On February 9, the NTSB held a public meeting on the crash of a Sikorsky S-76B that killed the pilot and eight occupants. As helicopter crashes go, other than killing superstar athlete Kobe Bryant, his daughter, and family friends, this one held few surprises. In a scenario that has been played out many times before, this accident flight included scud running, inadvertent flight into IMC, spatial disorientation, loss of control, and a tragic loss of life.
The obvious question here, as the late Matt Zuccaro said many times before, why don’t they just “land the damn helicopter?” Pilots need to take advantage of the most unique and valuable characteristics of vertical flight and just “land and live” rather than continually flying into bad weather.
For those that have not followed along, here is a quick recap. On Jan.26, 2020, the accident flight departed from Southern California’s John Wayne Airport Orange County (SNA) with a planned destination of Camarillo Airport (CMA). The operator of the aircraft, Island Express Helicopters, was a Part 135 charter operator certified only for VFR operations.
After the aircraft departed SNA under a Special VFR clearance, it flew at altitudes below 1,700 feet msl and generally between 400 and 600 feet agl at 150 knots into progressively deteriorating weather. The minimum flight altitude according to the company’s flight ops manual was 300 feet agl.
As the flight neared Burbank (BUR), the helicopter was asked by ATC to hold outside the Class C airspace, due to traffic, awaiting another Special VFR clearance. BUR and the neighboring Van Nuys (VNY) were now IFR (2.5 miles visibility and 1,100-foot ceiling). For the next 12 minutes, the helicopter would orbit, slowing to 40 to 60 knots at approximately 1,000 feet msl.
Once clear of the BUR and VNY airspace, the helicopter would accelerate back to 150 knots and begin to follow a path along U.S. Route 101 towards rising terrain. The pilot was now in contact with SoCal approach control. The controller asked, “You just gonna stay down low at that [altitude]…all the way to Camarillo,” and the pilot responded affirmatively.
Minutes later, the pilot would announce to the controller that he was initiating a climb above the cloud layer. Climbing at 1,500 fpm, the helicopter began to turn more tightly to the left. It reached a maximum altitude of 2,370 feet msl and then began to descend rapidly in a left turn to the ground. Within seconds of initiating the climb into IMC, the pilot became disoriented, lost control of the aircraft, and crashed.
According to the NTSB, the investigation focused on the following safety issues: pilot preflight weather and flight risk planning; entry into IMC and the pilot’s inadequate weather avoidance; spatial disorientation; the pilot’s decision to continue into adverse weather; the company’s inadequate implementation of a safety management system (SMS); and other safety and training technologies such as flight data monitoring, flight recorders, and flight simulators.
Preflight weather and flight risk planning by the accident pilot was poor. The pilot completed the flight-risk analysis form two hours before the accident flight departed SNA. According to the meteorology factual report available in the NTSB docket, there were a lot of weather sources available. Neither Leidos Flight Services nor ForeFlight could provide evidence that the pilot attempted any formal weather briefings.
On the flight risk analysis form, the score was a low enough “risk” that the pilot did not have to get input from the director of ops or come up with an alternate plan. Had the actual weather been used, it would have fallen in a much higher risk category where additional guidance would have been required before flight.
There was no evidence that the pilot attempted to avoid entry into IMC. The pilot’s adverse weather avoidance training emphasized avoiding IMC, slowing, descending, or even landing. Of interest, the NTSB cited the pilot’s self-induced pressure, a lack of an alternate plan, and plan-continuation bias as a factor in the decision to continue into adverse weather.
In the NTSB Ops Group discussions, twice in 2019, Island Express safety committee reviewed HAI’s “Land That Damn Helicopter” article. In response, the Island Express director of ops discussed weather diversions with passengers on board. His instructions: “land and call a taxi for the passengers” and the pilot can get a hotel room.
One of the most compelling reasons to “just land” is a discussion on apparent angles and spatial disorientation. Detailed in the performance study and human performance report available in the NTSB Docket, there are some very real human limitations backed by some “mad math” that should keep non-instrument-rated (or proficient) pilots out of the clouds.
As a refresher, the vestibular system of the inner ear allows a person to have a sense of balance and spatial orientation. The vestibular system, like other accelerometers, cannot distinguish between load factors due to motion versus load factors due to gravity. So, on its own, the inner ear cannot differentiate between acceleration and tilt. Sensory inputs, such as external visual cues, are required to correctly perceive attitude and acceleration. When these are misperceived, it is known as the somatogravic illusion and can cause spatial disorientation. Every pilot, VFR or IFR, should understand these very real human limitations.
As demonstrated in this crash investigation, there were several opportunities to “break the chain” of events that led to tragedy. To be fair—it is not all on the pilot. The operator lacked a comprehensive SMS, flight data monitoring, and did not use modern training tools such as flight simulators.
From the reports, there was little operational control of the flight other than some rudimentary flight tracking tools. So, the pilot, left on his own, made several poor choices (weather briefing and flight risk assessment) and created this self-induced pressure of flying a high-profile client to an event. In the end, the pilot just kept pressing; not once, did he consider aborting the trip or just landing, somewhere. If he did, the outcome would have been much different.
Pilot, safety expert, consultant, and aviation journalist Stuart “Kipp” Lau writes about flight safety and airmanship for AIN. He can be reached at [email protected].