The NTSB Determined The Probable Cause Of The Kobe Bryant Crash And Identified A Significant Contributing Factor

Today I watched a live stream of the National Transportation Board (NTSB) meeting that determined the probable cause of the helicopter crash that took the life of Kobe Bryant. As I had predicted in a post right after the accident, the NTSB announced that the probable cause of the accident was the pilot’s decision to continue flight under visual flight rules (VFR) into instrument meteoritical conditions (IMC) resulting in his becoming disoriented and losing control of the helicopter. The NTSB also concluded that the pilot’s decision to fly into IMC was likely influenced by self-induced pressure and continuation bias on the pilot’s part.

Relevant Facts

The accident occurred on the morning of January 26, 2020. Kobe Bryant chartered a helicopter belonging to Island Express Helicopters to transport himself, his 13-year-old daughter, Gianna, and six other passengers from John Wayne airport in Orange County, California to a youth basketball tournament at his Mamba Sports Academy in Thousand Oaks in Ventura County. When the flight took off just after 0900 Pacific Standard Time (PST), the weather was low overcast and restricted visibility. Not the typical sunny Southern California weather.

At 0945 PST, the Sikorsky SK76B helicopter, N72EX, collided at high speed with hilly terrain near the city of Calabasas, California. The pilot and passengers were killed instantly, and the helicopter was destroyed by the impact and fire. The helicopter was flown by Ara Zobayan, an Island Express employee.

Because of the normally good weather in Southern California, Island Express Helicopters and most other Part 135 helicopter operators in the LA area obtain Federal Aviation Administration operating certification that limits their pilots to flying under VFR, which for helicopters operating at low altitude requires at least a half-mile of daytime visibility and visual reference to the ground. Island Express was not able to conduct flights under instrument flight rules (IFR) where a pilot has no visual reference to the horizon.

Bryant had flown with Zobayan and Island Helicopters many times. Zobayan was a very experienced helicopter pilot. He had logged more than 8,200 total hours of total flight time with about 1,250 total hours in the Sikorsky SK76B. Zobayan was rated for flying in IMC under instrument flight rules (IFR). His most recent flight review on May 8, 2019 included proficiency training in inadvertent entry into instrument meteorological conditions and unusual attitude recovery. The helicopter he was flying was equipped with attitude, airspeed, and vertical speed indicators and other instruments that made it suitable for flight in IMC if Island Express had the proper FAA certification.

Spatial Disorientation Has Caused Numerous Airplane Crashes

As a private pilot who has an instrument rating for fixed-wing aircraft, the scenario of this accident is all too familiar. From 2010 to 2019, the NTSB noted 184 fatal aircraft crashes related to spatial disorientation, including 20 that involved helicopters.

When I was flying regularly, I read numerous accident reports involving VFR pilots or instrument-rated pilots who had not maintained instrument proficiency crashing when they are unable to avoid IMC. In cloud, pilots are unable to see the horizon, and visual reference to the horizon is how we determine the attitude of the aircraft. In IMC, the aircraft attitude (climbing, descending or turning) is determined only by refence to instruments. Physical sensations produce faulty perceptions of the aircraft’s attitude. In cloud, what feels like straight-and-level flight might actually be a climb, turn or dive.

In this case, as the pilot approached the Calabasas Hills he was rapidly becoming squeezed between rising terrain and the base of the overcast. He told air traffic control he was going to climb above the cloud layer. But investigators concluded Zobayan became disoriented shortly after entering the clouds and instead of climbing, the helicopter entered a left turn and descended rapidly.

Pilot Errors

In the final analysis, the accident was the result of bad pilot decisions. Taking off wasn’t one of them according to the NTSB. Although Zobayan had no alternate plan in case weather deteriorated, the NTSB found no fault in the pilot’s decision to begin the flight in marginal VFR weather conditions. He checked the weather before departing. The weather was marginal for VFR flight, but it appeared that the flight could be completed safely .

The pilot’s fatal errors were flying into IMC in an attempt to avoid terrain and flying too fast. Zobayan should have never entered the clouds. He was not authorized to do so on a VFR flight plan or while flying for Island Express. Zobayan should have turned around and landed at the airport he had recently passed or found any other suitable spot, like a parking lot, to set the helicopter down.

They could then wait for conditions to improve or arrange for transportation by car. Being able to land off airport easily is an advantage that helicopters have over fixed-wing aircraft.

Another bad decision was flying fast into deteriorating weather. Flying at around 150 knots (172 mph) reduced the amount of time to evaluate the situation and make a good decision. Again, a helicopter has advantages over fixed wing aircraft because helicopters can fly very slowly and even hover without entering an aerodynamic stall where the amount of lift being produced is insufficient to keep the aircraft in the air. Zobayan enjoyed two safety features fixed-wing pilots don’t have and he didn’t use either of them.

The Real Issue Is The Source Of Self-Induced Pressure And Continuation Bias

The NTSB found the the decision to enter IMC was affected by “self-induced pressure and continuation bias.” Those factors are present to some degree in nearly all situations of intentional VFR flight into IMC. Some call it “getthereitis” when the desire to reach the destination becomes paramount. In my opinion the NTSB did not delve sufficiently into the way the particular circumstance of this incident may have affected pressure the pilot felt.

All charter operations and pilots feel pressure to get their customers to their destinations on time. That is what they are hired to do. Facts present in this case may have added to the normal amount of pressure to perform. Bryant had flown with Zobayan and Island Helicopters many times. Bryant often used helicopters to avoid LA traffic, and Ara Zobayan was his favorite pilot. It was reported that over the years Kobe and Zobayan had developed a friendly relationship of mutual respect. Kobe often requested his services to fly his family members when Kobe wasn’t joining them. No doubt that trust pleased Zobayan and his employer.

Through their relationship and Kobe’s public persona, Zobayan would have been well aware of Kobe’s “mamba mentality” philosophy of overcoming obstacles with determination, dedication and effort. Because Kobe Bryant was a loyal, important and prestigious customer, there would be a natural desire to make every effort to complete his charters as scheduled. The fact that Kobe had invited a large number of guests might also have played a role in Zobayan’s decisions. He may not have wanted to let down his friend in front of his guests. The NTSB did not state that there was any overt pressure by Kobe or any of the passengers that the flight be completed as scheduled.

The same factors could have led to an increased sense of continuation bias. Continuation bias is an unconscious cognitive bias to continue with the original plan in spite of changing conditions. Essentially, it is our tendency to discount the seriousness of potential hazards the closer we are to completion of a task. With the flight close to the destination, turning around was harder decision.

According to an Island Express employee, Kobe did not like being told no. Still the helicopter charter company had canceled an unknown number of flights for Kobe, Kawaii Leonard and other famous people. Still, under all of the circumstances of this situation, I think it would have been extremely difficult for the pilot to bite the bullet and call off the flight more than half way to the destination.

NTSB Recommendations

The five-member board unanimously recommended that charter helicopter pilots get more simulator and scenario-based training in dealing with spatial disorientation. It also reiterated a previous recommendation that turbine-powered helicopters such as the Sikorsky S-76B that Zobayan was piloting be equipped with crash-resistant flight data, voice, and image recorders. The FAA has never implemented the NTSB’s recommendations for flight data, voice and image recordings in helicopters in spite of numerous NTSB recommendations following similar accidents.

My Take

Thinking back to my instrument training and flying, I would recommend that as much time as possible in initial and recurrent instrument training should be performed in actual instrument conditions rather than “under the hood” in an airplane or in a simulator on the ground.

The hood is a device that is intended to restrict vision to the instrument panel and the interior of the cockpit. Every time I’ve flown under the hood it is still possible to see glimpses of terrain from time to time. That degrades the effectiveness of the training. Training with simulators has deficiencies, too. All but the most sophisticated (and expensive) simulators are stationary. They cannot produce the feeling of conflicting signals between the instruments and the seat of the pants that leads to spatial disorientation in IMC. The ability to maintain situational awareness and control of an aircraft when going into the clouds is a perishable skill. Flying in actual IMC is very important to maintaining that skill.

The exact wording for my recommendation presents difficulties. It is not wise for pilots to fly in thunderstorms or icing conditions to remain current. And some locations, such as the Los Angeles area, don’t have many opportunities to train in IMC. While Zobayan had over 8,200 hours of flight time, only 76 hours were classified as being under IFR. Even though he was a skilled, experienced pilot who had met the requirements for instrument flight, his unfamiliarity with actual instrument conditions seems to have resulted in spatial disorientation that led to the crash.

Final Thoughts

I don’t charter airplanes or helicopters for travel but will occasionally take helicopter sightseeing flights. In the future I’ll check weather forecasts and if there might be an issue with low clouds, I’ll ask if the operator and pilot if they are licensed for instrument conditions and if there is a back up plan if we encounter bad weather. Choosing a company that uses two pilots instead of one is better although few sightseeing companies go to that extra expense. If I’m putting my life in the hands of a company and its employees, I should feel comfortable asking about their experience and qualifications and any other issues, like weather, that might relate to the safety of the flight. The final decision about taking a charter flight is up to the passengers.

Hopefully lessons can be learned from the tragic loss of nine precious lives on January 26, 2020 that may save other lives in the future. Do you have thoughts on the crash or the results of the investigation?