Question about the Kobe Bryant Crash

[tdracer]

Ok, I know the basic facts - the pilot inadvertently flew into IMC conditions, experienced spatial disorientation, and flew into the ground.
Here's what I don't get:
The pilot was a highly experienced professional helicopter pilot with over 8,000 hours, but he wasn't instrument rated. Now, in the fixed wing world it would be very unusual a relatively high time professional pilot to lack an instrument rating.
Is this fundamentally different in the rotorcraft world? Why wouldn't the pilot be instrument rated? Are instrument rated helicopter pilots relatively rare?
TIA

[wrench1]

Ok, The pilot was a highly experienced professional helicopter pilot with over 8,000 hours, but he wasn't instrument rated.
FYI: He was instrument rated but with less than a 100hrs of instrument time and most of that simulated. The key though was the Part 135 ops certificate was VFR only. While I can't speak for all corners of the industry, I've known many pilots complete their entire career without an instrument ticket mainly due to the type of ops or due to the aircraft flown as most single helicopters are VFR only.

[SASless]

TD,

Use the search function here and you can find multiple Threads for the Bryant Crash....the longest running of them dealt with that aspect of the tragedy.

It was very much a Pilot error that caused it but the Pilot had a lot of help in doing it.

He was set up for failure as are Pilots in so many of these kinds of things.

Done right it could make for a great made for TV movie.

[FH1100 Pilot]

1) Some people say that an Instrument Rating by itself is relatively useless without the practice to keep the holder current and proficient.

2) Most helicopters do not fly on IFR flight plans.

3) Most helicopter operators (even commercial operators) are not certified to perform IFR flights (e.g., Island Express).

4 Employers are loathe to allow pilots to regularly go out and "burn flight time" (or said another way, "waste flight time") while getting instrument current/proficient.

The blame for "the Kobe Bryant accident" can be laid squarely on Ara's shoulders. He evidently forgot that he was in a helicopter. When he got into worse and worse weather, he did not slow down. Just because he was in a big, sophisticated, twin-engine, IFR-capable helicopter, it was, in the end, no different from a 206. He *should* have slowed down, turned around, or made a precautionary landing. Those of us who've been in this business for a while have done all three of those things and lived to tell the tale. Ara did none of those things and made the rest of us look bad...oh, and killed Kobe Bryant in the process.

[visibility3miles]

California normally has outstandingly good weather, unless it doesn’t due to rain or fog

Ever heard the Mamas and the Papas song, “It never Rains in California”?

Especially Southern California, when you can probably count on nine or ten months or more in a row without a single drop of rain.

Fog, on the other hand, can creep in when the inland valleys cool off at night and pull in the moist ocean air over land that has cooled off in the evening due to the clear skies, then you can get a very dense fog that takes a while to burn off in the morning.

Not quite the same as the notorious Tule fog farther north in California, which I can tell you is utterly miserable to drive through, but something similar.
https://en.wikipedia.org/wiki/Tule_fog
Tule fog is a radiation fog (https://en.wikipedia.org/wiki/Fog#Types), which condenses when there is a high relative humidity (https://en.wikipedia.org/wiki/Relative_humidity) (typically after a heavy rain), calm winds, and rapid cooling during the night. The nights are longer in the winter months, which allows an extended period of ground cooling, and thereby a pronounced temperature inversion (https://en.wikipedia.org/wiki/Temperature_inversion) at a low altitude.

Anyway, as mentioned on the aforementioned thread, the pilot expected a straight shot on his usual route, but was diverted due to the fog, then tried to fly under it along a roadway, then into it rather than land, and did not succeed in reaching his destination.

[SASless]

Of what value is a fully instrumented, autopilot equipped twin engined helicopter if you do not use all of the attributes of the aircraft and do so on every flight.

That S-76 was fully capable of flying itself with commands from the Pilot.

Proper Airmanship by the Pilot would have prevented what happened.....but proper oversight by company management, the company's insurance company, the third party training company, and the FAA also should have prevented the accident from happening.

That the Pilot was the Chief Pilot of the Operation, yet violated Company SOP's, clearly shows the breakdown in the procedures and structures that showed on paper proper safety and training standards were in place.

As I have said earlier....the Pilot had lots of help in arriving in that smoking hole in the ground.

[Winemaker]

Of what value is a fully instrumented, autopilot equipped twin engined helicopter if you do not use all of the attributes of the aircraft and do so on every flight.

That S-76 was fully capable of flying itself with commands from the Pilot.

Proper Airmanship by the Pilot would have prevented what happened.....but proper oversight by company management, the company's insurance company, the third party training company, and the FAA also should have prevented the accident from happening.

That the Pilot was the Chief Pilot of the Operation, yet violated Company SOP's, clearly shows the breakdown in the procedures and structures that showed on paper proper safety and training standards were in place.

As I have said earlier....the Pilot had lots of help in arriving in that smoking hole in the ground.
Interesting analysis. I do a lot of solo mountaineering stuff and always have a turn back time that I never violate, even if the summit is 250 feet above. It just isn't worth it. If there is lightning activity I just bail....... I would think pilots might have the same sort of personal constraints. Live to climb another day.

[tdracer]

Thanks all. I'm just a little surprised to find out that most helicopter pilots are not instrument rated/proficient - especially professional pilots.
So the rotorcraft world is fundamentally different.

[gipsymagpie]

In UK and northern Europe another couple of factors are the icing level being too low to allow IMC for half the year for most -27 certified helis and the extreme cost of getting the IR. However almost all of our offshore operations are IFR (helis with icing clearance)

[Dick Smith]

Always remember the HAI safety advice;

Land and Live!

[Dunhovrin]

Ever heard the Mamas and the Papas song, “It never Rains in California”?

Nope. Albert Hammond, yes.

[ShyTorque]

In UK and northern Europe another couple of factors are the icing level being too low to allow IMC for half the year for most -27 certified helis and the extreme cost of getting the IR. However almost all of our offshore operations are IFR (helis with icing clearance)

There are a number of U.K. helicopter pilots who do hold IRs and regularly use them during onshore ops. It’s quite legal to fly VFR - IFR - VFR (or continue to an airfield under IFR) in U.K. without having to file a written flight plan. Some operators now even have approved “point in space” letdowns of their own.

But obviously, you need to plan for the worst case weather scenario because that’s the nature of the U.K. weather. The Bryant accident would never have happened if this had been done.

[SASless]

Please do not try to apply UK Rules and Practices to US Rules and Practices......they are quite different from one another.

As an analogy....swap London Area for Los Angeles area and throw in some mountains and high ground to boot......then apply what you just said for flights in that kind of congested area.....using UK Rules.

I seem to recall an Agusta 109 cutting down a Crane Boom in downtown London in bad weather conditions somewhat similar to the Bryant Crash.

I started a Thread about two weeks ago raising the issue of Low Altitude IFR Routes for Helicopters.....and it drew scant comment or discussion.

That is symbolic of the interest shown by the FAA and the American Helicopter Industry.

The Island Express operation that was involved in the Bryant Crash could be the Poster Child for the standard on-shore Helicopter operation.

Helicopter EMS Operators are the leading edge in IFR Onshore Operations these days as they are scattered all through the Country while the Corporate Operators were usually in the Big City Northeast or Chicago area.

The Gulf of Mexico Offshore Operators also do a fair bit of IFR flying these days.

Had there been a Low Level IFR Route system in place in the LAX area....and Island Express had embraced IFR Operations....perhaps that tragedy might have been avoided.

[OldLurker]

I seem to recall an Agusta 109 cutting down a Crane Boom in downtown London in bad weather conditions somewhat similar to the Bryant Crash.Maybe more accurate to say that the crane boom cut down the 109 – which shouldn't have been there, of course – with tragic results.
Unsurprisingly, the crane was damaged by the collision and the outer part of the 'jib' (boom) fell into the street.
Aircraft Accident Report 3/2014 - Agusta A109E, G-CRST, 16 January 2013 (https://www.gov.uk/aaib-reports/aar-3-2014-g-crst-16-january-2013)

[SASless]

Old,

Quoting from the opening page of the linked Accident Report..... The investigation identified the following contributory factor:


The pilot continued with his intention to land at the London Heliport despite being unable to remain clear of cloud.


Are there any Helicopter Low Level IFR Routes in the London Area?

[mnttech]

Is this fundamentally different in the rotorcraft world? Why wouldn't the pilot be instrument rated? Are instrument rated helicopter pilots relatively rare? TIA
In the US, yes, it is fundamentally different.
"§ 61.133 Commercial pilot privileges and limitations.
(b) Limitations.
(1) A person who applies for a commercial pilot certificate with an airplane category or powered-lift category rating and does not hold an instrument rating in the same category and class will be issued a commercial pilot certificate that contains the limitation, “The carriage of passengers for hire in (airplanes) (powered-lifts) on cross-country flights in excess of 50 nautical miles or at night is prohibited.”
In Theory, you don't have to have an helicopter instrument rating to be a US commercial pilot.
IMO, the other detail would be the lack of single engine IFR approved helicopters. The AS350B3, EC130T2, Bell 407 are all Day Night VFR approved. I know, the newest 407 GXi can be IFR if the Bell STC is installed at Bell Piney Flats.
Most single engine airplanes are Day Night VFR IFR from the factory, even without an Autopilot

[FH1100 Pilot]

Proper Airmanship by the Pilot would have prevented what happened.....but proper oversight by company management, the company's insurance company, the third party training company, and the FAA also should have prevented the accident from happening.
Perhaps one of the dumbest things I've ever read on this forum. SASless obviously does not know how commercial Part 135 helicopter aviation works.

1) Ara was the Chief Pilot - he WAS "the management" of which you speak.
2) The company's insurance carrier does not provide "oversight" of flight operations.
3) The company's third-party training company does not provide "oversight" of flight operations
4) The FAA does not provide day-to-day "oversight" of flight operations. (No do we want them to.)

Even if the D.O. had questions about the flight, we can be sure that Ara would have given him some B.S. about how, "...The weather is generally good, and if it gets bad I'll just turn around and land at Van Nuys." At that, the D.O. would have said, "Okay Ara, it's your call. You're the Chief Pilot, I trust you." Aaaaand off we go.

Perhaps we might suggest that Island Express's insurance company require the company have IFR certification for all of their operations and pilots? That would be highly unusual. Wouldn't it be interesting if insurance companies required that of *every* Part 135 operator!

Maybe Island Express's third-party training company should have had more comprehensive training for inadvertent-IFR encounters? Who says they didn't? They probably trained Ara to the current industry standard. Such things were part of every Part-135 Recurrent checkride I've ever taken. Put the hood on, then put you head down and close your eyes. The IP will do some maneuvering and then put the ship into an unusual attitude. He'll then say, "Okay, open your eyes and recover." (Some were more, um, "enthusiastic" about this than others.) Fun times!

What SASless is suggesting is that our whole helicopter industry here in the U.S. is defective because we give so much responsibility and authority to just one guy...you know, the PILOT IN COMMAND? And when that Pilot In Command makes a dumb, fatal decision based on his stupidity, then it's not just *his* fault - oh no! It's his AND the entire industry's fault for existing as it does in the first place.

Uhhhh, uh-huh. If SAS wasn't as old as he is (and apparently pushing senility), I'd swear his post was written by some young, "not-my-fault!" millennial.

[ShyTorque]

Please do not try to apply UK Rules and Practices to US Rules and Practices......they are quite different from one another.

I didn’t!

Read my post again; I was responding to the post that I quoted.

[Devil 49]

When in doubt of the safe, successful completion of the flight there is no doubt- chicken out.

Or- It's better to be on the ground wishing you were flying than it is to be flying wishing you were on the ground.

Never, ever continue a flight you don't have a safe, attainable landing from at any point. That's a more or less logical extension from my 1969 warrant officer training in which the instructor would chop the throttle and declare 'engine failure'! A pink slip, the result of a failed instructional flight.;


Edit: "Tactical ticket" out of Army flight school. Good enough for the next two decades. At that point I wanted a 'beach' job with PHI, so I got my ATP, which included an instrument test.
At that time most IFR was to get out of, and into on-shore bases, legally.
Many IFR ships just didn't bother, 300 feet and 2 miles is pretty VFR crappy but was permitted twins and IFR ships, crews. Did that for about 10 years before I 'up-graded'

[SASless]

Perhaps one of the dumbest things I've ever read on this forum. SASless obviously does not know how commercial Part 135 helicopter aviation works.

1) Ara was the Chief Pilot - he WAS "the management" of which you speak.
2) The company's insurance carrier does not provide "oversight" of flight operations.
3) The company's third-party training company does not provide "oversight" of flight operations
4) The FAA does not provide day-to-day "oversight" of flight operations. (No do we want them to.)

Even if the D.O. had questions about the flight, we can be sure that Ara would have given him some B.S. about how, "...The weather is generally good, and if it gets bad I'll just turn around and land at Van Nuys." At that, the D.O. would have said, "Okay Ara, it's your call. You're the Chief Pilot, I trust you." Aaaaand off we go.

Perhaps we might suggest that Island Express's insurance company require the company have IFR certification for all of their operations and pilots? That would be highly unusual. Wouldn't it be interesting if insurance companies required that of *every* Part 135 operator!

Maybe Island Express's third-party training company should have had more comprehensive training for inadvertent-IFR encounters? Who says they didn't? They probably trained Ara to the current industry standard. Such things were part of every Part-135 Recurrent checkride I've ever taken. Put the hood on, then put you head down and close your eyes. The IP will do some maneuvering and then put the ship into an unusual attitude. He'll then say, "Okay, open your eyes and recover." (Some were more, um, "enthusiastic" about this than others.) Fun times!

What SASless is suggesting is that our whole helicopter industry here in the U.S. is defective because we give so much responsibility and authority to just one guy...you know, the PILOT IN COMMAND? And when that Pilot In Command makes a dumb, fatal decision based on his stupidity, then it's not just *his* fault - oh no! It's his AND the entire industry's fault for existing as it does in the first place.

Uhhhh, uh-huh. If SAS wasn't as old as he is (and apparently pushing senility), I'd swear his post was written by some young, "not-my-fault!" millennial.

Now aside from the personal attack which borders upon slander which we know can be a mortal Sin hereabouts....there are some other aspects of you post that are factually wrong.

The Pilot involved was the Chief Pilot....a member of Management but only one link in that chain of command.

The Island Express SOP required the DO to be consulted during the Risk Analysis Protocol....but. he was not.

Insurance Providers can and often do write minimum standards into their policies and oft times cancel policies if those standards are not met.

The Third Party Training company does not monitor flight operations....but they do pass upon the fitness of the Trainee upon completion of their training of the Pilot to include Check Rides and the performance level of the Pilot.

By doing so they are "certifying" the Pilot has or has not met their Training Standards and Syllabus as documented in writing during the performance of that training.

The FAA uses FAA Inspectors to monitor the Operators compliance with the FAR's to include Part 61,91, and 135 as well as the 135 OpSpecs among other criterion.

I would suggest you stick to speaking for yourself and leave off trying to put words in my mouth....as you do a very poor job of both.

The Pilot-In-Command is the last link in a chain that is supposed to act to prevent such tragedies....and as we know....any chain is only as strong as the weakest link.

Which link do you wish to identify as the Link that had the most effect in failing to prevent this accident?

Was it the Pilot all by his lonesome or did some of that safety program, management enforcement of its written policies, the trainers who did not ferret out a weakness in the Pilot's use of the installed avionics and systems?

As the Pilot paid for his Sins we should be fair to him and question how it was he felt able to do what he did only to discover far too late that he was not adequately trained, experienced, or capable of coping with the situation he found himself in that day.

[[email protected]]

Commercial helicopter operations invite the same abuses as any other commercial operation - pay lip service to the regulations which are often written allowing 'interpretation' and rely on operators to apply the standards the regulators would 'like' them to adhere to but don't actually mandate (light touch regulation is desired). Add a couple of other layers of 'supervision' to provide checks and balances which again are not properly regulated or audited (other than by a tick-box form) and you have a recipe for cowboy operations which look superficially to be professional aviation outfits but are actually exploiting the loopholes to provide a service to unwary customers which those in the know would deem 'unsafe'.

[visibility3miles]

Part of the problem was probably that the pilot felt extreme pressure, whether implicit or explicit, to get the passengers to their destination in time for a basketball game for the children.

It must be pretty hard to think to yourself, “Oh, landing on the side of the freeway and telling them to call an Uber is the best move to make right now,” rather than, “I think I can, I think I can.”

Push-through-itis can be deadly.

[Ascend Charlie]

So the rotorcraft world is fundamentally different.

Yes, Mr Racer, because an aeroplane is dynamically stable and will fly, with the pilot dead in the front seat. Easy to add an El Cheapo autopilot to make it do stuff.

Helicopters are dynamically unstable, and need a brilliant, good-looking hero to FLY it the whole time. A small control diversion can be fatal. An autopilot has to work rather hard to make it stay pointed in the desired direction. Until a few years ago, chopper autopilots were very expensive, so you didn't see them in the single-engine machines - which stayed VFR anyway. Now, the autopilots are much cheaper, and when fitted with glass screens, a machine like a B206 can be made IFR without breaking the bank.

But choppers are used for the down-and-dirty work. The client catches an IFR plane to the airport, then gets in the VFR chopper to do the task.

[Bravo73]

Thanks all. I'm just a little surprised to find out that most helicopter pilots are not instrument rated/proficient - especially professional pilots.
So the rotorcraft world is fundamentally different.

I don’t know the numbers but I wouldn’t necessarily say that ‘most’ helicopter pilots aren’t IFR rated. Plenty of us are and use it on a regular basis.

[SASless]

Vis,

While enroute the aircraft was delayed for about several minutes due to arriving IFR Traffic....memory serves me it was the Burbank Control Zone.

That in itself may not have been a factor that created the felt need to hurry that might have happened..

One key factor was the not slowing down as the deteriorating weather was encountered....no telling why that was (not slowing down).

The Operator had a written policy that embraced the "Slow Down, Go Down, Land out if necessary" instruction to its Pilots.....something the Pilot flying did not comply with....despite being the Chief Pilot.

[JimEli]

IMHO, the FAA, the operator and the pilot are equally to blame.

1. On May 10, 2019 (260 days prior to the accident), the pilot performed two S-76 training flights with a contract training company. During the NTSB interview of the instructor for the above flight, regards wearing a view limiting device during IIMC training, the instructor stated, “so sometimes yes, sometimes no. Especially if you wear a helmet it's difficult to use a hood on something like that. If you wear a headset that may or may not. It depends on what's available, somebody wants it, somebody doesn't want it. Again, it is more tailored for the check ride.” And specifically, on whether the accident pilot wore a view limiting device, the instructor stated, “I don't remember that part.”

2. The operator didn’t have procedures for unusual attitude recovery and IIMC. These procedures were absent from the operator’s S-76 maneuvers guide and training manual at the time of the accident. These procedures were added to the company’s documents after the accident. This added material lacks proper indications highlighting what text was added/altered.

3. The accident docket information is not clear what, if any procedures were in place at the time of the accident.

4. In the absence of a specific delineated procedure, maybe the accident pilot was attempting to perform exactly what the operator’s GOM instructed him to do, “pilots will never take an aircraft into IMC…”?

5. Was the pilot attempting to use the AP? Was he leveling the wings? Was he turning around and/or climbing? Was he attempting a transition to IMC? Was he making things up as he flew?

6. Part 135 IIMC training and checking have existed at least since 2014 (accident date of 3/6/20). FAA Inspector guidance states they must ensure that operators have procedures for recovery from IIMC and that these procedures are incorporated into the certificate holder’s initial, transition, upgrade, and recurrent training curriculums (my emphasis). In addition to training, the certificate holder should establish a GOM loss of control IIMC avoidance policy that supports the emergency authority of the pilot to divert, make a precautionary landing, or make an emergency transition to IFR (my emphasis). Within 60 days of the FAA’s Part 135 Helicopter Training and Qualification Program Review and Competency Check Requirements notice, POIs should have conducted 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 … training and checking on recovery from IIMC.” By all accounts, this was overlooked.

7. The FAA POI characterized the training with this company 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 when asked if he would say that it meets the definition of best practices as the FAA uses that term, he added, “I can't answer that. Because I just don't -- you know, I'm not an expert on their training, or their facility, or really you know, I don't have information -- enough information to make that distinction.”

[Sikpilot]

Back in the day, our insurance carrier always had a say in how we flew our 76. ALL pilots MUST be instrument rated AND current. They also MANDATED that no single pilot ops allowed. We were NYC based and our client list was a who's who of millionaire/billionaire's. Didn't matter if you had 10,000 hours S76 time, you were NEVER gonna fly a high profile celebrity by yourself. I think if there was a second pilot on this flight, this accident would not have happened.

[havick]

Back in the day, our insurance carrier always had a say in how we flew our 76. ALL pilots MUST be instrument rated AND current. They also MANDATED that no single pilot ops allowed. We were NYC based and our client list was a who's who of millionaire/billionaire's. Didn't matter if you had 10,000 hours S76 time, you were NEVER gonna fly a high profile celebrity by yourself. I think if there was a second pilot on this flight, this accident would not have happened.

I disagree, just look at the 139 accident in the Caribbean with two pilots in the cockpit.

One well trained, experienced (actual IMC etc etc) and current pilot would’ve prevented both accidents.

[[email protected]]

I disagree, just look at the 139 accident in the Caribbean with two pilots in the cockpit. And the 139 crash in UK with two pilots who couldn't manage an IF departure between them.

[Torquetalk]

Both the UK and Caribbean crash are good examples of pretend multi-crew ops and inadequate procedural familiarity and training for the type of aircraft and operation (a confined area take-off at night in fog - a truly daft idea; an ad hoc night departure into a no external reference environment without applying a recognised procedure).

Paper-ticking instrument currency and two bods on seats is nowhere near the level needed to have avoided those accidents. And having an extra bod in with the pilot in the crash in question would have been part of an inculcation into an operations culture which would lead to an accident that day or another.

[wrench1]

I don’t know the numbers but I wouldn’t necessarily say that ‘most’ helicopter pilots aren’t IFR rated. Plenty of us are and use it on a regular basis.
The numbers are available in some countries via private/public databases from sources like the FAA below. In general, of all active pilots in the US only 50% have an instrument ticket with less than 20% current. When the number of helicopter pilots is extracted the instrument ratio drops. So depending on your definition of "most" there are a solid majority of helicopter pilots in the US that are not instrument rated. However, in certain specific sectors the IR ratio is much higher due to regulatory requirements such as EMS helicopter pilot who are required to have an IR per Part 135. The discussion of instrument ratings/proficiency/currency vs flight safety has been an ongoing topic in many circles which drives the data availability.
https://www.faa.gov/data_research/aviation_data_statistics/civil_airmen_statistics

[SASless]

Some excellent article and video selections can be found here at this site.

https://ushst.org

If some of these had been made part of the Recurrent Training and Safety Training at every Operator....I wonder if it would make a difference?

Being exposed but failing to embrace the teachings has always been an issue in Aviation.

Ernest Gann made mention of that back in his time in the Cockpit when he wrote "Fate Is The Hunter".

He knew that we gave constant lip service to the dictates of safety and howled like Christians condemned to the arena if any compromise were made of it. He knew we were seekers after ease, suspicious, egotistic, and stubborn to a fault. He also knew that none of us would have continued our careers unless we had always been, and still were, helpless before this opportunity to take a chance.

[Aser]

I'm with SASless,
It isn't about the number of engines/pilots/autpilots etc. it's deeper than that...
This article applies to FAAland/EASAland and UKland by the way, in my experience in all of them...
https://www.ainonline.com/aviation-news/business-aviation/2021-07-01/let-flyer-beware

[Tibbsy]

Back in the day, our insurance carrier always had a say in how we flew our 76. ALL pilots MUST be instrument rated AND current. They also MANDATED that no single pilot ops allowed. We were NYC based and our client list was a who's who of millionaire/billionaire's. Didn't matter if you had 10,000 hours S76 time, you were NEVER gonna fly a high profile celebrity by yourself. I think if there was a second pilot on this flight, this accident would not have happened.


I don't agree with the notion that multi-pilot operations are inherently safer than single pilot operations. What is dangerous, is flying VFR in conditions that aren't VMC. Additionally, all accidents require consideration of the context in which the accidents occur. SASless is entirely correct when pointing out that pilots operate within a system, and that systemic factors are often equally or even more significant than the active failure that leads to the actual crash.

[SASless]

The sad part of this is in this case the "System" did not realize what failures were taking place until AFTER the tragedy occurred.

These were not bad people out to scam the system.....they were good, decent, professionals as is the case most times.

The Pilot did not set out that day to wind up as he did, the Operations people were doing what they thought was right, the trainers were doing a good job they thought and the FAA was doing what most bureaucrats do.

The cumulative effect is what set the stage for what turned out to be akin to a Greek Tragedy.

The Pilot made one critical mistake that took him outside his safe zone into one that is a real killer of Helicopter Pilots....IIMC.

He was going too fast which removed the option of being able to turn around, stop ....or land safely.

He had an Instrument Rating to include an Instrument Instructor's Rating....but scant experience flying in IMC.

He may even have been legally current and by FAR's considered proficient but in reality was not.

I have a question whether he really ever had been trained/taught to use the Autopilot/FD system to its fullest benefit during all phases of flight.

Same thing for the 139 Crash in the Bahamas....was that Crew using the excellent capability of that aircraft?

We not only have to be trained Industry Best Practices....we must use them.

The "system" should ensure we do....and it be a cooperative effort.....which I see as being "Professionalism" in its truest form.

[roscoe1]

I agree that the system failed to provide a safe trip for the passengers but all the system failures did was inhibit the pilot from making a choice that would have resulted in a less memorable outcome. It's like asking why putting up a big poster that says "BE CAREFUL" doesn't ensure people will ( be careful). The system is not a root cause, it only provides a minimum framework for exercising good judgement. He always could have said that it would be best to go by ground this morning, or sorry folks, we need to land right now to be safe, I'll get a cab for you and so on. He could have made those choices despite anything the system didn't provide. Plus, he broke rules that were in the system already. I feel the system could just as likley been successful if he had been willing to risk some passenger disappointment or unjustified irritation of his boss. Who knows, maybe his boss would have said " good call, I like to see that". The crystal that remains in the beaker when everything else boils away is thar poor soul didn't see it coming. A system of training, rules and regulations and aircraft capabilities helps for sure, but it will not prevent this sort of accident.

I'm reminded of a conversation I had with a cabinet maker who had one of those qick-stop devices on his table saw that slammed on a blade brake and retracted the blade in milliseconds if it sensed conductivity with a finger. They really do work but they always demonstrate them with a hotdog ( or a banger depending on where you live). I asked why they didn't have marketing videos with real fingers on real people. His answer was " why that would be foolish, it might not work". The system is there but there is no substitute for sound judgement.

[JimEli]

I agree that the system failed to provide a safe trip for the passengers but all the system failures did was inhibit the pilot from making a choice that would have resulted in a less memorable outcome. It's like asking why putting up a big poster that says "BE CAREFUL" doesn't ensure people will ( be careful). The system is not a root cause, it only provides a minimum framework for exercising good judgement. He always could have said that it would be best to go by ground this morning, or sorry folks, we need to land right now to be safe, I'll get a cab for you and so on. He could have made those choices despite anything the system didn't provide. Plus, he broke rules that were in the system already. I feel the system could just as likley been successful if he had been willing to risk some passenger disappointment or unjustified irritation of his boss. Who knows, maybe his boss would have said " good call, I like to see that". The crystal that remains in the beaker when everything else boils away is thar poor soul didn't see it coming. A system of training, rules and regulations and aircraft capabilities helps for sure, but it will not prevent this sort of accident.

I'm reminded of a conversation I had with a cabinet maker who had one of those qick-stop devices on his table saw that slammed on a blade brake and retracted the blade in milliseconds if it sensed conductivity with a finger. They really do work but they always demonstrate them with a hotdog ( or a banger depending on where you live). I asked why they didn't have marketing videos with real fingers on real people. His answer was " why that would be foolish, it might not work". The system is there but there is no substitute for sound judgement.Spoken like someone who has never exceeded a speed limit.

[SASless]

We should all strive to be "Stutz'!

“When he climbed into the Penelope or any other airplane, the same change always came over him and the character of the change was so strong that even Stutz himself was aware of it. He exchanged his earthly freedom of thinking for what had to be a series of disciplined facts. To absorb and segregate these facts, all in their right and proper order, was his duty, as it was of any professional pilot. Not only was it his duty but it was his sole defense against dependency on luck, and although he was aware of the power of luck, it was indicative that Stutz never considered it as a means to an end as long as he was flying.”
― Ernest K. Gann, Island in the Sky (https://www.goodreads.com/work/quotes/2057835)

[ShyTorque]

A favourite exchange between my wife and I, as I was leaving for work, was “Good luck!”

My reply was always “Thanks, but I’m not going to depend on luck!”

Same thing when I take a car or motorcycle for its annual MOT test. No point hoping for a successful outcome if you depend on luck to get you through.

[roscoe1]

Spoken like someone who has never exceeded a speed limit.

I do a pretty good imitation of a chicken clucking but I've never laid an egg. I guess I should park that routine. Your comment leaves me confused, Perhaps you have more to say that would clarify why you think I was somehow being hypocritical. I have been disoriented in scud and it scared the bejesus out of me but I survived. I had no passengers and it would have been more egregious if I had people paying for a safe flight on board. I have also J walked in a busy city, used a questionably unsound ladder and even left a few stove burners on by accident. I don't even fly anymore and am. not current but I think I can still give a good safety seminar if need be ( clucking is included).

[HeliMannUK]

The Pilot-In-Command is the last link in a chain that is supposed to act to prevent such tragedies....and as we know....any chain is only as strong as the weakest link.

Which link do you wish to identify as the Link that had the most effect in failing to prevent this accident?


I would hope we all agree with this statement above, as pilots we are the last line of defence in our aviation system, gross negligence aside.
​​​​​​

[EMS R22]

Always remember the HAI safety advice;

Land and Live!


100% Dick!

Whatever the consequence of landing never out ways dying.

Get on the ground and worry about the rest later.

[lowlevelflier]

So many weak links in this chain.
A total failure to protect the passengers.
One button...
One button is all he had to push..
If only he knew the button was there..

[SASless]

Which one button is it you think would have saved the day?

[[email protected]]

If only he knew the button was there.. i don't think he had Autoland fitted........................:)

[Lonewolf_50]

So many weak links in this chain.
A total failure to protect the passengers.
One button...
One button is all he had to push..
If only he knew the button was there.. I don't think that this is a healthy attitude to take, that pushing a button is what solves your immediate flying problems.
If the mishap the pilot had more recency of experience in instrument flying, and perhaps a better internalized Inadvertent IFR procedures - in other words, had he been able to draw on the full suite of flying skills that a pilot with an instrument rating would be expected to have - then which button was or was not pushed to aid their flying efforts isn't the primary thing to address. Those buttons are there to help you fly.

[[email protected]]

With the poor levels of airmanship, decision making and professionalism displayed in that accident, no button in the world was going to save him from himself.

[JimEli]

I don't think that this is a healthy attitude to take, that pushing a button is what solves your immediate flying problems.
If the mishap the pilot had more recency of experience in instrument flying, and perhaps a better internalized Inadvertent IFR procedures - in other words, had he been able to draw on the full suite of flying skills that a pilot with an instrument rating would be expected to have - then which button was or was not pushed to aid their flying efforts isn't the primary thing to address. Those buttons are there to help you fly.

not necessarily the time to be looking for a button. reminds me of Children of the Magenta Line.

[lowlevelflier]

Which one button is it you think would have saved the day?
The Go Around button
Wings level
Vbroc
700fpm RoC

[lowlevelflier]

i don't think he had Autoland fitted........................:)
Not talking about Autoland
The SPZ7600 has a G/A feature that levels the wings, initiates a 700fpm climb at Vbroc
It requires knowing you're in deep **** ... but had he engaged it,, he'd have popped out into gin clear skies in less than 30 sec

[[email protected]]

Not talking about Autoland My comment was tongue in cheek.

Many aircraft have the G/A feature but you need to have the AP set up correctly to allow for upper mode engagement - we have discussed his lack of awareness of how dangerous his situation was and there were many occasions when he didn't even need the AP to save him, just turning round or slowing down would have done that.

[212man]

Not talking about Autoland
The SPZ7600 has a G/A feature that levels the wings, initiates a 700fpm climb at Vbroc
It requires knowing you're in deep **** ... but had he engaged it,, he'd have popped out into gin clear skies in less than 30 sec
To be pedantic, this aircraft had the SPZ-7000, but the point is valid. However, I'd put money on it was being flown in SAS mode with the trim off, so G/A wouldn't have helped. Just relooked at the NTSB report and I'm surprised there is not more mention of what state the AFCS selector panel was in - should have been possible from bulb filament analysis.

[SASless]

Also the NTSB gave scant attention to exactly what was the Company SOP's re use of the installed Autopilot, did not delve into the details of what was taught about using the Autopilot during Training, and there was zero mention of what the Accident Pilot did during his flights in the S-76 re use of the Autopilot.

By investigate fully....I mean going deeper than just a cursory examination of the practices.

Being a VFR Only Operation.....I can see some Cheese Holes appearing that would not happen had it been an IFR Operation.

As the S-76 was being used more like an upscale JetRanger I can imagine all that Gucci Kit was not being used to its maximum benefit.

212Man echoes my earlier posts when I espoused always flying with the Force Trim ON....and using ATT Mode at all times.

The weather conditions and height above ground the aircraft was flying in.....and the FAR's, and Part 135 OpSpecs for the Operator may have influenced the use or non-use of the Autopilot in a Hands Off Level.

General limitations are usually no use of an Autopilot below 500 Feet AGL unless on an approved Instrument Approach where both lateral and vertical guidance is being received.

[helonorth]

The Go Around button
Wings level
Vbroc
700fpm RoC
As said, you would have to be coupled to the autopilot for this to possibly work and he certainly was not or this wouldn't have happened. I hope the go-around button only works in approach mode as accidental engagement in cruise in the weather would be most unpleasant. There really would be zero reasons to hit the go-around button if coupled.

[megan]

I hope the go-around button only works in approach mode as accidental engagement in cruise in the weather would be most unpleasantFor the GA mode to work you need to be already coupled, selection of GA cancels all other modes but after engagement any lateral mode may be used, if any pitch mode (VS, ALT, ILS, IAS) is then selected GA is cancelled. would work if the button were pressed in the cruise, but difficult to see, given the position of the buttons, how you could do this accidentally.

Nothing unpleasant if you were to hit it in the cruise, it just commands a 750 ft ROC and maintains the current heading.

[lowlevelflier]

To be pedantic, this aircraft had the SPZ-7000, but the point is valid. However, I'd put money on it was being flown in SAS mode with the trim off, so G/A wouldn't have helped. Just relooked at the NTSB report and I'm surprised there is not more mention of what state the AFCS selector panel was in - should have been possible from bulb filament analysis.
It's possible he was in SAS mode .. although never really should be out of ATT mode in this type of operation..
He had the entire SPZ 7000 suite to help him out.. but, as you mentioned,, it was being flown like a jet-box

[helonorth]

For the GA mode to work you need to be already coupled, selection of GA cancels all other modes but after engagement any lateral mode may be used, if any pitch mode (VS, ALT, ILS, IAS) is then selected GA is cancelled. would work if the button were pressed in the cruise, but difficult to see, given the position of the buttons, how you could do this accidentally.

Nothing unpleasant if you were to hit it in the cruise, it just commands a 750 ft ROC and maintains the current heading.
Okay, I was wrong about the GA mode, at least in the 109 anyway. I engaged it in cruise (not coupled to the autopilot) and it started a climb. Nothing abrupt or steep, probably because I was already at a high power setting. I still don't see how it would have helped the accident pilot though as he probably was just hand flying after getting spatial disoriented. I have the feeling he rarely if ever used the autopilot and was not terribly familiar with it's operation.

[lowlevelflier]

As said, you would have to be coupled to the autopilot for this to possibly work and he certainly was not or this wouldn't have happened. I hope the go-around button only works in approach mode as accidental engagement in cruise in the weather would be most unpleasant. There really would be zero reasons to hit the go-around button if coupled.
It's not unpleasant at all...and if memory serves me, so long as both AP's are on and you're in ATT mode (default setting) and G/A is engaged, it will activate.
I can't imagine any reason he'd be in SAS only mode...but it's possible.

[airplanecrazy]

To be pedantic, this aircraft had the SPZ-7000, but the point is valid. However, I'd put money on it was being flown in SAS mode with the trim off, so G/A wouldn't have helped. Just relooked at the NTSB report and I'm surprised there is not more mention of what state the AFCS selector panel was in - should have been possible from bulb filament analysis.

I don't think it was in the final report, but from the materials report: "No bulbs were found in the AP1 ON, AP2 ON, COLL RAD, FD2 and SAS/ATT annunciators." https://data.ntsb.gov/Docket/Document/docBLOB?ID=11602271&FileExtension=pdf&FileName=20-043%20Factual%20Final-Rel.pdf

[[email protected]]

There are those - not me BTW - who don't like or trust autopilots, usually because they were trained on basic (or old) helicopters and were never taught to use them or never bothered to learn.

It wouldn't be a surprise that he was flying completely manually if he was one of those.

[SLFMS]

There are those - not me BTW - who don't like or trust autopilots, usually because they were trained on basic (or old) helicopters and were never taught to use them or never bothered to learn.

It wouldn't be a surprise that he was flying completely manually if he was one of those.


I agree completely and always wondered this. Another option is Auto Trims off SAS on. Pretty stable for VFR flight but doesn’t interfere with hand flying.

[[email protected]]

Yes, we flew our 412 EPs in SAS mode for VFR stuff and ATT mode for IFR stuff - pretty much the way it was designed to be used.

For those that don't know, SAS mode is generally rate damping in pitch and roll to make the aircraft more stable but slightly less responsive - it will maintain straight and level more or less if well trimmed but will gradually wander away from any set datum. It typically has about 10% control authority and is fast acting.

ATT mode is intended to hold the aircraft attitude and return it to that attitude following a displacement - it will have 100% authority but be slower moving to prevent a runaway in an actuator being uncontrolled. ATT mode is often required to couple upper modes ie ALT hold, TAS hold, ALTA/GA etc.

Not trying to be authoritative or teach granny to suck eggs, just providing basic info for those that don't use APs.

[lowlevelflier]

I agree completely and always wondered this. Another option is Auto Trims off SAS on. Pretty stable for VFR flight but doesn’t interfere with hand flying.
76C.. all 3 trims must be on...or no SAS nor ATT engagement.
A new inexperienced pilot would have a very hard time conducting a smooth lift off and flight in this mode ...besides contradicting directly , the RFM

[lowlevelflier]

Yes, we flew our 412 EPs in SAS mode for VFR stuff and ATT mode for IFR stuff - pretty much the way it was designed to be used.

For those that don't know, SAS mode is generally rate damping in pitch and roll to make the aircraft more stable but slightly less responsive - it will maintain straight and level more or less if well trimmed but will gradually wander away from any set datum. It typically has about 10% control authority and is fast acting.

ATT mode is intended to hold the aircraft attitude and return it to that attitude following a displacement - it will have 100% authority but be slower moving to prevent a runaway in an actuator being uncontrolled. ATT mode is often required to couple upper modes ie ALT hold, TAS .

Yes, much like the 76.
I'm rarely out of ATT Mode in normal ops but for jinxing around close to ground, SAS MODE is ideal .
I do occasionally fly without any stab on [deselect yaw, pitch and roll trims,,...now its a big sloppy Jet ranger...
but good for practice..
I suggest strongly that Kobes pilot had no usefull knowledge of the SPZ7000 autopilot system... and in the end, what could have saved him..