At its final press conference briefing in the Kobe Bryant fatal helicopter crash last week, the NTSB’s Jennifer Homendy reminded reporters that the FAA failed to act on two safety recommendations that would have required Terrain Awareness and Warning Systems (TAWs) and both flight data and cockpit voice recorders for aircraft above a certain size. Those recommendations were made in 2004 and 2005, but Homendy said the NTSB closed them as unacceptable after the FAA failed to act. TAWs is mandatory for air ambulance flights.
Late last week, the NTSB turned the crash site over to local law enforcement and safety agencies, but it continues its investigation into the Jan. 26, 2020, Sikorsky S-76B crash that killed former Los Angeles Lakers star Bryant, his daughter and seven others. The group was enroute from Santa Ana to Camarillo, California, to take part in basketball practice. The weather at the time was marginal VFR and the terrain at the crash site had been obscured by low visibility.
Investigators say they don’t know what terrain data pilot Ara Zobayan had available, but they confirmed that the aircraft was not equipped with TAWs. Zobayan did have an iPad with ForeFlight and although an iPad was recovered, it’s not known if it was Zobayan’s. The iPad and a recovered cellphone have been sent to the NTSB’s lab for examination.
When Homendy was asked if information gathered thus far sheds any light on the pilot’s decision making, she said, “That’s a difficult part of the investigation. And we look at the facts. And that’s what we’re focused on. We can’t make any assumptions about what someone is thinking,” she said.
While TAWs came up as a discussion point, the NTSB’s investigator in charge, Bill English, said no assumptions are being made about equipment. “We don’t have a conclusion that TAWs and this scenario are related to each other,” he told reporters during the press conference.
Investigators say the pilot appeared to be trying to climb, either out of the weather or away from terrain. But the aircraft eventually crashed at high speed in a left descending turn. Although the site was 20 or 30 feet below the top of the hill it impacted, English said the terrain was in an undulating ravine.
Homendy didn’t say if the NTSB would revisit its prior recommendations, but she did review the history. Following the crash of an S-76 in Galveston, Texas, that killed 10, Homendy said, “We issued a recommendation that stated: Require all existing and new U.S.-registered turbine-powered rotorcraft certificated for six or more passengers to be equipped with TAWs.” The FAA declined to pursue rulemaking. “In 2014, we closed the recommendation as unacceptable,” Homendy said.
In 2005, the NTSB assisted in another high-fatality crash into the Baltic Sea off Estonia. The S-76T crash killed 12 of 14 aboard.
“We issued a recommendation to require all rotorcraft operating under Parts 91 and 135 to be equipped with a CVR and FDR. The FAA failed to implement that recommendation. So we closed that as unacceptable,” Homendy said.
She said the NTSB will issue a preliminary report sometime this week or next and a final report, possibly with recommendations, in a year to 18 months.
CVR’s only capture the last words.
The last words are always the same; “Oh Sh****”
How does that increase safety?
From: NTSB
To: FAA
Date: 8/30/1982
Response: The board does not accept your assumption that cvr benefits accrue where safety improvements arise from accidents in which cause/factordata were obtainable from no source other than the cvr. We have never considered the information obtained from the cvr in isolation, but have used it primarily as a tool in uncovering (sometimes) subtle clues to assist us in determining probable cause and in making recommendations for preventing future accidents. More often than not, the raw cvr data has (1)provided extremely valuable clues to the cause, (2) allowed more rapid dissemination of safety information to operators, (3) established the sequence of events in the cockpit and the timing of critical events, and (4) in conjunction with the fdr, provided the basis for aircraft perform- ance analysis which, in turn, either uncovers or corroborates the probable cause and contributes to safety recommendations to prevent future accidents. . . . . Because of the factors discussed above, the safety board does not accept the faa’s cost benefit analysis as demonstrating that its recommendation is not feasible. We are, therefore, classifying recommenda-tion a-78-29 as closed–unacceptable action.
Telemetry makes more sense for crash analysis. 1) First off, you don’t have to try and find a CVR buried somewhere in the rubble, and then pray that it survived. 2) Secondly, pilots are not a primary source of good information because what people say is not always what they are thinking or doing. 3) Telemetry is already proven in the space program; it keeps providing data even after a crew is incapacitated.
I can’t endorse real-time surveillance of every flight in the skies.
Cockpit voice telemetry? No, thanks.
I can’t endorse a lot of laws that were enacted in the name of “safety”.
Telemetry is a lot easier to capture real-time from a vehicle that is always* within line-of-sight of a ground-based (or space-based) receiver. Aircraft may not always be within line-of-sight, and even if it is, there may be situations where it can’t transmit, so an on-board collector is needed. Even the space program used on-board recorders.
* Yes, until NASA implemented the space-based communication system (TDRS) there were still gaps in coverage, but the space vehicle was always above any obstructions to LOS communication. It was only the lack of coverage on a spherical body that caused the signal gaps.
Thank you Raf for your service to this community by posting this 1982 NTSB reply to the FAA. It’s slightly horrifying and very embarrassing that anyone who reads the same forums I do needs to have the value of CVRs and FDRs explained. Let’s assume this needn’t have been done for any of the flying professionals among us. Please?
I agree John, I rarely read these posts for just that reason. Internet surfing pilots. They are all accident reconstruction experts.
YARS said:
> I can’t endorse real-time surveillance of every flight in the skies.
We already have it, it is called ADS-B. It has already provided lots of information about this flight (yes, it was ADS-B equipped) that would have otherwise been unavailable before. That is, second by second position, direction, speed. This will be instrumental in the final accident analysis.
ADS-B will revolutionize accident investigation (by providing detailed flight path data and even details such as autopilot selections and settings) and search and rescue operations (by providing bread crumbs to the accident site). ELTs are worthless and the FAA should eliminate the requirement to carry one if you have 1090ES ADS-B equipment.
As for TAWS, that is a red herring. The rapid roll over and descent was not due to unawareness of terrain, but due most likely to spatial disorientation in cloud. TAWS doesn’t change that. TAWS also doesn’t work in many cases. Read about Flying Tiger Line 66, the pilot flew calmly right into a mountain with the TAWS yelling at them.
As for CVR/FDR, they don’t prevents a crash, and they won’t add a lot for a spatial disorientation event like this one seems to be. The FAA makes the standards for CVR/FDR so high and so costly that everybody fights having them. So their own rules make it LESS safe because they won’t accept a lesser standard for the devices. Indeed, the NTSB often gets FAR better data from consumer devices like the iPad or portable GPS units than they do from certified expensive black boxes. The FAA is sometimes negative safety and this is such a case.
Mike C.
ELTs can be removed from the aircraft and taken with the occupants to another location (assuming they survive the crash). I support the continued requirement for an ELT (they aren’t that expensive compared to some other mandated equipment).
I would estimate that the dollars that will be spent on this tragedy could equip (with TAWS and CVR) the balance of the helo fleet not already equipped. Not saying that CVR or TAWS would have prevented this accident, but the total cost, when done, will be mind blowing. One of the hidden costs, of the total cost, will be new regulations; such as no more special VFR for helo’s etc….. and yes mandatory CVR and TAWS for 6 pax+ turbine 91/135 helo’s. And then the NTSB will remind us that they have recommended cameras in cockpits too…. …
I don’t get a warm, “fuzzy” from this inspector’s comments. She must be “the” appointed NTSB spokesman because she doesn’t know anything about aviation and they want her out of the way. The only thing that would have saved this flight is if the pilot stayed home.
> …the NTSB’s Jennifer Homendy reminded reporters that the FAA failed to act on two safety recommendations that would have required Terrain Awareness and Warning Systems (TAWs)…
How would TAWS have helped? TAWS warns a pilot when they are flying near terrain. This pilot deliberately flew into a canyon. TAWS alerts telling this pilot something he already knew would have been distracting, not helpful.
> …the NTSB’s investigator in charge, Bill English, said no assumptions are being made about equipment. “We don’t have a conclusion that TAWs and this scenario are related to each other,” he told reporters during the press conference.
Exactly. So why the hell even mention it? All Ms. Homendy has done is stoke ignorant media interest in finding “the culprit.”
I suspect that the pilot may very well already have been disoriented when he flew into the canyon and I also suspect a voice recorder may — in this case — been revealing. That said, I am not in favor of the latter.
There is another angle here — which is definitely less glamorous to the general media than embedding technology in the cockpit. And that is certification and training and best practices. From what I have heard, Island Express was certified for Part 135 VFR helicopter only. Which could mean — having looked at the regs: 1) helos were not adequately IFR equipped (tho this one could have been) 2) pilots were not necessarily current IFR (or should I say comfortably current) and 3) operator limitations/guidelines about operating in Special VFR that added a safety margin to these operations.
but maybe should be considered
I’m in agreement with all you say here, Barbara. My additional thought is; why does the FAA issue VFR only certificates for charter ops?
In the wonderful world of aviation, human errors contribute more to incidents and accidents than any other factor. Be it from regulators, management, product designers, aircraft or avionics factory workers, mechanics, air traffic controllers, ground or flight crews. Throw in more training, another “safety” piece of equipment, separate wire bundles, reinforce vertical stabs, limit rudder controls, and don’t forget the MAX and the British Comet and the A300. In a perfect world, the goal post keeps moving. It’s complicated. But, we keep a-goin!
Investigators say the pilot appeared to be trying to climb, either out of the weather or away from terrain. The aircraft crashed at high speed in a left descending turn.
Huh??
TAWS is a bit silly. If you are unable to not see and avoid a planet, you should not be in the left seat.