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

Hello 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 accident was

caused

by the pilot flying VFR and imc, that's visual flying in weather conditions by instruments, in case you're not familiar, what contributed to the accident was the pilot's self-imposed pressure to get Bryant and his companions to their destination, but board members had many discussions over the fine points about wording. That particular finding because you can never know what's inside a pilot's head, especially one who is no longer among the living, the NTSB also found that the charter company Island Express did not have a rigorous method of helping pilots. to make alternative plans when things went

wrong

. i definitely did on this flight from the ntsb hearing, it is obvious that there were two intertwined threads in this accident, one was a sort of slow motion train wreck involving a continuous assessment of the deteriorating weather, this unfolded over many minutes, the

second

was an instantaneous

split

-

second

action that

caused

a

fatal

loss of control, let's start with the refresher Brian had booked on Island Express to fly from Santa Ana, California to Camarillo, northwest, that's 65 nautical miles and 35 or 40 minutes by helicopter, but a two hour trip in highway traffic to at least brian and his daughter along with six other people were going 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 covered by a marine layer of the type typical of california roofs were in the range of 1000 to 1600 feet with visibility of three to four miles, except that Van Nuys was reduced to two miles and On average, there were air mats for IFR conditions and the observation tops of the cloud mountains were flat and smooth at 2400 to 2500 feet, that is also typical of a marine layer, it is unknown if a pilot could have maintained constant contact with the ground when it chose to climb through the layer, but it's unlikely that ion express was approved for flying on demand, day and night, it just wasn't approved for IFR flights.

The pilot was experienced, well rested, and qualified for the flight. Here's a look from Fabián Salazar of ntsb. The pilot had a current certification and was qualified to fly in visual flight rules in accordance with federal regulations and company requirements. He had about 8 57 hours of flying experience that he included. approximately 1,250 hours in the sikorsky s-76 series helicopter and approximately 75 hours of instrument flying there was no evidence of any pre-existing medical conditions and no evidence of acute or chronic sleep loss after obtaining employment with Island Express the pilot completed all It 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 to recover from inadvertent entry into meteorological conditions. instruments and spatial disorientation, as lead pilot he had the responsibility of supervising and training.

All Island Express pilots upon promotion to Czech aviator 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 lead investigator bill english if the pilot's

decision

. Was the launch appropriate? Was it an appropriate decision to begin that flight, Mr. President? Even with the hindsight we have of the weather conditions and knowing what was available to the pilot, we do not see that the weather conditions were such that it should necessarily have affected the start of the flight, having said that your point about the chain of errors is exactly right, as far as in-flight aeronautical decision making goes, as things came up throughout the flight that indicated things weren't as good as they might have been.

They would have hoped that should have started the aeronautical decision making process and made a different plan, but there is nothing there that should have said no, so if the pilot was justified in starting the trip, where did he do it? went

wrong

as required, he filled out a flight risk assessment form assigning points to all potential hazards that the pilot determined and the ntsb agreed after the fact that the risk level was low at the time of his departure However, researchers found that as the climate deteriorated. The pilot did not update his risk form. If he had done so, he would have required that he have an alternative plan in mind.

He says it right here on the form. He was also supposed to check with the director of operations if the maximum limits were below 500 feet, which he also did not do. As the trip progressed, he could have landed in Van Nuys, returned to home base, or even landed in any suitable parking lot or field. Helicopters can do it and the FAA helicopter safety team encourages it and even has a term for landing and living without having a plan b in mind before the pilot's favorite choice was to continue to the destination camarillo the ntsb calls this type of tunnel vision planned continuation bias, but in general aviation we have a more colorful term to get home is to continue west past van nuys, the pilot followed Highway 101 and when he encountered descending clouds where the highway crosses a high ground, he had first descended and then apparently realized that this would not work, he then informed the atc that he was climbing and This is where the

fatal

decision occurred in a

split

second, as the five or so pilots were trained to react correctly in the event of inadvertent flight under instrument conditions.

Here's Fabian Salazar from the NTSB explaining what's involved with the company's chief FAA operations inspector and third-party training provider. used similar standards to evaluate pilots performing actions after inadvertently entering instrument conditions while wearing a vision-limiting device and referencing the helicopter's instruments, the pilot was required to level the fuselage and pitch and roll maintain current heading turn only to avoid known obstacles apply a climb power of 70 to 75 percent and adjust the pitch attitude to achieve a climb speed of 75 to 80 knots. After these steps were completed, the aircraft would be in a stabilized climb and the 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 are unattainable request a precision instrument approach to an airport, but there is a broader doctrine here that requires reducing speed, leveling the aircraft and activating the autopilot to reduce the workload to tamp things down while the pilot resets and the The s76b has a good autopilot, a 4-axis Honeywell design that is more than capable of controlling the plane safely and is even approved for IFR flight, but the pilot kept the his crew speed of 140 knots and apparently attempted to manually fly his way out of an episode of spatial disorientation and clearly had not anticipated the difficulty he would encounter at the time he decided to board the clag.

I'm sure you've heard enough about space d to teach the master class yourself, but here's ntsb human factors expert dewan civil with a summary of what brian's pilot probably found that the inner ear detects balance and orientation when flying an airplane and there is a lack of external visual references. Our inner ear can give us a false sense of direction because our inner ear cannot distinguish between accelerations and pitch if a pilot cannot see outside. Visual references must rely on flight instruments when there are no external visual references the pilot is more susceptible to inner ear illusions a common illusion that can trick the pilot's perception into believing he is flying straight and level but is in a turn.

Constant is called pitches during climb in BMI, the helicopter entered a constant left turn conducive for the pilot to experience the pitches, the vestibular system will generally detect the initial roll and roll motion; However, once the aircraft stabilizes at a constant rate of turn and pitch angle, the vestibule system will catch up to the aircraft and the pilot may believe that the aircraft is straight and level when it is not when the helicopter climbed. . The air traffic controller asked the pilot to identify what required the pilot to move his hand toward the center of the instrument. panel and pressing a button the pilot's tasks associated with communicating with the controller and pressing the identification button introduced operational distractions from his primary task of monitoring the flight instruments the resulting interruptions in the instrument scanning head and hand movements of the pilot. pilot would make him more vulnerable to misleading vestibular signals that could negatively affect his ability to effectively interpret the instruments and maintain control of the helicopter.

The helicopter was in a rapid climb up the left bank. Its pitch increased and it entered a tighter turn to the left. that moved away from us 101 the increase in pitch would exacerbate the aspects of the encumbrances, the resulting descent and acceleration caused the pilot to experience a somatographic illusion in which he would incorrectly perceive that the helicopter was ascending when it was descending as the helicopter continued its steep climb. descent, the pilot was not referring to the helicopter's instruments or has difficulty interpreting or believing them due to convincing vestibular illusions and was unable to recover the helicopter.

This is a common accident scenario for helicopters, especially for emergency medical services or hemming missions. Many of these accidents end with a loss of control in a rapid descent to the left. between 2010 and 2019, 20 helicopters

crash

ed in similar circumstances. Here's why it's so difficult to recover from an unintentional encounter with an IMC in a helicopter. He didn't have much real instrument time. Can you explain it? And you are a very experienced helicopter. Pilot, I know we don't like to think about ourselves, but how many hours do you have in helicopters? Approximately 6,500, sir. I would say he has quite a bit of experience.

Can you describe what it's like to fly under the hood, so to speak? a device that restricts vision, how would that be different from just flying and suddenly entering the clouds somewhat unexpectedly? How would that be different from a pilot's performance? pilot the ability to look around and, as they say, you know a peak is worth a thousand cross checks, um, going to fly real instruments, there's nothing, um, fooling the system by looking at a set of view-limiting devices with whom you are committed. instrument conditions that force you to commit to actual flight instruments. Thank you and could I say that?

Would you agree that there could be an element of surprise if you are flying under a vision limiting device? So you've had time. to acclimate to your instrument scan versus if you're flying visually and suddenly encounter instrument conditions, could there be some element of surprise associated with that that would potentially affect your performance as well? Yes, sir, be prepared for the instrument. Conditions are part of the secret to the success of flight instruments. When it's a surprise and you're not prepared for it, that's when unfortunate and 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 board members spent a lot of time refining the language around this finding. Board member Tom Chapman argued that without questioning the pirate it was speculative to say that his friendship with Brian put pressure on him to make bad decisions. However, by making poor decisions, investigators were satisfied that the charter company did not put more pressure on the pilot to completed the trip against its discretion, although Island Express was criticized for lack of pilot supervision and lacked the safety management system that 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, so to speak, and tsb president sumwall nevertheless objected to the research staff's conclusion on this issue, mr.English, I want to go back to something that was said before the break, sorry, in my last line of questioning you had indicated that I think you said that Island Express was a safe operation.

Am I paraphrasing that correctly? I would say there would be nothing, no indication that Island Express was particularly unsafe or problematic Operator Which company had this accident? Mr. English Well Island Express, of course, so I'm seeing a disconnect here. What do you think about that? I mean, this company had an accident and you say there's nothing to do. indicate that they were not safe, well, you asked, I think this the concept of that question was how a consumer could know how to detect an unsafe operator and there was nothing inherent in this operator that would indicate that they were not safe, I mean, I think we see we see crashes with other carriers and they don't particularly indicate that they are unsafe, but they have had a gap, they have had a defect, maybe they didn't know any better, but that doesn't necessarily make them a problem. operator just need to do some things differently or know something different from the comfort of our armchairs it is easy to find fault with the pilot because well his actions and lack of actions were the cause of this accident even so he was well regarded in the company and had a reputation for being willing to cancel flights when the English investigator justified it and allowed us to say that this accident is another. example of good pilots making bad decisions, something that happens every day, the president of the board used a term that I had never heard before and I think that's a lesson: we are all subject to the term that I was told years ago was mud s-l-o-j s-l-o-j sudden loss of judgment and here is a case where a pilot who is well regarded apparently got into a very bad situation, so let me see if I understand this, so basically the scenario that we think happened is that he is flying and he realizes that he is being cornered. with visibility and then he must have made the decision, you know, I'm going to break through these clouds and get to the top.

That's basically the scenario we think happened. I think I think that's right and I and I don't agree with your statement that you know this is good, good people can make a bad decision and we really want to get to the bottom of why to prevent this from happening again like result of this accident. The ntsb recommends better simulation. training for helicopter pilots who encounter involuntary BMI and are calling on the industry to conduct research into what technology would work best for this. The agency is also asking the FAA to require commercial and permanent-use helicopters to have digital flight data and cockpit voice recorders.

Recorders with an exterior camera view would assist in accident investigations and could be routinely analyzed to see how pilots are performing. Yeah, he's kind of a snitch. Pilots don't necessarily like that idea, but we should all really like the idea of ​​crashing into slopes. less for atweb I'm paul bertorelli reporting thanks for watching