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Question about the Kobe Bryant Crash

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Question about the Kobe Bryant Crash

Old 1st May 2022, 19:16
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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'.
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Old 1st May 2022, 21:40
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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.
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Old 1st May 2022, 22:29
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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.
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Old 1st May 2022, 22:38
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Originally Posted by tdracer View Post
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.
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Old 1st May 2022, 22:47
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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.

Last edited by SASless; 2nd May 2022 at 01:02. Reason: corrected Van Nuys to Burbank
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Old 1st May 2022, 23:58
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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.”

Last edited by JimEli; 2nd May 2022 at 13:35. Reason: added point 5 and 7.
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Old 2nd May 2022, 00:54
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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.
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Old 2nd May 2022, 07:23
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Originally Posted by Sikpilot View Post
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.
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Old 2nd May 2022, 08:08
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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.
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Old 2nd May 2022, 09:23
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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.
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Old 2nd May 2022, 09:32
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I believe two major UK onshore operators had "incidents", and I am sure there are others

Both of these operators are/were supposed to be proper IFR multi-crew

https://www.gov.uk/aaib-reports/aaib...y-s-92a-g-lawx

https://www.gov.uk/aaib-reports/aaib...lletin-s4-2012

There was also these (single pilot, although highly experienced)

https://assets.publishing.service.go...N2NR_11-11.pdf

https://www.gov.uk/aaib-reports/aar-...6-january-2013

The simple fact is that despite there being a lot of IR holders in the UK, not much actual IMC flying happens onshore and the two-crew procedures/training/culture can leave a lot to be desired.

The vast majority of UK IMC helicopter flying happens offshore. Police hardly do hardly any at all, and HEMS don't do much more either.

Last edited by johni; 3rd May 2022 at 11:38.
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Old 2nd May 2022, 15:29
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Originally Posted by Bravo73 View Post
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/av...men_statistics
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Old 2nd May 2022, 16:02
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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.
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Old 2nd May 2022, 17:19
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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-n...t-flyer-beware
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Old 3rd May 2022, 11:50
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Originally Posted by Sikpilot View Post
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.
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Old 3rd May 2022, 12:34
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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.

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Old 3rd May 2022, 20:45
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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.
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Old 4th May 2022, 18:52
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Originally Posted by roscoe1 View Post
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.
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Old 4th May 2022, 19:07
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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
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Old 4th May 2022, 21:27
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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.
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