N72EX (Kobe Bryant) Crash Reconstruction with new ATC Audio

[Hughes500]

Er, the Captain of the aircraft's primary responsibility is its safety. So he is not obliged to obey ATC if it puts the aircraft in an unsafe place. Well that is what I was told at the start of my flying at Middle Wallop in teh 1980's

[212pete]

Hmm, let me see; VMC into IMC, fully IFR capable aircraft; how about a Pan Pan call and climb IMC back to VMC. Sort it out later with the feds.
In reference to the law suit, attorneys always will find a way to encourage a client to a law suit.

[Fareastdriver]

Island Express going to go bankrupt?

[OvertHawk]

Originally Posted by Fareastdriver

Island Express going to go bankrupt?

They're just trying to throw enough mud around in the hope that some of it sticks to someone else rather than themselves.

[airplanecrazy]

Originally Posted by Cyclic Hotline

"The suit claims at some point -- presumably when the pilot was in the fog -- radio contact came back, and Conley tried reaching the pilot repeatedly, and that caused the pilot additional stress."

A couple of months ago I created a crash reconstruction with the full ATC audio I obtained from the FAA. I am not a pilot or an air traffic controller, but I don't believe the controllers had any responsibility for the crash.

You Tube

Here is a statement that the last controller (CO) said in his NTSB interview that really struck me;

Group: Hindsight being 20/20, when you look back is there anything you would have done differently, or anything you think could have been done differently?
CO: I think the circumstances were beyond control of anyone in this building.:

The full transcript is in the docket.

[Twist & Shout]

Airplanecrazy

Group: Hindsight being 20/20, when you look back is there anything you would have done differently, or anything you think could have been done differently?
CO: I think the circumstances were beyond control of anyone in this building.:

This ^
The end.

[FWRWATPLX2]

Further Information

Is it fair to say we still do not know definitively the cause of the accident?

It has been speculated that conditions reported as foggy or misty at the time of the crash with visibility of 2.5 miles and ceilings of about 1,100 feet contributed to the accident.

The fact was the Pilot-in-Command was instructed, “maintain Special VFR condition at or below 2,500 feet", which confirms the less-than-VFR weather.

According to NTSB: “Examination of the main and tail rotor assemblies found damage consistent with powered rotation at the time of impact." and "Viewable sections of the engines showed no evidence of an uncontained or catastrophic internal failure"

https://app.ntsb.gov/pdfgenerator/Re...relim&IType=MA
https://www.ntsb.gov/investigations/...CA20MA059.aspx
https://www.ntsb.gov/news/press-rele...r20200207.aspx

P-I-C: ARA G. ZOBAYAN 50 years old, had 1,200 Hours S-76 and was the Chief Pilot for Island Express, with 8,200 Hours (approximately) Total and had flown about 270 hours the previous 6 months, which is about average . . . Typically, one can expect to fly 500 hours/year, unless flying "long haul". How much Actual Weather Flying had he logged? Flight Simulator experience logged? How much had he logged wearing a View Limiting Device or Hood? Again, would need to see his Pilot Logbook. That might give a clue to his competency and level of self-confidence to climb, with sole reference to Instruments, into VFR conditions, above the clouds. For example, pick a westerly heading over the highway, keeping within +/- 10 degrees, pull up on the Collective, watching the Altimeter and VSI increase, maintain airspeed or maybe slow a bit to increase Rate of Climb, keep the Needle and Ball centered . . . And, that would work just fine without a Gyro Horizon or Attitude Indicator. A true bonus if the aircraft had one of those that functioned.

Zobayan went to Group 3 Aviation in 1998 for flying lessons. Were all of his flying and ground school lessons received, there? Would be interesting to see all of the sign-offs by his Instructors and lesson syllabuses/syllabai to know exactly what he was taught.

FAA notes: "violated federal flight rules in 2015, when he flew into busy airspace near Los Angeles International Airport despite being ordered not to by air traffic control" He was criticized by the FAA, “Had Mr. Zobayan properly planned and reviewed current weather at LAX, he would have been able to anticipate the required action to transit … resulting in proper coordination”.

Trend?

CFI/FLIGHT INSTRUCTOR - INSTRUMENT HELICOPTER (2020-08-31)
CFI/FLIGHT INSTRUCTOR - ROTORCRAFT-HELICOPTER (2020-08-31)
GI/GROUND INSTRUCTOR - INSTRUMENT
PILOT/COMMERCIAL - INSTRUMENT HELICOPTER
PILOT/COMMERCIAL - ROTORCRAFT-HELICOPTER
PILOT/PRIVATE - INSTRUMENT HELICOPTER
PILOT/PRIVATE - ROTORCRAFT-HELICOPTER

The The Sikorsky S-76B is capable of single-pilot instrument flying certified or not and regardless the company was restricted to VFR operations, or not, in an Abnormal or Emergency situation, the Pilot-in-Command can do what the heck he wants to save the day. Apologize and explain later, but best to fess-up and submit a NASA Aviation Safety Reporting System (ASRS) Report.

I first earned a Commercial Pilot License Rotorcraft-Helicopter with an Instrument Rating March 1979, after graduating US Army flight training, at Mother Rucker. Earned Airline Transport Pilot License with Instrument Rating Rotorcraft-Helicopter October 1983 . . . Then offered a Corporate Pilot job flying both multi-engine turboprops and multi-engine IFR helicopters based at LAX, July 1987. By September 1987, I earned a Certificated Flight Instructor-Instruments Rating Rotorcraft-Helicopter and became a Helicopter Instrument Examiner for the Corporate Flight Department. After five years there, before the Defense industry wind down and half the Flight Department was let go, I went on to fly a BK-17A3/A4 in the same area . . . All the while, I had been flying the Bell Huey out of Los Alamitos Army Air Field. So, I had quite a bit of experience flying in the same operational area and terrain. Up to the Santa Susana rocket facility in the Simi Hills, out to Thousand Oaks, over to Palmdale Air Force Plant, out to Vandenberg Air Force Base, Van Nuys, Burbank, Santa Monica, you get the idea . . . I know the area like the back of my hand, including the canyons, the canyons with wires, and particularly the scuddy weather.

During my career spanning 36 years, have had lapses in Instrument currency? Of course. I could still keep shiny side up and might have been a bit rough during recurrent training. Let's see a show of hands how many have flown Instruments on Partial Panel, either during training or out of necessity, when something failed? Compass Card not working, no problem, that's what the Standby Compass is for. Don't need a Gyro Horizon, just makes it a whole lot smoother and easier. Right?

So, with 1,200 hours in the S-76, being an Instrument Rated Commercial Pilot and an Instrument Instructor and the Chief Pilot (that is the one who sets the example for all the Pilots he employed), it seems hard to understand Spatial Disorientation or Vertigo.

How many Instrument Rated Pilots have heard the axiom, "Believe Your Instruments"? That is, ignore what your body, nerves in your musculoskeletal system, and inner ear are directing you to do, just use the Instruments and do not fixate on any one. When you do, force yourself to increase your scan. This is just basic Human Factors stuff. Most importantly, don't put yourself in that position, in the first place. If there is any doubt about the weather or how low you will have to go and how slow you will have to fly doing Special VFR, then do not take off. If in rapidly declining weather, #1 slow down. Maintain straight and level. Maintain Visual contact with the ground. Look at the Compass Card, pick a 180 degree heading or a heading that will take you to VFR. Have I ever gone up a canyon parallel to the 405 and the weather would not allow any further progress? Indeed. I simply made a tight course reversal (180 degrees from what I was flying), at the same altitude, using my basic "Six Pack" of Instruments and returned to VFR, and got either IFR Clearance to go On-Top or Over-The-Top or returned to LAX, all coordinated with ATC. If Plan A does work, then have a Plan B. Have I ever said "No" to an Employer or Chief Pilot or passenger? Indeed. I only ever cared about protecting my Pilot License.

I am not blaming Ara Zobayan, because I do not know him, have not worked for him, have not flown the S-76, but I have flown comparable and even more sophisticated and faster aircraft and I have not seen a final Accident Investigation Report from NTSB, but if all the rotating parts were rotating . . . Did he suffer a medical episode or was it simply Spatial Disorientation? If it was the later, then we should want to know why, with all the experience and credentials he had.

[gulliBell]

Originally Posted by FWRWATPLX2

..That might give a clue to his competency and level of self-confidence to climb, with sole reference to Instruments...

The critical competency was to have the nous to push one button on George, take hands off the flight controls, and monitor the instruments. It's not that difficult when George is available to help.

[airplanecrazy]

Text of cross complaint

The user cazzipropri on Reddit posted a name anonymized version of the claims against the controllers. I obviously have a lot to learn about atc responsibilities. https://www.reddit.com/r/ATC/comment..._press_review/

Edit: Changed link to reddit page.

[JimEli]

First and foremost, the views and opinions expressed here are those of the author. The content is not intended to malign any individual, group, organization or company, nor imply any illegal act occurred. I’ve authored this simply to raise questions on the appropriateness and efficacy of current policies, procedures and oversight of Part 135 helicopter operations. My opinions are primarily derived from information provided in the NTSB accident investigation docket. Please bear with me, this is lengthy.

Do you think this pilot was prepared to perform an IIMC recovery--because the checked boxes seem to say so?

On June 21, 2019 (218 days prior to the accident), the accident pilot completed a concurrent FAA Part 135.293 and 299 check flight in the S-76. The check was conducted by the FAA POI and lasted only 1.0 hour. During this flight, among other maneuvers, the pilot was evaluated performing both “IIMC MANEUVER” and “ILS DEMO.” No additional instrument approaches were evaluated. During this flight, which was accomplished at Long Beach, the maneuvers “High Altitude Takeoff & Landings,” “Autorotations (Single Engine)” and “Hovering Autorotations (Single Engine)” were also checked.

The previous year’s (2018) concurrent Part 135.293/299 S-76 check flight lasted just 36 minutes and it was noted the pilot was evaluated performing “IIMC MANEUVER” and “ILS OPERATION.” No additional instrument approaches were evaluated. Is 36 minutes, or even 1-hour adequate time to conduct an FAA Part 135.293/299 checkride in a complex helicopter like the S-76?

On May 10, 2019 (260 days prior to the accident), the NTSB docket notes the pilot performed two S-76 training flights with a contract training company. These two flights lasted a total of 3.6 hours. The document notes, among many others, an “IIMC MANEUVER” and “ILS Operation” were graded satisfactorily, with no other instrument approaches noted.

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.” How was the time logged? Shouldn’t this be stipulated by policy and regulation?

Furthermore, 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.” This was the only training in the year prior to the accident that was noted in the NTSB docket.

An example of uninhibited check-boxing occurred in 2018, with the accident pilot receiving in-house training. Accordingly, the pilot completed the following maneuvers in two flights (0.8 and 0.5) totaling 1.3 hours: ILS and VOR approach, company heliport, oil-rig, confined area, pinnacle and slope landings, rapid deceleration, unusual attitude, IIMC, landing gear failure, T/R control failure, generator failure, engine fire, loss of engine in cruise, loss of engine during takeoff, loss of engine hovering OGE (both landing and fly-away), loss of engine IGE and loss of engine hover taxi, engine trim failures, cyclic trim failure, SAS failure, steep approach, Vy climb, steep turns, max-endurance and MCP flight, shallow approach and run-on landing. Further compounding incredulity, all of the above maneuvers with the exception of the VOR approach are checked on both flights. Is this just an example of sloppy bookkeeping?

Given all of the above, what exactly was being checked? According to the FAA, the “IIMC Maneuver” is a recovery from IIMC, and must include attitude instrument flying, recovery from unusual attitudes, navigation, ATC communications, and at least one instrument approach. Further complicating matters, the demonstration should be scenario-based. The instrument approach is apparently the “ILS DEMO.” Which begs the question, can a pilot fail a demonstration?

Indications from the docket are not completely clear on whether the operator even had procedures for unusual attitude recovery and IIMC. These procedures may have been absent from the operator’s S-76 maneuvers guide and training manual. Evidence shows that procedures were “added” versus “replaced” in the company’s documents after the accident (3/6/20). However, the docket information is not entirely clear what, if any procedures were in place at the time of the accident. Furthermore, the added material lacks proper indications highlighting what text was altered. During an NTSB interview, an FAA lawyer interjected comments, that if nothing else, displayed a heightened sensitivity towards the topic. 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…”?

To my knowledge, the Part 135 IIMC training and checking have existed at least since 2014. 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. 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. 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.” Was this overlooked by both the FAA and the operator?

But one must acknowledge that the totality of the FAA requirements is convoluted and confusing. The final rule for IIMC recovery training and checking was published in 2014, compliance required in 2015, POI focused review in late 2017, and then the policy with its invaluable guidance was cancelled in late 2018. What’s an operator to do?

Further, regarding Part 135.293 checking of a pilot’s knowledge of “escaping from severe weather situations, in case of inadvertent encounters,” (assuming IFR is viewed as “severe weather” to a VFR operator) the FAA acknowledges this area relates to general aeronautical knowledge and not aircraft specific, and only requires the areas associated with aircraft operational capabilities to be evaluated on separate check flights. Yet, in an aircraft like the S-76, these related areas would seem manifold (performance, instrumentation, autopilot, approach capability, etc.).

Yet, how effective is the prescribed annual IIMC training and checking? During the NPRM period many operators commented that the IIMC recovery training should be demonstrated semi-annually, while several individual commenters recommended quarterly training for pilots to maintain proficiency. Identical comments from two individuals suggested requiring frequent short training sessions involving unplanned entry into IMC followed by an instrument approach to landing at least quarterly in an approved aircraft or simulator. They suggested a requirement that a table-top PC-based navigation system trainer or similar device be used at least monthly. These were primarily pilots, practically begging for more training.

The Part 135 regulations are equally valid for both Helicopter Air Ambulance (HAA) and commercial operators. With this in mind, the NTSB agreed with the NPRM requirement for a HAA pilot to hold an instrument rating, and stated that HAA pilots should maintain instrument currency. It commented that instrument currency is generally acknowledged to be a skill that deteriorates rapidly without continued practice and use. Numerous other commenters also suggested that the FAA require HAA pilots to maintain currency or routinely demonstrate the ability to recover from IIMC. Several commenters noted that this requirement should be applied to all commercial pilots.

However, the FAA concluded that an annual check is sufficient because it can be incorporated into a certificate holder's existing competency check schedule. Does that sound like the convenience of the annual implementation overshadowed any concern for effectiveness?

The system seems to be failing us. Have we reached the point where the paperwork has become the exercise and effectual training is secondary? Could the requisites and paperwork be so unclear, complicated and baffling that they have actually become a hinderance? We should all ask ourselves, “what is the purpose of a check box?” Because ultimately, the pilot is the victim of an unmindfully checked box.

---

References

NTSB DCA20MA059 Accident Investigation Docket

14 CFR § 135 Operating Requirements: Commuter and On Demand Operations and Rules Governing Persons on Board Such Aircraft

Federal Register, Vol. 79, No. 35, Part II, FAA 14 CFR Parts 91, 120, and 135 Helicopter Air Ambulance, Commercial Helicopter, and Part 91 Helicopter Operations; Final Rule

FAA FSIMS 8900.1, Volume 3, Chapter 19 Flightcrew Member Training and Qualification Programs

FAA National Policy, 8900.270, Part 135 Check Pilot (Check Airman) Functions

FAANational Policy , 8900.437, Part 135 Helicopter Training and Qualification Program Review and Competency Check Requirements

[Torquetalk]

Originally Posted by airplanecrazy

The user cazzipropri on Reddit posted a name anonymized version of the claims against the controllers. I obviously have a lot to learn about atc responsibilities. https://www.reddit.com/r/ATC/comment..._press_review/

Edit: Changed link to reddit page.

Well the plaintiffs will try and tell it to suit them. And maybe they will succeed unless the court clearly understands the reasonableness and legality of the denial of service. But by the plaintiff’s own submission, no service was provided, they were just on frequency hoping to get one. So if no service is being provided, there is no service to be terminated. And if no service was being provided, there is nothing to hand over.

One for the lawyers and insurance companies. Doubt there will be any case law written changing ATC obligations on the basis of this.

But maybe Island Express could levy their customers a few bob in the price to ensure proper IFR competency for their pilots. All that kit just to smash it into the hillside.

[[email protected]]

In the US is there not a requirement for the pilot and controller to both establish a verbal contract on what service is being provided?

[FWRWATPLX2]

Jim, you made excellent points. Blame-shifting does not resolve the Pilot-in-Command is ultimately responsible and is the Final Authority. The Pilot-in-Command is the only one who can and should make the Go - No-Go decision, whether he has a check in the appropriate box or not. At what point does a Pilot's ego relent and acknowledge the risks to "Go", to takeoff, to continue, are too great?

[megan]

The suit that has been filed. Lets destroy the lives of two controllers. Only in America. One is reminded of the definition of waste - a bus full of lawyers going over a cliff with two empty seats.

https://ca-times.brightspotcdn.com/6...ountersuit.pdf

[[email protected]]

The lawsuit mentions the poor controller handover and loss of radar service as causes of the accident - the only cause was poor piloting, anything else is just a contributory factor.

The controller handover didn't make the pilot fail to keep the wings level in the climb or make him enter a spiral descent. I hope the defendants team point this out quite clearly.

[Winnie]

ATC Literally stands for Air TRAFFIC Control, and the term VFR Services TERMINATED means just that...

[megan]

crab And if a controller was to do something silly like give a radar vector into the side of a mountain or massive CB it's still the PIC fault for not having awareness of where he's at, nor is a PIC obliged to follow ATC directions if s/he considers it places them in jeopardy.

[ApolloHeli]

Originally Posted by megan

crab And if a controller was to do something silly like give a radar vector into the side of a mountain or massive CB it's still the PIC fault for not having awareness of where he's at, nor is a PIC obliged to follow ATC directions if s/he considers it places them in jeopardy.

Except that for an aircraft under radar vectors the controller is responsible for ensuring terrain and obstacle clearance. Mistakes may happen and you might be forgotten about so it's still good to be alert after being given a vector, but if a controller uses the standard phraseology "radar vectors", this indicates they take over responsibility for your terrain/obstacle clearance.

It won't be much consolation for you if you fly yourself into a hillside, but it'll make a world of difference for the controller afterwards. In this case, N72EX was not under radar vectors, so the controller is not responsible.

[[email protected]]

And you wouldn't expect radar vectors under VFR anyway - IFR positioning for an approach yes but he definitely wasn't doing that.

[MikeNYC]

Originally Posted by [email protected]

And you wouldn't expect radar vectors under VFR anyway - IFR positioning for an approach yes but he definitely wasn't doing that.

Relevant that even IFR approaches are sometimes flawed:

https://www.ainonline.com/aviation-n...-wont-get-hurt