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

hey everyone a little over a year ago we reported on the helicopter crash that killed basketball great kobe bryant this week the national transportation safety board held its probable cause hearing and to no one's surprise the board said the crash was caused by the pilot flying vfr and imc that's visual flight into instrument weather conditions in case you're not familiar contributing to the accident was the pilot's self-imposed pressure to get bryant and his companions to their destination but the board members had a lot of fine point discussion about the wording on that particular finding because you could never know what's inside a pilot's head especially one who's no longer among the living the ntsb also found that the charter company island express didn't have a rigorous method to help pilots make alternate plans when things went south as they definitely did on this flight from the ntsb hearing it's obvious that there were two interwoven threads in this accident one was kind of a slow-motion train wreck involving continuing assessment of deteriorating weather this unfolded over many minutes the second was a snap split second action that led to fatal loss of control let's start with the refresher brian had hired island express to fly in from santa ana california to camarillo to the northwest that's 65 nautical miles and 35 or 40 minutes in the helicopter but a two-hour drive in freeway traffic at least brian and his daughter along with six others were to attend a basketball tournament the weather wasn't great but it wasn't horrible either at least not for a helicopter the entire route was blanketed by a marine layer of the sort typical of california ceilings were in the 1000 to 1600 foot range with visibility three to four miles except van nuys was down to two and a half miles there were air mats for ifr conditions and mountain observation tops of the overcast were flat and smooth at 2400 to 2500 feet that's also typical of a marine layer it's unknown if a pilot could have maintained consistent ground contact when he elected to climb up through the layer but it's unlikely ion express was approved to fly on demand charter day and night vfr only it was not approved for ifr flights the pilot was experienced well rested and qualified for the flight here's a look at that from ntsb's fabian salazar the pilot was certificated current and qualified to fly in visual flight rules in accordance with federal regulations and company requirements he had about 8 57 hours flying experience which included about 1 250 hours in the sikorsky s-76 series helicopter and about 75 hours of instrument flying time there was no evidence of any pre-existing medical conditions and no evidence of acute or chronic sleep loss after gaining employment with island express the pilot completed all required company training including sikorsky s 76 ground and flight training which contained modules for aeronautical decision making and judgment instrument procedures unusual attitude flight procedures for recovering from inadvertent entry into instrument meteorological conditions and spatial disorientation as the chief pilot he held the responsibility of supervising and training all island express pilots upon advancement to czech airman he gained the additional responsibility of evaluating sikorsky s76 pilots during their annual proficiency and line checks given the aircraft the pilot in the weather ntsb chairman robert sumwalt asked the investigator in charge that's bill english if the pilot's decision to launch was appropriate was it an appropriate decision to begin that flight mr chairman um with even with the hindsight that we have of the weather conditions um and knowing what was available to the pilot we don't see that this the weather conditions were such that should have necessarily affected the initiation of the flight having said that your point about the error chain is exactly correct um as far as in-flight aeronautical decision-making as things cropped up along the flight that were indicating that things were not as good as maybe they would have hoped um that that should have started the aeronautical decision-making process going that um and and to make a different plan but uh there's nothing there that should have said no go so if the pilot was justified in starting the trip where did he go wrong as he was required to do he filled out a flight risk assessment form assigning points to all the potential hazards the pilot determined and the ntsb agreed after the fact that the risk level was low at the time he departed however investigators found that as the weather deteriorated the pilot didn't update his risk form if he had it would have required him to have an alternate plan in mind it says so right here on the form he was also supposed to consult with the operations director if the ceilings were below 500 feet which he also didn't do as the trip progressed he could have landed at van nuys return to home base or even landed at any suitable parking lot or field helicopters are allowed to do that and the faa's helicopter safety team encourages it and even has a term for it land and live not having a plan b in mind ahead of the fact the pilot's favorite choice was to continue to the destination camarillo the ntsb calls this kind of tunnel vision planned continuation bias but in general aviation we have a more colorful term for it get home itis continuing westbound past van nuys the pilot followed the 101 freeway and when he encountered lowering clouds where the highway cuts through rising terrain he had first descended then apparently realized this wouldn't work he then informed atc that he was climbing and this is where the fatal split second decision occurred as all five or higher pilots are the pilot had been trained to react correctly to an inadvertent flight into instrument conditions here's the ntsb's fabian salazar explaining what's involved the company's faa principal operations inspector and the outside training vendor used similar standards for evaluating pilots performing actions after inadvertently entering instrument conditions while wearing a view limiting device and referencing the helicopter's instruments the pilot was to level the fuselage and pitch and roll maintain the current heading turning only to avoid known obstacles apply climb power of 70 to 75 percent and adjust the pitch attitude to attain a climb air speed of 75 to 80 knots after these steps were accomplished the aircraft would be in a stabilized climb and the pilot would then contact air traffic control declare an emergency announce instrument conditions and request vectors to visual flight rules or if those conditions were unattainable request a precision instrument approach to an airport but there's a wider doctrine here that calls for slowing down leveling the aircraft and engaging the autopilot to reduce the workload to tamp things down while the pilot resets and the s76b has a good autopilot a honeywell 4-axis design that's more than capable of controlling the aircraft safely and is even approved for ifr flight but the pilot maintained his 140 knot crew speed and apparently tried to hand fly out of a spatial disorientation episode and he clearly had not anticipated the difficulty he would encounter the moment he decided to climb into the clag i'm sure you've heard enough about spatial d to teach the master class yourself but here's the ntsb's human factors expert dewan civilian with a summary of what brian's pilot probably encountered the inner ear senses balance and orientation when flying an aircraft and there's a lack of outside visual references our inner ear can give us a false sense of orientation because our inner ear cannot distinguish between accelerations and tilt if a pilot cannot see outside visual references he must rely on flight instruments when there are no outside visual references the pilot is more susceptible to inner ear illusions one common illusion that can trick a pilot's perception into believing he is flying straight and level but he is a steady turn is called the leans during the climb in imc the helicopter entered a steady left turn conducive for the pilot to experience the leans the vestibular system will usually detect initial rolling and turning movement however once the aircraft is stabilized in a steady rate of turn and angle of bank the vestibular system will catch up with the aircraft and the pilot can believe that the aircraft is straight and level when it is not as the helicopter climbed the air traffic controller asked the pilot to ident which required the pilot to move his hand to the center of the instrument panel and press a button the pilot's tasks associated with communicating with the controller and pushing the ident button introduced operational distractions from his primary task of monitoring the flight instruments the resultant interruptions in the pilot's instrument scan head and hand movements would make him more vulnerable to misleading vestibular cues that could adversely affect his ability to effectively interpret the instruments and maintain control of the helicopter helicopter was in a left bank rapid climb its bank increased and it entered a tighter left turn that diverged away from us 101 the increasing bank would exacerbate the aspects of the liens the resultant descent and acceleration were conducive for the pilot to experience a somatographic illusion in which he would incorrectly perceive that the helicopter was climbing when it was descending as the helicopter continue its steep descent the pilot was either not referencing the helicopter's instruments or having difficulty interpreting or believing them due to the compelling vestibular illusions and he did not successfully recover the helicopter this is a common accident scenario for helicopters especially medical emergency services or hems missions many of these crashes terminate with loss of control out of a rapidly descending left turn between 2010 and 2019 20 helicopters crashed under similar circumstances here's why it's so difficult to recover from an inadvertent imc encounter in a helicopter did not have a lot of hard actual instrument time can you explain and you're you're a very experienced helicopter pilot i know we don't like to think about ourselves but how many hours do you have in helicopters about 6 500 sir i'd say that's pretty darn experienced and um so can you describe what it just flying under the hood if you will with a view restricting device how would that be different than just flying along and all of a sudden entering clouds somewhat unexpectedly how would that that differ for a pilot's performance video limiting devices are are good training aids for flying instruments but they do have they do give the pilot the ability to look around them and as it's stated you know one peak is worth a thousand cross checks um going uh to flying actual instruments there's there's no um cheating the system by looking over a set of view limiting devices you're committed to the instrument conditions which forces you to commit to the actual flight instruments thank you and would you uh say that there would you agree that there might be somewhat of an element of surprise if you're flying under a view limiting device then you've had time to acclimate to your instrument scan versus if you're flying visually and all of a sudden you encounter uh instrument conditions could there be somewhat of a element of surprise associated with that which would potentially also affect your performance yes sir uh being prepared for the instrument conditions is part of the secret to success of flying instruments when it's a surprise and you're unprepared for it is when the unfortunate bad things happen the ntsb determined that the pilot's self-induced pressure to complete the trip was a factor because he had flown bryant many times and the two were friends but during the meeting the board members spent quite a bit of time finessing the language on this finding board member tom chapman argued that without interrogating the pirate it was speculative to say that his friendship with brian pressured him into making bad decisions the investigators were however satisfied that the charter company did not pressure the pilot to complete the trip against his judgment further although island express was faulted for lack of pilot oversight and it lacked the safety management system the faa has been encouraging operators to adopt there was no evidence that it was a shoddy operator a crater looking for a grid reference if you will and tsb chairman sumwall however took exception to the investigation staff's conclusion on this count mr english i want to come back to something that was said um before the break i'm sorry in my last line of questioning you had indicated that i think you said that island express was a safe operation is is that am i paraphrasing that correctly um i would say there wouldn't be anything any indication that island express was uniquely unsafe or a problem operator which company had this crash mr english well island express of course so i'm seeing a uh a disconnect here um what are your thoughts on that i mean this company had a crash and you're saying there's nothing to indicate that they were not safe well you asked i think this the concept of that questioning was how a consumer could you know detect an unsafe operator and there's there was nothing inherent about this this operator that would that would indicate they were unsafe i mean i i think we see we see crashes with other carriers and don't particularly indicate that they are unsafe but they've had a gap they've had a flaw perhaps they didn't know know any better but that doesn't necessarily make them a problem operator they just need to do some things differently or know something differently from the comfort of our armchairs it's easy to find fault with the pilot because well his actions and lack of actions were the cause of this accident still he was well regarded at the company and had a reputation for being willing to cancel flights when warranted investigator english allowed us how this accident is another example of good pilots making bad decisions something that happens every day board chairman somewhat used another term i never heard before and and i think that's a lesson right there is that we all are subjected to the term i was told years ago was sludge s-l-o-j s-l-o-j sudden loss of judgment and here's a case where a pilot who's well regarded apparently got into a very bad situation so let me see if i understand this so is basically the scenario that we believe happened is that he's flying along he realizes that he's sort of getting boxed in with visibility and then he must have made the decision you know what i'm just going to punch up through these clouds and get on top is that is that basically the scenario that we believe happened i i think that i think that's correct and i and i hardly agree with your your statement that you know this is a good good people can make a bad decision and we really want to get to the bottom of why to keep it from happening again as a result of this accident the ntsb is recommending better simulation training for helicopter pilots who encounter inadvertent imc and they're asking the industry to conduct research on which technology would work best for this the agency is also asking the faa to require all-term and commercial helicopters to have digital flight data recorders and cockpit voice recorders with an outside camera view these would aid in accident investigations and could be analyzed routinely to see how pilots are performing yeah it's a snitch of sorts pilots don't necessarily like that idea but we should all like the idea of crashing into hillsides a lot less for atweb i'm paul bertorelli reporting thanks for watching

Channel: AVweb

Views: 159,308

Rating: 4.9270144 out of 5

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Id: 0MbBmJ-X66c

Length: 17min 34sec (1054 seconds)

Published: Wed Feb 10 2021