.

[SASless]

FH.....Playing the "What was he thinking?" game is utterly useless as there is no way ever to know what any person is thinking at any given point in their Lives.

Only they know and shy of them telling you in person....would you come close to knowing as they might not be telling the truth in their admission.

One thing is certain....and requires very little "thinking"....if you are scud running...doing so at a 140 Knots....close to the ground...in a valley with high ground on both sides of your flight path....that is all you are going to be cogitating about.

Ara failed to cope with the situation he had gotten himself into.....and from what evidence we have....was trying to do so and initially was doing the right thing....executing a climb to VMC on top of a thin layer of cloud.

He failed to perform that maneuver.

The NTSB says it was because of Spatial Disorientation.

Much is being made of his task loading as he made the climb...and anyone that has gone IIMC. KNOWS how burdened you are if it is unplanned, unexpected, and you had not prepared yourself for that eventuality.

That preparation begins long before you take your seat in the aircraft and continues until that IIMC event occurs.

Successful encounters with IIMC should be as investigated as are failed encounters....to determine what Pilots did right and build training and testing to inculcate that knowledge into all of us.

In a fully kitted out IFR Twin like the S76B that Ara was flying....a straight ahead IMC Climb to VMC on Top should have been easy to accomplish yet Ara failed......why?

It was not because ATC asked something of him in response to his calling them about his intentions.....or being distracted as he punched the Ident Button on the Transponder Control Panel.

He had been cut loose from SCT ATC...told to squawk VFR (1200) and to contact ATC when closer to Camarillo.....thus the Transponder should have already been set to 1200 from the specific squawk he had been using....leaving him to push one button one time in order to comply with ATC's request.....an action he did not have to do immediately or at all as he was certainly dealing with an Emergency situation.

You want to ask what he was thinking.....then ask some useful questions and summon up an answer that means something and might explain what happened.

I ask what was he thinking when I ask why he did not use the Autopilot System to HIS best advantage during routine VMC Flights and carry that good thinking over to flights like the one he was making the day of the crash.

Why did he ignore the very procedure he tested other company pilots on....re the existing IIMC SOP of slow down, divert, turn around, or land?

Why did he not discuss alternative plans with his Director of Operations as was required by the Operator's Risk Assessment Policy?

Those are the kinds of questions that need to be asked and answered.

Ara is no different than any of us....but something happened to take him and his passengers from us that day.

It was not Spatial Disorientation that did it....it was something that set him up in the situation that allowed that to happen.

That is the real cause of the accident...not Ara getting Vertigo as says the NTSB.

[FH1100 Pilot]

Gullibell, I think it has been established that Ara was not using the autopilot - as he "should have been."

SAS, of course we cannot know what Ara was thinking. But we can make a good guess. One of Ara's pilots relayed a story to the NTSB about how Ara flew offshore and made an IMC descent to get under an overcast so he could get back in toward land. We can derive from that that Ara was at least competent controlling the helicopter on instruments. By watching the various video recreations of the Kobe crash and pairing them with his ATC conversations, it appears that when Ara reported that he was climbing to 4,000 feet he was *actually* in a steep descending left turn. Clearly, Ara was not - could not have been - looking at his instruments as he pulled the trigger for that transmission. So what *was* he doing? Where were his eyes?

The Big Question is: What caused a proficient instrument pilot to screw up what "should" have been a relatively simple climb-to-VFR through a thin layer? To even try to answer that leads to the thirteen pages of speculation on websites like this. And obviously, we'll never know. But many of us have been in his shoes. Those of us who have - and lived to tell the tale - have "some" idea of what was going on in that cockpit. Even taking your eyes off the gauges for a couple of seconds can cause a pilot to get Spatial-D, whether to re-center the GPS or to look down and hit the IDENT button...whatever. Sh*t happens fast, especially when you're bopping along at 140 knots.