Continued VFR-into-IMC followed by spatial disorientation caused the crash of a Sikorsky S-76 helicopter that killed basketball star Kobe Bryant and eight others in January 2020, according to NTSB findings revealed at the probable cause hearing on Tuesday. Contributing to the crash were the pilot’s self-induced pressure to complete the flight and the charter company’s failure to exercise sufficient oversight of pilot aeronautical decision making and judgment, the agency concluded.
As a result of the Bryant accident, the NTSB is recommending helicopter pilots have better simulation training for inadvertent IMC encounters and that the industry adopt a multidisciplinary approach to evaluate the best technology for this type of training. It’s also recommending digital flight data recorders and cockpit voice recorders with outside views for turbine helicopters.
During a four-hour virtual hearing, the board’s investigators also found that although the weather was marginal at the time the flight departed, nothing in the current or forecast weather suggested the pilot should have canceled the trip. But investigators also determined that the charter operator, Island Express, lacked a rigorous mechanism to help pilots make alternative plans and what protocol it did have was ignored by the pilot. The board said that it was likely that self-induced pressure caused what it calls “plan continuation bias” that led the pilot to press on instead of landing and waiting for better weather.
The flight was a Part 135 on-demand charter carrying Bryant, his daughter and others from Santa Ana, to Camarillo, along the California coast to participate in a basketball tournament on Jan. 26, 2020. The weather was marginal VFR along the route when the S-76B departed and while attempting to negotiate cloud-obscured rising terrain near Calabasas, the pilot climbed into a low marine layer and entered a tightening left turn before losing control and crashing into a hillside near the 101 freeway. All nine persons aboard, including the pilot, were killed in the crash.
Investigators determined that the S-76B was properly equipped and that the pilot was well thought of and qualified and, as required, he conducted a risk assessment that concluded that the flight risk was low. According to the docket, weather along the route was better than 1000-foot ceilings with visibility greater than 3 miles. Van Nuys, northwest of the departure airport, reported 3 miles, but an amended forecast reduced that to 2 miles.
When the flight approached the Burbank Class C airspace, diminishing visibility required the pilot to request a special VFR clearance to transition. He had to orbit for 11 minutes while controllers sorted out conflicting traffic. Once cleared through Burbank and by Van Nuys, controllers informed the pilot that he was too low for further radar advisories and he continued west along the 101 freeway. According to the recorded data and witnesses, the local terrain was obscured by low cloud and a ground camera caught the aircraft skirting the bases of the layer before climbing up into it.
The investigators determined that the pilot had been trained to respond to inadvertent entry into IMC by slowing down, climbing, maintaining course and engaging the autopilot. However, he did none of these, except a rapid climb. Upon entering IMC, the pilot initiated a shallow left turn that tightened and transitioned into a rapid descent into the terrain. NTSB investigator-in-charge Bill English said, “The path of the helicopter was not consistent with commitment to the instruments.”
NTSB human factors expert Dr. Dujuan Sevillian said what flight data investigators had was consistent with a type of spatial disorientation known as “the leans” in which the inner ear’s vestibular sensing can’t distinguish between acceleration and a bank. Because of the rapid pitch, the pilot may also have experienced somatogravic illusion, which causes a pilot to mistake acceleration for a climb. Because of the low altitude, he had insufficient time and terrain clearance to recover.
San Pedro-based Island Express is a small charter company with about 25 employees and six helicopters, according to the NTSB. It’s a Part 135 operator approved for day and night VFR operation. The accident pilot was the company’s chief pilot and had 1250 hours in the S-76B and 8200 hours total time. Pilot medical or fatigue issues were not deemed factors. However, the company’s operational procedures were a factor.
Although its operations specifications called for VFR limits more conservative than those allowed by the FAA, the board found that the company lacked strong oversight of pilot decision making. When the pilot encountered lower weather than expected enroute, he was supposed to revise his risk assessment form and confer with the director of operations before proceeding. But this wasn’t done. Further, Island Express lacks a Safety Management System, a voluntary FAA-involved program intended to help operators with safety oversight. It has not been widely adopted.
During the hearing, IIC English said investigators found nothing to suggest that Island Express was an unsafe operation. NTSB Chairman Robert Sumwalt took sharp exception this: “I think you said that Island Express was a safe operation … which company had this crash? I’m seeing a disconnect here.”
English replied by saying nothing the investigators uncovered revealed that Island Express was a problem operator. “I think the concept of that question was how a consumer could detect an unsafe operator. There was nothing inherent about this operator that would indicate they were unsafe. We see crashes with other carriers that don’t indicate they are particularly unsafe,” English said.
We are so good at avoiding the elephant in the room : “Investigators determined that the S-76 was properly equipped” and all blame on the pilot. I don’t buy that. I blame the FAA and its certification policies. It’s very easy these days to get 3D terrain in the cockpit… for experimentals. Shouldn’t cost more than a few AMUs imho, in any case insignificant for anything turbine driven. But the FAA keeps enforcing Flintstone standards and self-serving hefty requirements that make progress economically insane. There is a dim light these last few years as approvals are finally forthcoming but nothing near where we ought to be. The only measure should be : “proven more reliable than what is currently installed”, a very very low bar considering the equipment installed in much of the GA and yes even airline fleets. My drone is better equipped than that S76 or a 10 yr old Gulfstream, let alone a 1960’s Bonanza. Every year there is still a vacuum pump driving a critical function on any N-reg aicraft, the head of the FAA should be fired for incompetence.
The S-76 had a 4 axis Autopilot, I don’t think your Bonanza came with one. A 4 Axis autopilot has hover capability. This accident should never have happened. Qualified Rotorcraft pilots routinely fly into instrument conditions, do instrument approaches and land safely. This pilot made a bad decision, compounded it with losing spatial orientation and it cost 9 lives. A simple IFR clearance and climb to VFR above the marine layer would have safely ended the situation. He knew the route and the terrain. I am pretty certain Island Helicopter was a ‘VFR only’ 135 operator.
You are spot on re: the FAA and it’s Flintstone Standards. Anything that helps safety should be allowed. If you can put it in an experimental you should have it in a Certified Aircraft.
Having said that, The FAA should require the same VFR/IFR rules for Helicopters. Over my 53 years of corporate flying I cannot tell you how many times I have had scary encounters with “RUDE” Helicopter pilots flying around in Fixed wing IFR conditions.
Lawyers that sue companies into non existence prevent this… not the FAA.
You should try to fly a helicopter in IFR conditions before you talk about something you know little to nothing about.
Very Interesting viewpoint. While I am not arguing about the efficiency or lack thereof of the FAA, this crash is 100% the responsibility of the pilot. To enter into Marginal VFR conditions in rising terrain is dangerous. Terrain warning equipment on a helicopter is also an interesting idea. Nevertheless, you got no business being at or below 1000 feet when the hills around you are higher, UNLESS YOU CAN SEE the terrain. Try that in any aircraft. BTW the entire time his TAWS would be screaming “terrain terrain” visual conditions or not. By definition, helicopters fly close to the terrain regularly and well below that acceptable for most other forms of flight. Why? Because we can hover and can land almost anywhere. When the pilot got to Van Nuys and asked to transition, the tower questioned why he wasn’t on a special VFR clearance, because it was already below VFR minimums for normal flights. Then after getting his code, SOCAL couldn’t see him due to terrain. The 11 minutes he waited for clearance he was hovering over a parking lot with low clouds above and rising terrain around. It was that moment when he made a climbing left hand turn INTO the clouds and impacted seconds later. As a 6000 hour commercial rated pilot who used to own and operate a heli almost daily, I agree with the NTSB conclusion, not so much with all the equipment recommendations. Very simply, the pilot had made this run probably hundreds of times and was over confident and pressed on into IFR conditions near rising terrain, costing the lives of all souls on board. How can an operator anticipate this marginal VFR day is better or worse than the last one. BTW there was no VFR traffic flying into or out of Van Nuys at the time. No police helicopters flying either. Its the answer to the oldest question in flying, “Do you want to be there when you get there?”
I think his boss having fired several pilots before him for not making the trip had a lot to do with it. I would argue in a court, the person chartering had as much to do with the bad decision as the pilot.
This is a case of the coffee being served to hot and McDonalds had to pay, not the person serving the coffee and spilled it.
I blame the pilot, with no qualms whatsoever.
It is the companies, not the FAA. They don’t want to be sued into non existence.
An experimental aircraft is ‘experimental and the person that put what ever they wanted to experiment with… is responsible for the end result.
You can go to the hardware store and use whatever they have there to put on your plane, and in the end, YOU are responsible for what happens if you crash.
That is why experimental aircraft have cool stuff. No liability tied to the company that made it.
I wonder when the NTSB will start to add the attitudes of high-power passengers to the list of causes. Initial articles published indicated that Kobe had “fired” other pilots for not getting him where he needed to be and that this pilot was his “preferred pilot”. I feel extremely bad for all of these families, don’t get me wrong. However, like the Aaliyah crash in 2001, the attitude and demands of a high-power passenger were a factor. The pilot’s decisions were causal, but the passenger was a factor.
I meant to say “list of factors” in the first sentence, not causes. I tried to edit but it won’t let me.
The threat of getting fired by High Profile clients or employers is the first thing that should cause a pilot to quit “on the spot”. I have been the sacrificial lamb in this case more than once. I like living too much to have cratered to a moron High Profile boss.
A subject that is rarely taught in any aviation related training, dealing with “high profile” or celebrity types who pressure crews to do things they know better. I have been lucky enough to fly for companies that do a good job at screening out these type of clients. As one chief pilot told me that is his job. My current company has such a long waiting list of prospective clients, they can afford to. It is also a skill to know how to say unable to a client without being confrontational or getting fired. Not a lot of pilots have this skill, a lot of time this is gained through experience!
I had to say ‘no’ to my boss before. This was when I was with the FAA. They understood the aircraft flying part when I said, ‘NO’… but when I said no to certifying a ground air traffic control radar system I was hung out to dry and punished, eventually losing my job and my livelihood.
Yes, I was homeless once for saying ‘NO’ when I thought it wasn’t safe. Even when to jail because I couldn’t pay the demanded child support…
And this was the FAA.
So, yes, this pilot was in a horrible position.
You need better lawyers.
When you have no money… you get what you get. Yes, I was told I should have won my cases. I didn’t see anyone jumping to take my case, not like you can advertise. These were cases I had to fight from another state, because I couldn’t afford to live where I was living anymore… then it got really interesting. The federal government AUSA, over my whistle blower case (defending the governments actions) told me to settle or they would put me in prison, because I couldn’t pay for support owed in another state.
Yes, life isn’t fare. This was almost 20 years ago. I never really recovered from it.
I’ve seen many people loose everything for saying ‘NO’, I’m one of them.
You would think there would be a law to protect the pilot (or anyone else for that matter when lives are at stake) when they say, ‘NO’ that is not safe’. I was supposed to be protected by law… and you see how that worked out for me. The so called ‘system’ really doesn’t work from first hand experience.
Good lawyer… I have yet to see one of those pink unicorns.
The aircraft didn’t need another device of any type to have easily avoided the accident. It was all on the pilot. He had tons of experience both as a pilot in the type copter and lots of experience flying the L.A. basin area. He was totally familiar with the weather. He was given visual routing by the controllers, routing given helicopters on a regular basis. He was obviously very familiar with what they issue , accepting it without question, probably having flown those visual routings many times. He just used poor, poor judgement. More regulations would not have changed that for a moment. He was scud running. Frank Talman, who’s credentials also fit those of the copter pilot, in fact probably even more experienced, did exactly the same thing in his Aztec when he was scud running and flew into the mountains east of L.A. As pilots we are expected to use good judgement. That can’t be legislated.
And, as mentioned by the NTSB, because helicopters have such excellent maneuvering ability, they are permitted to operate at lower altitudes and in reduced VFR visibility that fixed wings can’t. He could have slowed down, stopped, hovered, landed off airport, anything to study the weather ahead. He apparently though headed into it at cruise speed.
Classic pilot error. Nothing the FAA could do to a pilot that brakes the rules. Even if the FAA required TAWS you are still not supposed to fly IMC in a VFR aircraft on a VFR flight, and it does not help prevent vertigo. Who knows, having a TAWS requirement may emboldened pilots to brake the rules more, leading to more accidents.
Beating on any agency, operator or individual is not productive. I encourage everyone to look at the certification standards for Private and Commercial for fixed wing and then rotorcraft side by side. There is no instrument training or practical testing at the Private level for Rotorcraft. There is 5 hours training at the Commercial level but no practical testing on Rotorcraft. Yet the VFR requirements have always been lower for Rotorcraft. Under 135 there is only a requirement for training and testing if the operator is approved for IFR operations. Very few rotorcraft are certified for IFR. Historically the need for IFR has not been there and it does kill the utility of rotorcraft to fly IFR as there is really no infrastructure to support it increasing flight times dramatically when forced into fixed wing route structures.
A great alternate route would have been to fly towards Catalina then go north on the airway just past the Class B airspace. No terrain, no traffic, no altitude restrictions. Two engines and they flew to Catalina regularly. Stay on top to destination then find an area to descend.
Good point about requiring some IMC training for a private helicopter rating. But, that would not have helped in this situation as the pilot had the training. Beating up on the individual (pilot) is productive, his poor judgment killed 8 people.
Regardless of what the company’s or 135 rules require, when encountering IMC, the pilot must revert to flying the instruments. That’s basic. Pretty clearly, this pilot didn’t do that. Loss of control is inevitable, when the pilot relies instead on physiological “feelings” and/or glimpses outside the cockpit. As pilots, we can’t allow external pressures to complete a flight get in the way of basics.
The weather was IFR at Burbank yet company ops specs required it to be VFR (or better). Very simple decision if one has the right mindset. He should have punched the 180 button (assuming it was safe to go back), or at least have landed at Burbank. He flew through controlled airspace at KBUR knowing very well that he was breaking his ops specs rules. The same rules that were designed to keep his passengers safe. It’s one thing to get caught in un-forecast low vis then land, and an entirely different issue to continue in those conditions. Bad pilot decisions and terrible to non-existent company supervision. Off course the company was unsafe!
He did punch the 180 button… but he was already in the clouds. Wrong time to make that choice. It only makes things far worse if you try a 180 when you first enter IIMC.
Fly straight (because you should have an idea of what is in front of you) with a slow climb (so you don’t hit the ground) when you feel in control on instruments, 7700 goes in the box (so you don’t hit something in the air).
Controllers will move every away from you. Don’t call for clearance. This isn’t a planned instrument flight. Don’t think they haven’t noticed you are scud running, and you think you can get away with it. The only thing you need to get away with is your life. The controllers need to know there is a problem, and 7700 sets off that alarm to them.
Actually, that’s probably not correct. The turn he was in was almost certainly unintended and the result of a spatial-D. This is a common scenario in this type of accident and it’s very often an uncommanded descending left turn. His training called for climb straight ahead and engage the AP.
I echo what Roger A states above…
This wasn’t a case of “Inadvertent IFR”; this was a case of “Advertent IFR”: any time you’re mucking around in reduced visibility, there’s always a possibility that you could lose all visual reference. Especially in fog. (Been there; done that)
There’s a saying in the rotary wing world: “When you go down, you slow down”. I think that’s the main error here: the pilot did not manage his speed to compensate for his visual conditions; had he done so, it is possible he could have “winkled” through to destination. (Maybe not a smart thing to do, but in a situation where it’s an absolute necessity…) At a minimum, there would have been sufficient reaction time to land or do a “one eighty” and return to better conditions.
If you’re going to ‘muck about’ in low viz conditions, you have to have a plan – something in your hip pocket on which to rely.
Something like: Upon losing visual reference;
Go on the dials
Note your heading
Note the reciprocal and commence a level turn toward the low ground
Maintain altitude
Fly back to better conditions
Now, if you’re surrounded by hills as in the Kobe accident, you better have intimate knowledge of the lay of the land or be equipped with synthetic vision. (A real boon, BTW)
Given the general area of operations and historical weather conditions, I can’t believe that this was the pilot’s first encounter with reduced visibility operations; why he didn’t slow down will always remain a mystery.
(I post as a dual qualified pilot: rotary- and fixed-wing)
I have a different question. The pilot was told that he was to low for radar advisories.
When is ATC going to start using ADS-B real time?
ADS-B as it is called now was turned down by both the FAA and the DOD when I suggested this system of aircraft tracking in 1989. I was a radar, communication (sea, land, and satellite) and navigation tech that liked to fly search and rescue for the CAP and realized using the GPS how accurate this type system of aircraft tracking was over the ATC radar I maintained.
The problem has always been the fear of a single point of break down, jammed GPS signal. It is a handy side safety system that has no real back up. They are warming up to it now with numerous ground stations that can augment the satellites.
It still isn’t quite there yet, but once the ground stems are in place that can be ‘boosted’ they will likely move to it.
I think that a relatively cheap INS could be integrated, and periodically updated by the GPS signal, and used for “rough” navigation if the GPS signal wasn’t available. I say “rough” nav, as today’s sensors would be pretty good at putting you in position compared to what was used for nav the previous generation.
Bottom line: Nothing new here. Just another “use it wrong & face the consequences.”
This was an instrument rated pilot in a single pilot instrument equipped and certified helicopter complete with 4 axis autopilot. So, yes, it could have easily flown in this weather on instruments by this pilot safely.
However, the 135 operation was certified for VFR only. This had to play a roll in his decision not to go to the instruments. He flys these for a living, is the chief pilot, and knows the regulations. Many years ago, and even recently when questioning other newer pilots and student pilots, I ask the question; What should you do if you inadvertently fly into the clouds. They all replied “I’ll go to the instruments and do a 180”. This is a very bad idea. Instrument pilots set up their air craft equipment and prepare mentally for an instrument flight. Cruising low below scud is no place to set up instruments while single pilot in a helicopter. His head was out the window until it was too late.
The FAA use to have a Vertigo machine, that would force pilots to make movements that would bring on spatial disorientation. It is more disabling then blowing a 2.0 on a breathalyzer.
The hairs in your inner ear that let you know everything is level get screwed up even worse when you turn your head while turning the aircraft. Before going into the clouds this guys head was on a swivel looking outside the aircraft.when he went into the clouds he did what everyone I’ve asked said they would do… turn… do a 180… It is exactly what brings on spatial disorientation.
Low with instruments not set, and his head outside… he was set up to fail. Sad.
Don’t turn if this happens to you, climb out straight and as level as you can. Once you feel comfortable on the instruments… 7700. This is an emergency 🆘
You should have had an idea of what is in front of you before you went IIMC, climb out straight so you have some idea of where you are. If you do a 180, you will not pop out of the clouds where you went in. Don’t even try it. It has killed many pilots.
It is too bad we do not know the discussion between the pilot and the pax regarding get-there-itis. I am sure there was some, maybe convincing the pilot he could make it ontime.
A shame it happened but ultimately, most accidents are operator error.
~john
They were going to a basket ball game for the kids. This was supposed to be a fun ride to the shore along Ventura Highway. But turned into the only way they could arrive on time for the game.
I wonder who was sitting up front? Could they have helped?
Plowing head long into the clouds is not the time to set up instruments for IFR flight, even if rated and with 20,000 hrs… especially in a helicopter.
I thought I saw in one of the early stories that the pilot WAS instrument rated in helicopters, but the company was not allowed to fly IFR. I checked the airman registry, and Ara Zobayan holds an Instrument Helicopter rating. But if you don’t fly IFR regularly…
Yes, he was IFR rated and the aircraft was IFR, but he was flying low with his head out the window and head on a swivel… single pilot helicopter… low, he had his hand on the collective and the cyclic. No time or extra hands to set up the instruments.
Doesn’t matter if you have 100,000 hours on instruments in that aircraft. The decision to turn instead of go straight and climb, killed him. Spatial disorientation comes on very fast. If you remember getting drunk as a kid and puking… yea, that’s the feeling. Imagine trying to fly a helicopter like that.
I was real good at finding crashes when I flew SAR for the CAP, because I studied what pilots did before they crashed so much, I knew where to find the wreckage.
As helicopter pilots we are trained to do the four Cs when IIMC. Control, Climb, Course, Communicate. Sounds like he skipped the first C, Control and went to what his body was telling him was a Climb and then skipped Course and Communicated he was climbing.
About the time of the accident I had just started flying again to get my CFII reinstated after many years away, so many of the issues discussed here are relevant, especially from a teaching perspective. The one thing no one ever seems to discuss with regard to this tragedy is the true (to me anyway) elephant in the room: there was no need to fly a helicopter from KSNA, available rwy length 5700 ft to KCMA, available rwy length 6000 ft. There are no less than four instrument approaches into Camarillo (including a GPS LPV) and they are routine for airplane pilots. There was simply no requirement for a helicopter on this flight, helicopters generally being required when there is no runway to land on. Maybe it is easy to say in hindsight, but a responsible pilot would have referred this flight to a 135 operation using airplanes, e.g Gulfstreams, King Airs, etc. As stated by others, there is an irresistible urge to not turn away work. Money was not a consideration for Kobe Bryant, getting there safely was. You can use a snorkel tube to work underwater but a scuba tank does a much better job. Aside from the obvious, i.e. a pilot used to VFR flying into IMC, the even more obvious was that there was no immediate need to use a helicopter for a what is a routine airplane operation. You can look at this and see the cascading number of mistakes made that led to a disaster, but the biggest mistake was choosing the wrong equipment for the job. With reference to aeronautical decision making, this was the biggest mistake of all. Mr. Bryant was not trained to make this decision but his pilot was and should have done so.