Let’s be honest: We wouldn’t be talking about the Kobe Bryant crash unless it involved a celebrity, but it did, so let’s capitalize on it to prevent another one. In this AVweb vodcast, Paul Bertorelli interviews Bruce Landsberg of the NTSB and Jim Viola of Helicopter Association International, a rotary wing trade group.

21 COMMENTS

  2. I was a Captain for one of the 17 (of the 1900) FAR-135 companies who employ a System Safety Program. My employer was ahead of it’s time regarding charter marketing. The SMS program was a sales tool like ARGUS/WIVRN, and used solely to attract large customers and compete with the other “bigs” in that business. Yes the company went through the motions. Yes nothing happened as a result of the motions. For example the first summer I was employed two sets of wings were bent in turbulence. Bent as in a near disaster. Accidents were never shared with the pilots. Results of accidents were never incorporated into future training. Accidents were hushed up because the company didn’t want paying customers knowing what was really going on. A (serious) rejected takeoff in Ohio landed one of our birds in a maintenance facility for 6 months. Another lost control in Michigan on takeoff and went through some snow banks, etc, etc, etc. One of our pilots was fired for denying boarding to a drunken passenger. The company claims the pilot was fired because of the way the pilot handled the drunk. Maybe the pilot handled it wrong but have you ever experienced the wrath of a drunk who was just told he couldn’t board an aircraft he owns for the day. The pilot deserved a medal. He didn’t deserve being fired. He potentially saved lives of many. The law is clear that you must deny boarding to an intoxicated passenger. The company encouraged passenger to “have a good time”. They didn’t encourage pilots to deny boarding. The example of the pilot being fired made for certain no other pilot would deny boarding to a rich drunk. It was a message and not a SAFETY message. 14 months ago I had the drunken passenger conversation with the CFO in a recurrent training class. To date there has been no change in the drunken passenger policy that I know of. To recap, SMS is only as good as it’s managers. There is more but I will save you the pain….God bless.

  3. Without harping on the details of human factors.. Collectively, what the FAA has done, and the NTSB has suggested, up to this point is more than adequate and reasonable.. Moving forward, it should be the fear of death, brought upon the operator, to the passenger/s that influences flight safety.. Beyond that, don’t fly..!!

  4. All comes down to the ability to say no. Correction: the requirement, to say no. Even when knowing a whole bunch of folks want you to say yes. Knowing the answer might could’ve been yes. Knowing that saying no means inconvenience to folks paying you the big bucks. It means turning probably can, and shades of grey, into a final black and white no. Even though saying no, to a probably maybe could situation, might lead to loss of your employment. It’s an uncomfortable corner to find yourself in and best dealt with having thought it through ahead of time.
    Regards,
    Tom Charlton

  5. One human factor that I have not heard discussed related to the Bryant accident was the pilot’s past record of getting previously sanctioned by the FAA for flying into IMC without an IFR clearance. I have learned that same pilot went through a FAA legal sanctioning process in 2015 for a similar event. I do not know about all the issues relating to the 2015 incident. But that would explain a lot why he ended up scud running, attempting what appears to have been an attempt to do a fast 180, to avoid going through another FAA legal hassle.

    This is an excellent video and is very useful. Both Landsberg and Viola are experienced IFR pilots and instructors. But the premise of this accident seems to focus on inadvertent VFR flight into IMC, as most of these investigations seem to follow. Paul brought up the idea that this does not seem to be accidental VFR into IMC. I agree.

    There is a strong possibility the pilot did not want to deal with another potential legal FAA fight to keep his ticket for punching through a small marine layer IMC and getting on top without a clearance, repeating similar behavior that cost him a protracted legal battle in the past. Just as the video revealed that airline cockpit decision making is made knowing that everything said and done is being recorded. Check rides and BFR’s are flown with full knowledge the pilot is being continually critiqued. We fly different under scrutiny as Landsberg pointed out. We also can make really dumb decisions if we are trying to avoid being prosecuted for repeating behavior that got us a FAA bust in the past.

  6. This helicopter left with a forecast that would have led the pilot to believe the flight was possible. The problem in my opinion was as things got worse he just continued on at 140 knots. Had he just used the capability of the helicopter to just slow down to a sedate speed he probably could have just landed somewhere and waited it out. But going that fast he didn’t have the choice. I am sure the severe pull up in IMC conditions created a situation of vertigo and doomed the ship from then on. The need to please a VIP ended up killing them all.

    • Exactly. When you are VFR and your visibility is reduced you must reduce your airspeed and be prepared to land or go IFR under control. I noticed during my 40 of flying helicopters that if you unnecessarily risked their lives of your passengers but completed the mission they would pat you on the back and tell you how great you were. If you saved their lives by aborting the flight they were not so happy. Not all passengers but enough to notice.

      • That seems exactly right to me, David. Could I ask you how often you felt that the system was actually working against what would be the safest choice, or turning a quite safe mission into a marginally less safe or a no go situation?

        I know their is a PIC responsibility and defense of decisions, but don’t you believe most pilots are afraid of the likely consequences of choosing safety over ATC direction unless in obvious peril?

  7. It’s a horrible comment on our regulators that they actually believe that a “Safety Management System” actually WORKS–instead of actually DOING something–like encouraging helicopter pilots and operators to go IFR.
    The most interesting part of the video starts about the 17 minute mark. Paul asks the IFR question–the HAI rep states “On the East Coast, helicopter operators DO fly IFR–both single and two pilots.” The HAI rep alludes to the COST OF COMPLIANCE WITH FAA REGULATION FOR IFR. That’s bad thinking–you already have the “‘sunken cost” of the cost, insurance, and maintenance of a multi-million dollar aircraft–and won’t spend the time and money to not only make it SAFER, but to get FULL UTILITY FROM YOUR INVESTMENT?????

    The “marine layer” didn’t just start with “climate change”–it’s something pilots have been dealing with for a hundred years. Time for the helicopter charter people to wake up to the facts that their fixed-wing brethren have known almost since airplanes were invented–“You can’t tell your customer that we will go “only if the weather is good.” As mentioned in the video–it would have been an easy IFR flight–tops at 2500–approaches at many nearby airports.

    Note the long time (years) the FAA has been “working” on their “safety culture”‘ recommendations. Like fixed-wing, it is “preaching to the choir”–they admit that it hasn’t been readily embraced–it DOES NOT WORK.

    The FAA has promoted fixed wing IFR operations (and discouraged scud running) for years, why not helicopters?

  8. There are dozens of factors not going to be discussed or even under scrutiny here.

    I’m not familiar with IFR rules for helicopters so I cannot even name them all. Likely, there were other routes not available due to traffic under current rules. Are those rules really necessary? The flight was being conducted with ATC control, but supposedly VFR? ATC often directs VFR pilots into IFR conditions because they cannot see the clouds. This starts a discussion ATC doesn’t have time for, so they put you in a holding pattern. How often does this train the VFR pilot to instead dodge or skim clouds?

    I cannot count the number of times I couldn’t get a higher altitude to avoid scattered clouds because that space was secretly reserved for approaching airliners that weren’t going to be there. I’m not talking about an IFR route reserved for a particular flight either. I’m talking Class B space where they simply will not let a prop plane fly above a certain altitude, or at all even if it has sufficient airspeed (yes, I’ve been asked to slow my approach for jets on final, go Mooney!).

    I could go on, and on. My point is that while it’s useful to discuss what should have happened or what went wrong within the existing system, we should always be looking at outcomes that might actually be created or made my likely by how the system actually ends up working. A good example is how the community fought to stop fines for failing to close flight plans because it was causing VFR pilots to simply not file.

    Finally, these high profile tragedies are used by government, anti aviation interests, and others to hurt GA. As a community, we unfortunately need to enter that arena and fight back using whatever incidents the press or others raise the profile on.

  9. No one seems to consider that this helicopter had an excellent autopilot and that if the pilot was going to to do an unwise and illegal climb into the overcast, it could have very likely have been done safely by the pilot engaging the autopilot prior to starting the climb.

  10. As a former Army attack helicopter pilot and current major airline captain I have to say that if we don’t want to see this happen again we must enforce new rules that will prevent it from happening. As a republican leaning independent I naturally chafe at the suggestion that more government mandated regulations are necessary but as a professional pilot that has seen how cheap aviation management can get its the only way. If you’re going to hold yourself out as a company that carries passengers for hire in a helicopter you’re going to have to send your pilots to regular simulator training. Just as we do in the airlines and just like we did in the military.

    Additionally I cannot help but think how much of a different outcome could have been garnered by having a second pilot in that cockpit. Again just as we do in both the airlines and the military – are you starting to see a pattern yet ?

    • Paul, as you say we need new rules. I just want to say the impulse for new rules without the realization we have too many already has become a big problem. I’m not an anarchist, but I would be doubtful that anyone has ever read all the rules we have already so it’s bound to be too many. It’s very possible that the things you say those companies ought to have are things they do not because of cost incurred by the mountain of rules already in existence.

      Reducing and simplifying the existing regulatory framework is, in my opinion, a higher priority than adding more restrictions on top. Just as stopping more and more young people from getting federally backed student loans for classes that will never help them repay the loans is more important than loan forgiveness schemes, or stopping more and more people from moving to the US without permission is more important than amnesty.

      Can’t we put out fires before we start the clean up? Isn’t that wiser?

      • To inform your opinion on this, I would recommend anyone take a look at the NTSB commercial helicopter record for any given year. It’s easy to do. Just search the database through a date range.

        Compared to Part 121 ops, there are a lot of accidents. About a half dozen fatals a year, give or take. As you read those accident reports, ask yourself how further regulation or restrictive operating rules could have prevented them. It’s not a black and white consideration by any means. I have difficulty forming an opinion on it.

        One reason for this that many fixed wing pilots don’t understand is that helicopters do things other aircraft can’t and that necessarily places them in more hazardous environments. There’s a tradeoff there and having

        • Well……I have lived in both worlds so I UNDERSTAND ! I also have observed what works better and know what I would implement if I were king for a day !

  11. We have a single IFR rated (although not necessarily current) helicopter pilot flying for a Company who doesn’t have an IFR certificate in a super machine capable of IFR flight (but not necessarily current for same?). Add a demanding heavy hitter high visibility client who likely communicated what he wanted time wise (contributing to “get-there-itis”) either before or even during the flight (intercom?). They take off in marginal albeit still VFR weather. Now add in the holding delay around the Burbank Class C and then inadvertent immersion into IFR conditions. In the back of the pilot’s mind he’s remembering a prior run in with the FAA and now he has to do something right FAST. And we’re all discussing how this coulda happened? There were so many tools that coulda, shoulda and probably woulda but for …

    We’re all learning something from this evolution but one of the things I’m learning is that I will NOT ever climb into any airliner with a single pilot up front … no matter how many channels of remote control is hooked to the thing, Garmin Autoland notwithstanding. Having another pilot sitting next to me is often a calming influence if nothing else. I’d bet serious money that had there been two pilots up front, we wouldn’t be having this discussion.

    • For the record, there’s a persistent but of misinformation going around that says Bryant fired a pilot for not flying and that he was a demanding customer. There is no evidence of this in the investigation record and another pilot who flew him said the reverse was true. Bryant was a calm customer allowing the professionals to do their jobs.

      This is what the record shows. True or not, there’s no evidence to the contrary.

      • OK … I accept that probable finding but — in the pilot’s mind — there HAD to be self-induced pressure on him to produce for and satisfy a repeat heavy hitter.

        I forgot to add one other thing that I try to instill in my pilot buddies … that of dissipating kinetic energy. 1/2 * M * V squared. You can’t change the 1/2 or the M but you can sure limit the “V.” Even a small reduction in speed decreases the amount of energy in the machine that has to be dissipated if you’re in deep doo doo. This accident pilot apparently didn’t slow down … why is unknown. He had a machine that could hover yet he was cruising along SOUTH of the 101 where he surely knew there were hills and canyons? Another variable in the conundrum. I’da sought out the Ventura freeway (which he just passed) and gone IFR (roads).

        I’m not trying to point my finger as much as use this as still another learning point for myself including trying to put myself into HIS frame of mind.

        • I continue to believe it was largely just casual carelessness. That he had no discernible Plan B over many minutes caused him to box himself into the corner where there no alternative other than climbing up through the overcast.

          He may have done that with so little forethought that he didn’t grasp what was required to commit to the instruments.

          • For some reason, I just can’t stop thinking about this sad accident.

            I bet that the 2015 FAA sanctioning of the pilot – which we didn’t know about earlier – played a primary role driving his thought processes which were also obviously already task saturated and overloaded. Jim H may have hit upon it (above)? So the know it all Monday AM quarterbacks and their lawyers on Independence Ave who are always right and quick to discipline errant pilots won the battle and ultimately lost the war with this one. Had that not previously happened, I’d bet serious money that this pilot woulda gone on the gauges, climbed through the marine layer and found someplace safe to land either by declaring 91.3(b) or just trying to get away with it unnoticed. Who’da known? He could say he found a hole. Even in LA, when the marine layer is in there aren’t hoards of airplanes cloud surfing outside of the final approach courses into VNY and BUR in the area he was in; he was well SW of those. Instead, he was pushing the envelope trying to maintain VFR and it didn’t work out.

            So much for corrective discipline driving subsequent safety. All it did was keep this pilot from declaring an emergency and acting appropriately and safely. When “stuff” happens, pilots need to be super comfortable knowing they have the magic ‘get outta jail’ card as their last resort. I’d compare it to your video about how Cirrus/COPA teaches pilots not to wait to pull the big red handle. Maybe THAT is where the learning point for all of us is here ?

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