Avweb: How A Split Second Wrong Decision Caused the Kobe Bryant Fatal Crash

The main thing I got out of that video was a desire to use "SLOGJ" in a conversation. :)
 
Still curious as to how much actual he had. 75 hrs of instrument experience doesn’t mean actual weather. I agree with the investigator about the hood. Pretty useless in a helo unless using blackout devices.

Kind of confused about their interpretation of of the company’s risk assessment process. First, he didn’t have SVFR conditions on departure. That happened once arriving in the Burbank area. Are they expecting him to update this change and call it into management while airborne? He didn’t have less than a 500 ft ceiling either. Only evidence that suggests that is during the last moments of the flight. Is he supposed to look inside and be distracted by updating either a paper RA or iPad RA and then relaying that to management? Good luck with that.

Also not mentioned was the investigator who claimed HTAWS wouldn’t have made a difference. I agree, when you’re completely under spatial D, HTAWS is just going to be a distraction. I think SVT might have helped maintain orientation. Seeing actual surroundings of hills (green) vs the blue sky might have helped him. Really should’ve stuck with simplicity. Level the wings, engage that AP and climb straight ahead.

https://verticalmag.com/news/kobe-bryant-crash-ntsb-blames-spatial-disorientation/
 
In the limited representation given by the avweb video, it felt like the chairman was trying to drive the data a bit- wanting to classify the operator as unsafe- when the inspector- working within the parameters of the NTSB that Chairman Sumwalt leads, could not “objectively” come to the same conclusion.

huh.
 
Sounded like the FAA investigator was defending his turf and didn't want to be culpable for failing to pull the certificate for Island Operators. At least breathe down their neck more prior to the accident. The maint annex to the report last year showed that the CVR and WX radar were removed. Sure. Not needed for single pilot VFR. But does it indicate a trend to NOT fix equipment that is inop? Who hasn't continue to fly an aircraft with a questionable instrument. A sick ADI? Guilty. S-76's are delivered with standby steam gauges including a JET stand by ADI. Removed decades ago? Why was that high end autopilot not used? Busted and not written up? That alone would have saved the day. Just cruise around with the heading bug.
8700 hours is not a lot to be PIC in an "Igor". 75 hours of instrument time? That would barely get him a co-pilot seat in one of my carrier's S-76.
How would I handle It? (1) Confess. "I stepped in it". (2) Climb to the minimum safe altitude. (3) Communicate with any of the ATC facilities in the area. I would request vectors to the best (WX wise) airport that has an ILS. He likely didn't possess the IFR pubs, but he could have requested the freq and inbound course for the procedure. Its been done. Why an ILS and not an LPV? Approach lights are a component of the ILS. Really help on a crummy day. Not always available on a GPS procedure.
At least he didn't run out of gas.
 
Isn’t it just typical of how these regulations are put in place that the act named after Kobe Bryant proposes a new requirement for equipment which would not have prevented the accident in question.

This how aviation becomes endlessly more expensive.
 
Anyone with a clue knew what happened with ing minutes of the crash. Conclusion, pilot should not have been up in that. Operator should have never allowed that flight to go.
 
TommyG said:
Anyone with a clue knew what happened with ing minutes of the crash. Conclusion, pilot should not have been up in that. Operator should have never allowed that flight to go.
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Last years report had an annex that detailed the ADSB replies that were picked up around the vicinity. It was amazing to see how completely it was graphed out with alt, heading & airspeed. I may have deleted it, sorry.

When i saw that the lowest IAS was about 50 KTS before the 6,000 FPM descent began, I knew that Vortex Ring State was not to blame.
 
An "act" is unlikley. The FAA would amend the regulations to change the equipment/training/operating requirements. I've never seen an FAA NPRM named after someone. That level of politicking is usually relegated to congressional actions.
 
PeterNSteinmetz said:
Isn’t it just typical of how these regulations are put in place that the act named after Kobe Bryant proposes a new requirement for equipment which would not have prevented the accident in question.

This how aviation becomes endlessly more expensive.
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*agrees in ERAU piper bolt pulling AD*
 
Why did he not file an IFR flight plan?
 
asicer said:
The charter operation was only approved for VFR.
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I think there's fault in this too. Even though they're only approved VFR, they should maintain proficiency for IFR flight as a safety precaution.

I almost disbelieve the conclusion because I can't see how a pilot, knowing they're in IMC, doesn't at least look at their AI. Especially when the first task they're supposed to be trained on is "level the airframe".
 
I did like the phrase "a crater looking for grid coordinates." Consider that one stolen, my friend...
 
In the video there is a description of "the leans" meaning when flying straight and level the pilot's inner ear believes he is leaning and turning. I have experienced this for myself, and I can tell you it is the most powerful feeling in the world! It takes discipline to fight it, to believe the instruments are telling the truth, and to correctly fly straight and level when every nerve in you body says you are falling sideways in a turn. I am aware that this can affect me, so if I find myself in a "milk bottle", like I was once on my way to Tangier Island, I steady my head and restrict my scan to primary flight instruments. I think the analysis of hitting the ident (thus causing the pilot to move his head and divert his attention) causing increased spacial disorientation is a sound analysis based on the information at hand. It should serve as a warning to all of us VFR pilots that the first moments of penetration into IMC is a most dangerous time and requires all of our attention to maintain control and verify the aircraft is in a safe and stable flight condition before attending to other duties, ANY other duties.
 
I doubt there's a pilot who has flown a decent amount in IMC that hasn't sustained a somatogravic illusion (i.e., the leans). The key is to not "seat of the pants" it but to override it with what your instrument scan is telling you. As I've said before in many cases, VFR-into-IMC cases end poorly not because the pilot can't fly on instruments, but fails to realize that they must fly on instruments.
 
William Pete Hodges said:
It should serve as a warning to all of us VFR pilots that the first moments of penetration into IMC is a most dangerous time and requires all of our attention to maintain control and verify the aircraft is in a safe and stable flight condition before attending to other duties, ANY other duties.
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While I don’t know that this applies to helicopters, I think the FAA takes VFR Private Pilot training in flight by reference to instruments down a bad path. They try to make mini-IFR pilots with 3 hours of instrument training, and even though they’re proficient enough for the checkride, instrument proficiency goes away really quickly.

I think a better emphasis would be something along the lines of the old ASF/U of Illinois procedure that takes advantage of airplane trim and stability characteristics to allow minimal control input from the pilot to keep the airplane under control. Unfortunately the best instrument for the job (turn needle) is rapidly disappearing, so specifics would have to be adjusted.
 
While the AvWeb analysis is accurate in a literal sense, I don't know if it really captures the underlying issues. I'm more interested in looking a level or two below the accident. While I certainly understand that this was a helicopter operator limited to single pilot VFR ops, the fact is that an S-76 is an extremely capable IFR ship. Regardless of authorization or lack thereof, a brass tacks fact is that it would have been a trivial matter to conduct that flight on an IFR flight plan; but this option was not legally available to the pilot. As a result, he had to make VFR/SVFR work.

From a Human Factors perspective, I'm more of a realist about what really drives pilots to make the decisions they do. This flight appeared safe and achievable in the mind of the pilot. He had the experience and equipment to do it. But he had to operate closer to his own skill limits because he was unable to take advantage of filing IFR and using the AFCS to his advantage. His goal was to deliver his clients to their destination. He's going to do his darnedest within his skill level to achieve that goal. He could have easily done so on an IFR flight plan. Perhaps if a dual crew IFR ops authorization was in the cards for this operator, we'd have avoided this accident. And maybe others in the future.
 
Ryan F. said:
While the AvWeb analysis is accurate in a literal sense, I don't know if it really captures the underlying issues. I'm more interested in looking a level or two below the accident. While I certainly understand that this was a helicopter operator limited to single pilot VFR ops, the fact is that an S-76 is an extremely capable IFR ship. Regardless of authorization or lack thereof, a brass tacks fact is that it would have been a trivial matter to conduct that flight on an IFR flight plan; but this option was not legally available to the pilot. As a result, he had to make VFR/SVFR work.

From a Human Factors perspective, I'm more of a realist about what really drives pilots to make the decisions they do. This flight appeared safe and achievable in the mind of the pilot. He had the experience and equipment to do it. But he had to operate closer to his own skill limits because he was unable to take advantage of filing IFR and using the AFCS to his advantage. His goal was to deliver his clients to their destination. He's going to do his darnedest within his skill level to achieve that goal. He could have easily done so on an IFR flight plan. Perhaps if a dual crew IFR ops authorization was in the cards for this operator, we'd have avoided this accident. And maybe others in the future.
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I haven’t read enough to know...what was their destination? Did t have an instrument approach?

while I’m not familiar with helicopter 135 ops, I suspect that the ability to go IFR wouldn’t increase the utility/marketability of the helicopter operation, since a lot of the destinations seem to be “off airport”. Yes, an IFR clearance may have been a safer option, but more than likely the trip wouldn’t have happened if they were IFR.
 
MauleSkinner said:
since a lot of the destinations seem to be “off airport”.
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Its this mainly. While the equipment/training costs are higher developing the IFR routes can be more at off-airport site. And considering most helicopter ops are not airport to airport it does get into the bang for buck side of things. Even on the commercial side only the larger operators develop IFR routes at remote locations like an offshore platform. And its mostly only for the larger customers like Shell who will offset that cost. Throw in the basic operating limitation are low for helicopters and it is a completely different operating environment that airplanes.

So while you can try and compare the two it really isn't possible. But those same lower ops limits also reduce the fudge factor for helicopter ops when the weather changes for the worse. Unfortunately, some pilots simply don't use the #1 benefit of a helicopter by stopping and landing when SHTF which I guess is similar to those that don't pull the chute when they should. There is/was an industry catch phrase for years called "Land and Live." Unfortunately not every one follows that advise.
 
If they weren’t operating it dual pilot IFR, you can bet it would be due to cost.

I was picking up our helo at a customization center a couple years back and they had a H155 in there operated by a charter service. It had been there for a year already and waiting on the charter company to get the funds to start work. Person giving the tour told me the company was talking of cannibalizing parts for their other H155. They finally just completed the thing not long ago. These charter companies are operating on tight profit margins. Single pilot VFR would be a substantial savings.
 
bflynn said:
Yes, I'm aware. They need to do it better.
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So with your background in helicopter operations, especially IIMC and IFR procedures, please explain how they can do it better.

bflynn said:
A pilot screwing this up by flying into IMC and not picking up an instrument scan is incredible to me. It should be the next thing in your mind, right after "oh, s***, clouds".
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Accidents are a chain of small events leading to a conclusion. By the time this fellow was at the end of the chain, his senses were being overloaded. Go back a few links in the chain as he passed VNY and saw deteriorating conditions, had he turned around and landed at VNY and told his passengers "Sorry, but we can't continue due to weather" this would have been a non event.

Scud running has claimed lots of pilots and will continue to claim them. It comes down to set a limitation and stick to it, and stick with it even if it means being defeated such as non completion of a flight.
 
At 140 knots you have to see what's happening a minute before you get there. If you react when it hits, you're already behind the airplane and in bad shape. He should have landed as soon as he saw what was ahead, or throttled down to poke into it, or done whatever you do in a helicopter to slow down. He should have worried more about keeping his px safe than getting them there on time. SLOJ indeed. Sad thing is the guy sounds like a really good pilot. If he can do it so can any of us.
 
MauleSkinner said:
I haven’t read enough to know...what was their destination? Did t have an instrument approach?

while I’m not familiar with helicopter 135 ops, I suspect that the ability to go IFR wouldn’t increase the utility/marketability of the helicopter operation, since a lot of the destinations seem to be “off airport”. Yes, an IFR clearance may have been a safer option, but more than likely the trip wouldn’t have happened if they were IFR.
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As was posted earlier, it was Camarillo. Although the destination in this case was the airport itself, even if it was off the field, traversing the majority of the LA basin on an IFR flight plan would have been an easy task.

IFR ops may not increase marketability, but it would certainly increase utility. The cost of this maintaining the authorization to enjoy this benefit is likely the main problem.

My observation centers around the fact a great deal of equipment and resources were physically available to the pilot but were not legally accessible. It's a multi-faceted issue without a simple/central takeaway. Just worth thinking about, in my opinion.

Velocity173 said:
If they weren’t operating it dual pilot IFR, you can bet it would be due to cost.

These charter companies are operating on tight profit margins. Single pilot VFR would be a substantial savings.
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Agreed -- and those substantial savings represent a lot more than just the salary of a second pilot.

Even when it's striven for, safety can be an elusive goal when you're trying to make a buck.
 
Velocity173 said:
Single pilot VFR would be a substantial savings.
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Savings indeed.... until they crash it and that cost-shifting made it to my little ol' rec spam can insurance renewal bill. IOW, our world is metastasized with moral hazard.
 
Bell206 said:
FYI: As posted in another thread, there already is a requirement for all rotorcraft 135 ops to have inadvertent IMC manuvering competency.
https://www.pilotsofamerica.com/community/threads/r44-into-imc.104449/page-3#post-3044246
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Yeah, but! As posted in another thread re: EMS helos, everyone now requires an inst rating to get hired. However the requirement for the 135.293 check is intended for pilots assigned to VFR AC or copilots on a part 29 certified AC (Transport cat). Such as the accident AC. The accident pilot was current under 135.293. Most 135 operations require the PIC of a transport cat AC get a 135.297 check. The 293 Competency ride is a 12 month ride with an approach or two and the ability to fly on instruments.
The 297 ride requires a laundry list of approaches, inst proficiency, not mere competency. It takes most of a day in the aircraft or a 5 day trip to the sim. Its a six month check. If you didn't log the usual 6,6 & 6 you are covered by it being an IPC.

As for the equipment in the accident aircraft, It left the factory as a two pilot aircraft with complete dual instrumentation including WX radar and a third stand by altimeter, ASI and JET standby ADI. The AFCS was at one time upgraded to a high end Sperry dual autopilot system. In that while owned by Island Helos, the CVR and weather radar were removed and a four seat row was removed, I question how well the remaining equipment was maintained. The S-76 requires an avionix tech in addition to the standard 2.5 A&Ps for regular maint. I don't think it got it.
 
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Maxnr said:
In that while owned by Island Helos, the CVR and weather radar were removed and a four seat row was removed, I question how well the remaining equipment was maintained.
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Based on their operations, it also might make sense to remove this stuff without reflecting on maintenance practices.
 
The other reason for not going full dual pilot IFR program is the nature of heli ops. The IFR system doesn’t work well when your customer wants to be dropped off at their destination. We have remote helipad IAPs in EMS but it’s still no where near as flexible as going VFR.

You can’t discount the self imposed pressure to fly the customer that this pilot must have experienced either. They don’t really cover it in the vid because as they say, they don’t know what’s in that particular pilots mind.

I flew mostly VIPs in my Army days and whether I consciously knew it or not, there was pressure to get the “customer” to the destination. One of the most memorable experiences I had, and I tell this because it draws close parallels to the Bryant crash, was flying a 2 star in Afghanistan. This was a day where we were able to pick up (barely) the general in Kabul in the AM but during the day, the weather had gotten worse. Most other VFR return flights into Kabul had canceled for the day but since I had min weather (700/2), I was going to make a go of it. Pressure started when the general got in the back of the aircraft and said “chief, I hear you all are good at flying in bad weather.” I replied “well sir, our call sign IS Overcast.”He chuckled a bit but deep down I was thinking someone had told him we’d get the mission done. After a SVFR departure and not long after takeoff I knew I had gotten us into a real mess. We flew over a security check point 10 miles out at a very low altitude. I joked with chalk 2, “didn’t think we’d be flying NOE today huh?” Don’t recall his reply but I could tell by his voice that he was nervous. Anyway, I had gotten us right up until the final pass. If you look at the computer sim vid that the one guy did of the Bryant crash, it looked almost exactly like that. We’re at 150-200 ft, just below the clouds and I’m straining to see if “there’s light at the end of the tunnel.” Im pressing as far as I can take it but finally decide this just ain’t gonna work. I do a last second, hard right turn to keep from plowing into the mountain. PIC in chalk 2 says, “holy ****, there’s a mountain there!” So now my crew is nervous, my chalk 2 is nervous and I’ve got a 2 star who by the way is an Apache pilot who needs to get back to his FOB. I look left to the milky white abyss and say to my general “sir, I’m sorry but I just can’t get you home today.” I’ll never forget his calm, nonchalant reply. “Oh that’s OK chief...we can drive.” Here I wasted his day by trying to get him home in crap weather, now just added a 3 hr drive to his day and he didn’t care. In a strange way I think he knew exactly what I had done because he’d seen his Apache brethren die from those same exact circumstances. I had made a last minute decision with command / personal pressure and aborted to live to fight another day. He even gave us all coins!

Kinda long story. Sorry about that but I thought it’s relevance to the Bryant crash was appropriate. It’s the nature of the beast when dealing with helos, MVFR weather with no IAP and VIPs in the back. IFR capability means little in those scenarios...unless it becomes an emergency.

8F38EA30-3DCA-4D29-9D54-F4E053DEEAFF.jpeg
 
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Gotta believe if Kobe were asked whether he would pay extra for an IFR capable aircraft and crew, he would say yep. Same with that billionaire who lost his daughter and a bunch of friends flying back from their private island in the Bahamas. If you have enough cash for a private friggin' island, you have enough cash to hire former TF160 pilots, not a pair of goobers who could barely hold a job down. I guess they don't teach building your own one-bird airline at billionaire school. Somebody ought to go into business doing external evaluations of private and corporate flight departments for rich guys. (I'm sure they do already, just being sarcastic).

Not a helo pilot, but here's what I don't get. That rising terrain was not a surprise. Neither was the low ceiling. He could look forward several miles in front of him and see the valley floor rising into the clouds. Could he not slow down his forward speed to pick his way through and have more time to make decisions? Don't see a way forward, hover, do a pivot turn, and go back out the way you came. Just seems like putting the hammer down and turning the helo into an airplane gives away the advantage of being in a helo.

I spent 20 years in Army SOF. We always said if we were going to die, it would probably be in the back of a helo.
 
MauleSkinner said:
Based on their operations, it also might make sense to remove this stuff without reflecting on maintenance practices.
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Re: the radar. Probably would not have helped anyway in this instance. Its a big dead weight installed as far up front as you can get. If 8 pax carried little or no baggage in that 600 lb baggage compartment, aft of the rotor mast, guess how much a 76 busts the fwd cg limit. Been there done that. Improvise, adapt, overcome. I would gather up 3 or 4 empty 5 gallon water jugs. Strap them into the baggage compt and fill them with the hose. Re compute W & B and its good. Pour out the water at destination.
Island Helicopters only operated a few S-76's. Small operators that I know of usually don't have a big parts room. Call it a mere suspicion that minor squawks don't get fixed. Borne out from observation. The outfit that I flew for ran 200 aircraft in the states and maybe 100 or more international and Alaska. We could get a replacement instrument or part that night. Island seemed not to have depth on their bench, to use a sports term.
 
Maxnr said:
I question how well the remaining equipment was maintained.
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Why? Nothing I've read in the docket or in other sources indicates the aircraft were under maintained. The listed maintenance history showed discrepancy repair and inspection compliance I would expect on a 76 to include the avionics related maintenance. Having seen operators who do cut corners Island did not have those same indications.
Maxnr said:
The S-76 requires an avionix tech in addition to the standard 2.5 A&Ps for regular maint.
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Don't know your experience with mx manning but what you stated is not the norm. Most operators go by 2 engines per mechanic for full-time ops and 3-4 engines per mechanic on ad hoc ops. An avionics guy is simply a luxury item. Given Island had 6 aircraft, 3 Astars and 3 76s, that would be 4.5 mechanics for the entire fleet at full time vs 2.5 for the fleet at ad hoc. Island had 2 fulltime mechanics.

However they only performed minor routine inspections and non-routine minor repairs per their mx program with all the bigger stuff going mostly to Rotorcraft Support who also provided additional on site support. This mx setup sounds about right for an operator of Islands size and use. So unless you have some other insider info, from my experience of maintaining multiple helicopters (76s, 407s, 135s, etc) I don't see any obvious mx issues with Islands ops.
 
Ed Haywood said:
Gotta believe if Kobe were asked whether he would pay extra for an IFR capable aircraft and crew, he would say yep. Same with that billionaire who lost his daughter and a bunch of friends flying back from their private island in the Bahamas.
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You would think that would be correct but unfortunately it's quite the opposite. When the boss says go you go... or you don't have a job. So eventually they end up with a certain type of pilot who goes when they want to go. And the more money they have and the more successful they are the worse it usually gets. Plenty of accident files out there if you care to read about it in both fixed and rotor wing.
 
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Bell206 said:
Don't know your experience with mx manning but what you stated is not the norm. Most operators go by 2 engines per mechanic for full-time ops and 3-4 engines per mechanic on ad hoc ops. An avionics guy is simply a luxury item. Given Island had 6 aircraft, 3 Astars and 3 76s, that would be 4.5 mechanics for the entire fleet at full time vs 2.5 for the fleet at ad hoc. Island had 2 fulltime mechanics
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My experience w/ manning comes from my job as a Lead Pilot and base manager. Many times the Maint. Mgr and I had to put our heads together to make sure that all 18 (or sometime 22) would be able to "Jump the fence" tomorrow. We had a full time Avionics tech. Our Maint Techs/A&P's were allocated on numbers and types at field bases. Varied from week to week. Sheet metal guys were extra & sent in as req. We were authorized two and a half A&P/Techs per S-76. We always had a couple of 76's. Not counting the transients. Our tempo likely exceeded Island's.
 
Maintenance is always cheaper than buying extra aircraft to deal with a surge.
 
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