Examining why the Island Express S-76 carrying Kobe Bryant crashed
It’s hard to understand why a pilot chooses to take a risk he has been warned against taking. It’s even harder to understand when that pilot is a chief pilot, charged with training and checking other pilots and with supporting the safety practices of a company safety management program.
On Jan. 26, 2020, an experienced helicopter chief pilot with a celebrity client was handling a complex low-altitude flight skillfully until, over a very short period of time, he decided to take an unacceptable risk. While traveling at 140 kt., under a low overcast, and only 350 ft. above rising terrain, he decided to pull up into the overcast while operating under visual flight rules. Up to that point, he had several safe and reasonable options to deal with decreasing visibility. After that, his options narrowed. He became disoriented and the helicopter rolled over and impacted terrain 1 min. after he made that pull-up decision.
The accident took place in a hilly area in Calabasas, California. Calabasas is located at the west end of the San Fernando Valley, just 24 mi. from the flight’s destination. The flight departed from John Wayne Airport (KSNA), southeast of Los Angeles, and was bound for Camarillo Airport, California (KCMA), which is northwest of the city. The driving distance between the two airports along Interstate 5 and U.S. 101 is 92 mi.
On the day of the accident, the famous LA marine cloud layer covered the western part of the metropolitan area, making an IFR clearance the obvious plan of choice. Unfortunately, Island Express Helicopters, the FAR Part 135 operator of the flight, was not certified by the FAA to conduct IFR operations. The only VFR option was to stay low, below the cloud ceiling, which averaged about 1,000 feet AGL.
Los Angeles sits in a basin bounded along its north side by the San Gabriel Mountains, which rise to a height of 10,064 ft., and along its northwest side by the Santa Monica Mountains, which rise as high as 3,114 ft. To fly under a 1,000-ft. ceiling from KSNA to KCMA, a pilot must fly below the LA Class B airspace, past downtown LA, through the Elysian Valley along Interstate 5, through or around the Burbank Class C and the Van Nuys Class D airspace, and then through another pass at the west end of the San Fernando Valley. For a single pilot hand-flying a helicopter at high speed, the route was a tough obstacle course that would challenge the skills of even the best pilots. The Flight The Sikorsky S-76B helicopter, N72EX, departed KSNA at 0907. On board were the pilot and eight passengers, including former professional basketball player Kobe Bryant and his 13-year-old daughter. The flight was a repeat of a charter flight flown the previous day with the same pilot and passengers, and to the same destination. According to news reports, the purpose of the flight was for the passengers to attend a basketball tournament in which Bryant’s daughter was playing. Mr. Bryant was comfortable with the pilot, having flown with him many times before.
Before leaving, the pilot filled out a fight risk assessment form, a check box scoring system designed to help the pilot determine if conditions were too risky to fly. He calculated the flight’s risk at 17 out of 60 possible points, a very low score.
The helicopter skimmed along over the vast urban area following Interstate 5 North at altitudes above the ground of between 400 and 600 ft. and at speeds between 140 and 150 kt. Approaching the Los Angeles Zoo and just southeast of Burbank Airport (KBUR) Class C airspace, the pilot called KBUR tower and requested a Special VFR (SVFR) clearance through their airspace, specifically asking to follow the 101 Freeway westbound. SVFR rules allow a helicopter to be cleared through an area of controlled airspace when the visibility is less than the normal VFR minimum of 3 sm. However, it does not give the SVFR aircraft precedence over other aircraft that are operating under IFR, and there was IFR traffic operating at Burbank.
NTSB/GOOGLE EARTH
The helicopter began circling over Glendale while waiting for further clearance. Notably, the pilot asked the tower controller for a tops report while he was holding, and the KBUR tower stated cloud tops were 2,400 ft. MSL. After an 11-min. delay, KBUR tower cleared the flight to take a northwesterly course through his airspace rather than the requested westbound course due to traffic at Van Nuys Airport (KVNY). According to the KBUR and KVNY controllers, this northerly loop was a routine route, and apparently the pilot agreed, because when cleared that way, he said “no problem.”
Ten minutes later he had completed the semicircle around the valley and spotted the U.S. 101 freeway again, which when followed would take him to Camarillo. The pilot switched frequencies to Southern California TRACON (called SOCAL on the radio) and reported he was in VFR conditions and proceeding to KCMA. The controller told him he would lose radio and radar contact soon if the flight remained so low, and instructed him to change his squawk to 1200, the standard VFR code.
Within another 2 min. the helicopter began to encounter thicker clouds. A witness later said she saw the helicopter flying at or just below the cloud line and then disappear into a “thick wall” of cloud. At that moment, the pilot was telling SOCAL that he was “gonna go ahead and start our climb to go above the, uh, layers, and, uh, we can stay with you here.” He began climbing up into the cloud deck at 1,500 fpm and in a slight left bank.
The sequence of events during the next minute provides a textbook example of what happens during spatial disorientation. While in a rapid climb and gradual left bank, the pilot carried on several routine-sounding transmissions with the controller, each time causing him to think about something other than controlling the helicopter. Within a 30-sec. period, the pilot had to state his position, push the transponder “ident” button, answer if he wanted flight following, and reply to a request to “state intentions.” While this was happening, the helicopter was passing the highest point in its climb, rolling more to the left and beginning to descend. The pilot’s answer to that last request was the clincher. “Climbing to 4,000,” he said as the helicopter was now descending. The time of impact was just after 0945:34.
Ironically, if the last tops report was accurate, the helicopter got within 30 ft. of breaking out on top of the cloud deck before descending into the ground. The Investigation The NTSB is well-known for its thorough methods. Even when the cause of an accident seems apparent from the outset, they pursue every factual detail they can find. Even though it appeared the Island Express Helicopters pilot lost control after entering instrument meteorological conditions (IMC), and even though such accidents are common—on average, two per year among commercial helicopters--investigators looked carefully at mechanical and maintenance factors, meteorological and air traffic control factors to be sure that failures or errors in these areas did not contribute to the cause of the accident. No such issues were found.
Source: NTSB
It is important for investigators to be able to establish a timeline of events during the accident flight and to establish the aircraft’s attitude, speed, configuration and trajectory in detail. The best sources for this information are crash-hardened recorders—a flight data recorder (FDR) and a cockpit voice recorder (CVR). Since neither was on board the accident helicopter (the CVR originally installed had been removed), the investigative team had to devise other ways to plot the track of the aircraft. A performance study was done using FAA ADS-B data, which recorded latitude and longitude, pressure and geometric altitude, and inertial speeds. A performance specialist was able to reconstruct the flight path using this data.
The investigation moved on to operational, human performance and organizational factors. First on the list to examine were the pilot’s qualifications and experience. The pilot was 50 years old and lived near the company’s Long Beach offices. He obtained his first FAA rotorcraft certificate in 2001 at a school in Van Nuys, and upgraded his certificates to commercial, instrument and flight instructor in 2007-08. After instructing at the school for three years, he was hired by Island Express. He was charged with a Class B airspace violation in 2015, which he reported using the NASA Aviation Safety Reporting System (ASRS). He began S-76 training in late 2014 and became chief pilot and check airman on that helicopter in 2016. He was also qualified on the company’s Airbus AS350 helicopters.
Of the pilot’s total flight time of 8,577 hr., 1,250 were in the S-76. He had recorded 75 hr. of instrument time, but most of it (at least 68.2 hr.) was simulated instrument time. There were no ground or flight check failures on his record. He completed company safety management system (SMS) training in 2018 and training for “inadvertent IMC” multiple times, the last of which was in 2019.
Interviews with the company director of operations (DO), the FAA principal operations inspector (POI) and company pilots were favorable about the accident pilot. He was said to be skillful and proficient, although there were some undocumented stories about his taking occasional risks. Investigators found no issues arising from the pilot’s fatigue, medical condition, substance use or qualifications.
Island Express held a Part 135 on-demand certificate limited to day and night VFR only. (The NTSB noted that 411 out of 476 FAA-certificated Part 135 helicopter operators were VFR-only operators.) The company had 25 employees, including six pilots and two mechanics, and operated three S-76 and three AS350 helicopters. The company flew about 495 charter flights in 2019, including 13 flights for the accident client.
Investigators scrutinized Island Express’ policies, procedures and training and found no serious issues. The company had used well-known training vendors, and instructors from those vendors told investigators they taught Island Express pilots that when entering IMC they should fly straight and level, maintain heading, set power to 70-75% torque and establish a positive climb rate at 70-75 kt. The DO had issued repeated warnings about the dangers of flight in IMC. The company had canceled 150 flights due to weather in 2019, and 13 more in the two days before the accident flight.
As SMS is an ongoing focus of the NTSB, the company’s SMS program came in for detailed review. SMS programs are required for Part 121 air carriers but not yet for Part 135 operators. Island Express first established an SMS in 2013 using the services of a well-known vendor. Although the company had an SMS manual, conducted SMS training, kept records, held safety meetings and hired external auditors, the program had never been approved by the FAA.
One of the SMS tools Island Express used was a flight risk assessment form. Pilots could complete the form using a mobile application on their phone. The criteria on the risk form included: mission and operation, duty day and qualifications, weather, equipment and personal issues. This was the form the accident pilot used on the day of the accident flight. A score above 45 was considered an elevated risk and the pilot had to consult with his supervisor before flying. However, in the 14 months before the accident there had been no elevated risks. Safety Board Deliberations Before the five members of the NTSB approve a final accident report, they meet in public to hear the facts and circumstances of the case from the investigative staff and to deliberate as to the facts, analysis, findings, probable cause and recommendations that will issue from the report.
Safety Board members ask questions and offer comments that may not be reflected in the final report. Often the questions also exist in the minds of observers and members of the aviation industry, and the back-and-forth discussion with the staff can add interesting flavor to an otherwise straightforward accident report. I offer here a summary of some of those discussions.
Board Vice Chairman Bruce Landsberg asked if the helicopter had a functioning autopilot and if it could have been engaged when the helicopter entered IMC, and if the pilot could have returned to Van Nuys, only 10 to 12 mi. behind them. The answer to both questions was yes. Member Jennifer Homendy asked if a Terrain Awareness System (TAWS) would have been helpful. Investigator-in-charge Bill English explained that while TAWS is great technology, it is designed to prevent controlled flight into terrain (CFIT), not loss of control inflight (LOC-I). Member Michael Graham asked if the pilot followed his training when he encountered the loss of visibility. The answer was no. Member Thomas Chapman observed that there were 184 accidents involving spatial disorientation from 2010 to 2019, and 20 of them were fatal helicopter accidents. Chairman Robert Sumwalt made the point that the flight could have been flown under IFR, and that passenger charter helicopter flights probably should be flown routinely under IFR. He also pointed out that both the previous operator of the S-76 and Chevron Oil had required the use of two pilots.
The NTSB members raised other questions. One was why Island Express Helicopters had no alternative plan to get the passengers to their destination via ground transportation if the flight had to land. There was none. Another question pertained to the actual instrument experience of the pilot, which was very low considering his total flight time. Even the small amount of instrument time he had logged was mostly under a vision restricting device, not in actual IMC. A third question was related to what steps the FAA was taking to mandate SMS to Part 135 operators. The answer was that SMS for those operators is a long-term goal and no Notice of Proposed Rulemaking (NPRM) is currently in the works.
Homendy pointed out that when she filled out the risk assessment form, it generated a score of 37 under a worst-case scenario, leading to the idea that the form was ineffective. Graham said he was “not a big fan” of such numbered forms. Several members commented on the importance of flight data monitoring (FDM) equipment and analysis programs to identify deviations and trends in a non-punitive way so that mitigations can be devised.
Finally, Sumwalt commented that “even good pilots can end up in bad situations.” What he called “SLOJ”—sudden loss of judgment--justifies more redundancy in systems to trap errors, including use of autopilots and having two pilots. Probable Cause The NTSB determined that the probable cause of the accident was “the pilot’s decision to continue flight under visual flight rules into instrument meteorological conditions, which resulted in the pilot’s spatial disorientation and loss of control. Contributing to the accident was the pilot’s likely self-induced pressure and the pilot’s plan continuation bias, which adversely affected his decision-making, and Island Express Helicopters Inc.’s inadequate review and oversight of its safety management processes.” The Safety Board offered recommendations to the FAA on using simulation devices to train helicopter pilots for spatial disorientation and changing weather conditions, and to Island Express on installing FDM and participating in the FAA SMS program. Final Thoughts FDM programs within an SMS are intended to identify risky actions, and they are good at that. Island Express Helicopters will probably comply with the NTSB recommendation to install one. However, short of a camera in the cockpit, I don’t know how you would know from an FDM program when a helicopter is flying in IMC. Safety tools have to be tailored to the actual operation.
There are hints and suggestions in the report that make me think the accident pilot was more of a risk-taker than he appeared. Several pilots who knew him said he was known to take risks. One repeated a story about him descending below clouds over the water. He had a Class B airspace violation. He chose to fly on Jan. 25 and 26 even though the company had 13 cancellations for weather on Jan. 24 and 25. There was no direct evidence that he had penetrated IMC conditions previously, but that doesn’t mean he hadn’t done it. Disclosure on his part could have led to career consequences. Another pilot was downgraded for landing to refuel, and that may have sent a message to other pilots that mistakes were not tolerated. Finally, from the tops report he asked for, he knew the cloud layer was shallow and he could guess from radio calls that there was probably no nearby traffic. I think it is reasonable to conclude his decision to climb into the clouds without an IFR clearance was deliberate and possibly even pre-planned.
The fact that the chief pilot did not follow the safety precepts that he was responsible for teaching tells me that Island Express did not have real a buy-in to safety programs from its pilots. Even though the company had probably spent a lot of money on training and an SMS program, such programs are regarded by the pilots as just bureaucratic overhead until the participants really accept it. Getting that acceptance may be the hardest part of putting in an SMS.
