Celebrity allure met aviation safety culture and the pilot threw his training out the window. So concluded the NTSB today in issuing its long-awaited probable cause finding in the January 26, 2020 crash of a Sikorsky S-76B that killed retired basketball legend Kobe Bryant and eight others near Calabasas, California.
The NTSB found that pilot Ara Zobayan conducted the flight significantly counter to his training likely in an effort to please his celebrity passenger and deliver him to his final destination, even as weather progressively deteriorated during the Part 135 VFR flight. Zobayan, an 8,500-hour IFR-rated pilot, had logged just 75 hours of instrument time and all but 68 hours of that was simulated, the NTSB found. And although the S-76 was equipped with an autopilot, Zobayan did not use it as he attempted to climb through a cloud layer as terrain and ceiling began to converge.
The NTSB concluded that “the probable cause of this accident was the pilot's decision to continue flight under visual flight rules into instrument meteorological conditions (IMC), which resulted in the pilot’s spatial orientation 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 the pilot’s decision-making, and Island Express Helicopter Inc.’s inadequate review and oversight of the safety management processes.”
In reaching its decision, the NTSB made a number of findings and recommendations, including air traffic control procedures did not contribute to the accident or affect survivability; an internal company risk assessment concluded that the flight was within the company’s low-risk category, but, based on scoring, the pilot should have sought input from his director of operations for an alternative flight plan; losing outside visual reference was likely complete by the time the flight began to enter its final left turn prior to impact; flying at excessive airspeed (140 knots) into deteriorating weather conditions was inconsistent with the pilot's adverse weather training and reduced the time available for him to choose an alternative course of action to avoid entering IMC; and continuing the flight into deteriorating weather conditions was likely influenced by a self-induced pressure to fulfill the client’s travel needs, the pilot's lack of an alternative plan, and the plan continuation bias which strengthened as the flight neared the destination.
It further noted that Island Express lacked safety assurance evaluations to ensure pilots were consistently completing flight risk analysis forms, hindering their effectiveness as a risk management tool. The NTSB said a fully-implemented safety management system (SMS) could enhance Island Express’s ability to manage risks.
Recommendations from the NTSB include using appropriate simulation devices and scenario-based pilot training; improve the ability to assess weather and make appropriate decisions; evaluate spatial disorientation simulation technologies for use in training pilots to recognize the onset of spatial disorientation and successfully mitigate it; and establish a pilot data monitoring program for operators that conduct single-pilot operations and have little opportunity to directly observe pilots and the operational environment.
The NTSB also made a series of new safety recommendations and restated some older ones such as using simulators and scenario-based training to enhance pilot decision making with regard to inadvertent entry into IMC (IIMC) and spatial disorientation; mandating flight recorder installation in all turbine helicopters; and mandating flight data monitoring and SMS for all Part 135 operators.
“There are 1,940 Part 135 certificate holders," said Board member Thomas Chapman. "Of those, only 17 have an FAA-accepted voluntary safety management system and another 158 operators whose safety management systems are in various stages of development and have applied for acceptance under the voluntary program. So the level of participation on a voluntary basis on Part 135 operators is thin.”
Board member Jennifer Homendy noted that the NTSB has long proposed some of these recommendations. “We've recommended flight data monitoring for 12 years and recommended SMS for 12 years—and recommended recorders going back 22 years.”