N72EX (Kobe Bryant) Crash Update-

[Gordy]

Originally Posted by megan

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]

Originally Posted by [email protected]

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]

Originally Posted by [email protected]

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]

[QUOTE]

Originally Posted by [email protected]

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/Documen...Report-Rel.pdf
And also: https://www.ntsb.gov/news/events/Doc...G-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]

Originally Posted by [email protected]

...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]

Originally Posted by [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.

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]

Originally Posted by 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.

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/u...licopters.html

[Gordy]

Originally Posted by megan

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 truth

Since you know Gordy, what is the truth? We seek the truth.