N72EX (Kobe Bryant) Crash Update-
 

Final NTSB report due on 2/9/21
Finding well probably be spatial disorientation in IMC conditions.

Here's a rendering of the final minute of flight based on the granular ADSB data-

https://i.imgur.com/YsiA23k.png

And an update from Blancolirio-

I'm not expecting any surprises in the final report.

I think there may be one surprise. In December, the NTSB posted to the docket the data extracted from the Flight Management System (I only noticed it yesterday). I am not a pilot or aviation professional, but I noted some anomalies:

1) When the FMS was powered on at LGB the day of the crash, its last known position was at the IEX helipad on Catalina Island. Can someone more knowledgeable about FMS operations explain to me how that is possible? Do you have to turn on the FMS separately, or is it normally powered on by switching on the avionics power bus?
2) The NTSB notes: "When the FMS is initialized, it will default to the position stored when power was previously removed or the GPS position, if it is available. This position is presented to the crew on the FMS initialization page, where the crew can accept it, or manually change it before accepting it. Should the crew accept a Reference Position that is significantly different from the actual aircraft position, the FMS will annunciate position uncertain and post difference warning messages after GPS position becomes available. Over time, the Reference Position would converge to true position by using DME and GPS.
3) There are unseen (by the pilot) warning messages in the FMS: "GPS 1 DIFFERENCE 6 NM" "REFPOS and GPSPOS > 6.0 NM". "DEAD RECKONING MODE"
4) When the pilot selects DTO (Direct To) KCMA, the FMS records a present position (PPOS) not on the flight path (this is recorded in the NAV Leg Editing Buffer). I am wondering if the FMS has not yet converged to true position.
5) The CDU at the time of the crash appears to me to be showing errant data (Figure 4-1 in the report). I think it is saying the distance to the destination is closer that it actually is and that the bearing between the displayed PPOS and Destination is incorrect. It would be fantastic if someone with more experience with the UNS FMS can confirm.

If I am interpreting the information correctly, it seems that the above would have added to the pilot confusion and workload. Here is a link to the docket entry: https://data.ntsb.gov/Docket/Documen...edRev2-Rel.pdf

FMS especially an old one in the 76B is insignificant for low level VFR operations. Usually the pilot just has an iPad balanced on his lap - though EASA and USCG pilots are known to have them on knee boards. The EGPWS recommendation is just a tired old NTSB hobby horse that they trot out on every investigation, again, of no consequence in this situation.

The FMS (inc this UNS model) will update its position very quickly once it has sight of satellites (out of the hangar) and in receipt of signals from VORs and DME equipment (the aircraft was flying in well-served airspace). It is very unlikely that the UNS did not know exactly where it was. That is usually a pilot problem.

Let me first say that I acknowledge that I am out of my area of expertise, and so this is my amateur speculation. I believe the Reference Position in the NTSB report (l34.25080n 118.76038w) recorded at 17:37:43 does not accurately reflect the actual position of the aircraft at that time. I am wondering if the UNS incorrectly determines position in the following scenario:

1) UNS Powered off in Santa Catalina
2) UNS Powered on at LGB
3) UNS Never receives DME.
From the report:

• "DME Stations for shortrange navigation: No DMEs Received"
• "Scanned DME Stations: Fifteen DMEs being scanned. None responded."

4) UNS records Reference Position (according to the report "Reference Position is Blended GPS/DME position propagated with GPS velocities")

This is last reported position information as detailed in the report:

• System Position (GPS position propagated by heading and true air speed) N 34:08.17861 W118:41.55108 (34.1363101n 118.692518w)
• Reference Position (Blended GPS/DME position propagated with GPS velocities) N 34:08.17861 W118:50.54967 (34.1363101n 118.8424945w)
• DME Position (Position computed from DME range measurements) N 34:23.21876 W119:13.96316 (34.38697938n 119.2327194w)

As you suspected, the GPS position information is correct (very close to the crash location). However, the Reference and DME Positions are not. I wonder if this corner case is rare because most of the time UNS systems receive DME. I do not have a hypothesis as to why the FMS was not receiving DME data.

Red Herring. Furphy. Whatever you care to call it. The pilot was navigating visually in sight of the ground in an area well known to him. He knew exactly where he was until he lost sight of the ground, lost control, and crashed. The FMS had nothing to do with it.

Airplanecrazy,

Gullibell is sure to be right.

As a point of interest, the FMS sums all available sources to determine ppps, and tells you when it doesn‘t have a reliable determination. No or poor DME signal or a discrepancy means the FMS will disregard the unreliable source. No issue.

What might have helped him was regular real IR training and a greater willingness to use the automatics to get him out of trouble once he lost reference. Not pressing on and chomping it whilst scud running, with limited visibility, in a rising ground environment, would have avoided the accident altogether.

The S76 is not a great machine for scud running, ESPECIALLY single pilot. Sitting in the right seat, you cant look over your left shoulder and see out behind you if your trying to turn left. The high Sikorsky console doesn't can also block the horizon. While I never had a problem flying the 76 single pilot, I NEVER did it with VIP passengers. Kobe could afford to put a second pilot up front and as PIC I would have expressed to the customer that a second pilot is mandatory for safety reasons. I can't say I would or would not have taken off that day since I have never flown that route but if I did it would have been with 2 pilots and EVERY helipad between my takeoff point and destination punched in to the GPS ready to be pulled up for an emergency landing due to weather. The PNF would make sure we always had a pad to land at. No one would complain if we dropped on in when they saw Kobe get out, not even the sheriffs helipads. This was a completely avoidable tragedy.

Thanks for your reply. I have reviewed the FMS extraction report again and I still suspect that the FMS is using the wrong position. Either the authors of the report incorrectly decoded the position information, the FMS is confused, or I am confused. The "Active From Waypoint" recorded at 17:37:43 is 34.25080271n 118.7603827w, and that is over 15nm from the actual position at that time of 34.250610n 118.450834w. Furthermore, the aircraft never comes closer than 7nm to that waypoint.

I certainly defer to your experience on whether that possible discrepancy could have had any influence on the outcome. I was hypothesizing that when the pilot entered the steep left turn about 30 seconds before the crash, that something distracted him from watching the primary flight instruments. I was wondering if problems with the NAV radios could have been that distraction, but it sounds like you think that is unlikely. I guess we will see what the NTSB thinks in a couple of weeks. I really appreciate your time!

The left turn didn't happen because the FMS was doing something it shouldn't. The left turn happened due to spatial disorientation of a pilot who had never flown in cloud before.

Thank you for your reply!

Add in some potential complacency because he had flown the route before (possibly in similar conditions) and got through OK - plus the commercial pressure to get the job done and personal pressure since he seems to have had a good relationship with his pax.

All adds up to an accident waiting to happen that wouldn't have been prevented by TAWS which would have been constantly alerting at low level anyway.

Plan properly and know when to say no.

Interesting article on the final flight and crash in the March 2021 Vanity Fair Magazine.
(Yes, I know it is not March yet and I know V.F. Is not an aviation magazine, but sometimes they shine with well researched articles, this one seems to fall in that category)

Yes, the Vanity Fair Magazine story was well written. I found this comment compelling "If he handled it right, no one would ever know what he’d done." But, handle it wrong he did, and everybody found out. As an aside, $1800/hr for an S76B sounds on the cheap side to me.

Possible that Bryant purchased block time of 50-100h/year for that rate?

That's a 204L4 or AS350 charter rate. They would be lucky to break even at that rate for a 76B. $5000/hr would be a more realistic number. Give clients a 10% discount for block hours. Obviously having a prang really screws up the economics.

I think Kobe owned the S76 and then the charter service took it over .... maybe he got a special hourly rate within the deal.

I guess nobody uses the old “Climb, Confess,Comply” rule anymore.

You have to have control of your aircraft for that to work.:sad:

He started the Climb thingy, without using the autopilot and slowly but surely lost control and banked to the left until the climb turned into a descent then a crash into the hillside. :sad:

The Daily Mail has printed their pennies worth.

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

https://www.msn.com/en-us/news/us/nt...nt/ar-BB1dxqrr

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.

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.

Define "poor," Crab

"Poor", I suggest, defined as being weather which is below VMC.

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.

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'

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.

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.

That's when, in a well equipped twin, you use the upper mode functions of the AP to offload you - if you are too low and fast to do that then you have already made significant errors of judgement such that the HAI's Land and LIVE advice is the best solution.

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."

I agree FH1100 - but it seems plenty of people still need to learn how to fly in poor (crappy) weather safely.

And sadly this won’t be the last thread on here that has all the similar outcomes and reasons why it all went wrong!

Sadly crab we only get to learn that by doing, when and how to pull out has never been content of any course, other than reading others misfortunes.

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.

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.