N72EX (Kobe Bryant) Crash Update-
SkyGod
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The Daily Mail has printed their pennies worth.
https://www.dailymail.co.uk/news/art...ter-crash.html
https://www.dailymail.co.uk/news/art...ter-crash.html
Kobe 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
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https://www.msn.com/en-us/news/us/nt...nt/ar-BB1dxqrr
A helicopter pilot's "spatial disorientation" played a key role in the crash that killed basketball legend Kobe Bryant, his daughter and several friends last year, federal authorities said Tuesday.
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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.
Findings:
1) None of the following safety issues were identified for the accident flight. One - Pilot qualification deficiencies or impairment due to medical condition, alcohol, other drugs, or fatigue. Two - Helicopter malfunction or failure, or; Three - Pressure on the pilot from Island Express Helicopters Inc., the air charter broker, or the client, to complete the flight.
2) Although the air traffic controller's failure to report the loss of radar contact and radar communication with the accident flight was inconsistent with air traffic control procedures, this deficiency did not contribute to the accident or affect its survivability.
3) Had the pilot completed an updated flight risk analysis form for the accident flight that considered weather information available at the time the flight departed, the flight would have remained within the company's low risk category but would have required the pilot to seek input from the Director of operations and to provide an alternative plan.
4) At the time the pilot took action to initiate a climb, the helicopter had already begun penetrating clouds and the pilot lost visual reference to the horizon and the ground. The loss of outside visual reference was possibly intermittent at first, but likely complete by the time the flight began to enter the left turn that diverged from his route over U.S. 101.
5) The pilot's poor decision to fly at an excessive airspeed for the weather conditions was inconsistent with adverse weather avoidance training and reduced the time available for him to choose an alternative course of action to avoid entering instrument meteorological conditions.
6) The pilot experienced spatial disorientation while climbing the helicopter in instrument meteorological condition, which led to his loss of helicopter control and the resulting collision with terrain.
7) The pilot's decision to continue the flight into deteriorating weather conditions was likely influenced by a self-induced pressure to fulfill the clients travel needs, his lack of an alternative plan, and his plan continuation bias, which strengthened as the flight neared the destination.
8) Island Express Helicopters Inc's lack of a documented policy and safety assurance evaluations to ensure that its pilots were consistently and correctly completing the flight risk analysis forms hindered the effectiveness of the form as a risk management tool.
9) A fully implemented mandatory safety management system could enhance Island Express Helicopter Inc's ability to manage risks.
10) The use of appropriate simulation devices and scenario-based helicopter pilot training has the potential to improve pilot's abilities to accurately assess weather and make appropriate weather-related decisions.
11) Objective research to evaluate spatial disorientation simulation technologies may help determine which applications are most effective for training pilots to recognize the onset of spatial disorientation and successfully mitigate it.
12) A pilot data monitoring program which can enable an operator to identify and mitigate factors that may influence deviations from established norms and procedures can be particularly beneficial for operators like Island Express Helicopters Inc that conduct single pilot operations and have little opportunity to directly observe their pilots in the operational environment.
13) A crash resistant flight recorder system that records parametric data and cockpit audio and images with a view of the cockpit environment to include as much of the outside view as possible could have provided valuable information about the visual cues associated with the adverse weather and the pilots focus and attention in the cockpit following the flight's entry into instrument meteorological conditions.
Probable Cause:
The National Transportation Safety Board determines that the probable cause of this accident was the pilot's decision to continue flight under visual flight rules into instrument meteorological conditions which resulted in the pilot's spatial disorientation and loss of control. Contributing to the accident was the pilot's likely self-induced pressure and the pilot's plan continuation bias which adversely affected his decision-making, and Island Express Helicopter Inc's. inadequate review and oversight of its safety management process.
Last edited by airplanecrazy; 9th Feb 2021 at 18:50.
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.
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.
Last edited by roscoe1; 10th Feb 2021 at 04:19.
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'
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'
Below the Glidepath - not correcting
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.
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.
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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.
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.
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.
Call it a minor distraction or whatever .... but our brains lose focus when we communicate by phone or radio while driving or flying.
Head down changing freq/squawk at low level is not clever - another reason that twin pilot Ops for this sort of work are better.
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."
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."
I agree FH1100 - but it seems plenty of people still need to learn how to fly in poor (crappy) weather safely.
plenty of people still need to learn how to fly in poor (crappy) weather
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.
However, you don't need a course to follow the basic principles - Go Down, Slow Down, Land or Turn Back.
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.
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.
