Avweb: How A Split Second Wrong Decision Caused the Kobe Bryant Fatal Crash

[dmspilot]

What was the split second decision and why was it incorrect? Paul did not support his thesis well if at all, and his concluding remark was a nonsequitur about FDRs instead of a recap of the thesis.

 

[Bell206]

We were authorized two and a half A&P/Techs per S-76. We always had a couple of 76's.

How long ago was that? The highest manning I saw was 1.5 mechanics per "heavy ship" (212, 412, 76, 330) and 1 mechanic per 2 "lightships" (206, 350/5, 105, 407) back in the 80s and 90s. It then changed to the base engine manning method for most operators and combined all base mechanics under one group. The S92s and 139s have their own man system based on customer requirements.

Our tempo likely exceeded Island's.

Of course, just as any operator along the GOM. I guess I should have moved over to the "snow flake/pin wheel" and not worked as much then. Regardless, the mx manning at Island fit the operation.

 

[Tarheelpilot]

What was the split second decision and why was it incorrect? Paul did not support his thesis well if at all, and his concluding remark was a nonsequitur about FDRs instead of a recap of the thesis.

I like Paul’s material in general but it’s obvious when he’s talking out of his ass.

 

[Velocity173]

 

[Ed Haywood]

What was the split second decision and why was it incorrect?

He turned 180 instead of climbing.

 

[bflynn]

So with your background in helicopter operations, especially IIMC and IFR procedures, please explain how they can do it better.

not crashing? Doing what the training says to do?

Obviously the training was insufficient. Entering IMC, the pilot apparently continued to try to fly by kinesthetic senses rather starting an instrument scan. Under stress, he had the wrong response.

 

[dmspilot]

He turned 180 instead of climbing.

Paul stated the pilot's decision was to climb.

 

[Kritchlow]

Serious helicopters like the Sikorsky... charter ops one would think an instrument rating would be in order. I’m blown away.

 

[GRG55]

He turned 180 instead of climbing.

I believe it was a climbing left turn he initiated.

 

[GRG55]

Serious helicopters like the Sikorsky... charter ops one would think an instrument rating would be in order. I’m blown away.

I understood the pilot did have an instrument rating. The charter company was limited to day/night VFR only.

 

[Kritchlow]

I understood the pilot did have an instrument rating. The charter company was limited to day/night VFR only.

Perhaps you are correct, but one would think he should not have list control. Maybe it was a long time since he was imc..??
To lose control that fast as an IR helicopter pilot does not bode well.

 

[Salty]

The whole conversation is speculation. Even by the Ntsb. There’s just not enough info to know what happened. The public doesn’t like that answer however. The only decisions that we know anything about weren’t split second, they were what led to the necessity of a split second decision. They were pretty much the same as the gentleman in the other thread about scud running.

 

[flyingron]

There's no speculation that the pilot was operating in IMC without operating under all IFR rules. What specifically caused the lost control is intuited but not uncommon given the recorded flight regime and years of similar crashes.

 

[Doc Holliday]

not crashing? Doing what the training says to do?

How did you determine the training was insufficient? Did you attend the course?

Obviously the training was insufficient.

Again, how are you making this determination? Are you rotorcraft rated as well as rotorcraft instrument qualified? Did you review the operator's training manual and observe his last 135.293 evaluation?

Entering IMC, the pilot apparently continued to try to fly by kinesthetic senses rather starting an instrument scan.

And you know this how? By the time he was within a minute or two of crashing he was probably in task saturation and overloading himself, and essentially became a passenger.

Under stress, he had the wrong response.

Ah, now we're getting somewhere. Had he actually followed the training and the program, he wouldn't had been at that point. Somewhere between VNY and the point of impact he made a decision to toss out the procedures and attempt to scud run through. His GOM sets minimum altitudes and visibility requirements to conduct a flight under VFR, yet he pressed on, and we'll never know why he made that decision.

Fault of the FAA required and approved training? Hardly. Bad judgment on the PIC? Most likely.

 

[Bell206]

The whole conversation is speculation. Even by the Ntsb. There’s just not enough info to know what happened.

It’s not all speculation. We know the pilot didn’t follow the Island procedure for enroute weather limits and that he didn’t follow his documented training or Island procedure when the weather conditions deteriorated. And being the CP he also was one who exercised operational control requirements over the Island operation so he failed on that level also.

So the only speculation is why he specifically lost control as the flight should not have continued to that point.

 

[Velocity173]

The pilot WAS IFR rated. This dude wasn’t.

https://twitter.com/ConflictsW/stat...f-building-in-midtown-manhattan-killing-pilot

 

[Salty]

So the only speculation is why he specifically lost control as the flight should not have continued to that point.

And that's specifically what I was referring to. the so-called "split second decision" discussion is all speculation. It never should have come down to a split second decision.

 

[AeroLudite]

re: distracted pushing Ident button,
I used to fly a C421 that had an ident button mounted on the yoke opposite the auto pilot disconnect switch, trim, and transmit button.
The a/c had been based In, and operated under a European equivalent to FAR Part 135 for more than two decades.
I don’t know if it was a European requirement, but I thought it was a novel idea.

 

[bflynn]

How did you determine the training was insufficient? Did you attend the course?

I observed the outcome.

As part of my job, I conduct training, not in aviation, but I understanding training. When I train someone and they go out and do it wrong, something is wrong with 1) my training delivery, 2) my training content, 3) my evaluation of the student, or 4) the student's engagement. As the trainer, even that last one is up to me and if the student isn't engaged, then I have to know that and fail to give them credit.

Bottom line, when the student performs the task correctly, the training was done right. When the student makes an error, the training was wrong.

The trained response, according to the Avweb video, is to level the airframe, slow the aircraft and execute a climb. I believe they got that from the Island Express training manual, which was probably at least edited by the pilot since he was the company check airman.

Instead, the pilot made a descending turn to the left until he contacted the ground. What I observe is 1) he did not properly execute the described training, 2) there is no way he was referencing his instruments OR he was task saturated and couldn't process what he was seeing and 3) you seem very aggressively insulted that I believe the cause of an IMC CFIT crash is bad recovery training. But the bottom line is, if the pilot had done what the Island Express training said to do then he would have recovered.

 

[Velocity173]

re: distracted pushing Ident button,
I used to fly a C421 that had an ident button mounted on the yoke opposite the auto pilot disconnect switch, trim, and transmit button.
The a/c had been based In, and operated under a European equivalent to FAR Part 135 for more than two decades.
I don’t know if it was a European requirement, but I thought it was a novel idea.

Plenty of helicopters use an ident button on the cyclic as well. Doesn’t sound like this particular one had that mod though.

 

[bflynn]

So the only speculation is why he specifically lost control as the flight should not have continued to that point.

Well, when you're pushing to get there and suddenly you're in IMC, there's no discontinuing the flight at that point. You have to properly execute a recovery.

Maybe he was trying to do a 180, but the recorded flight track says he didn't slow down and he was descending, with the turn tightening at the end. That's a classic graveyard spiral.

I think the correct take away is that entry to IMC immediately becomes about aviate and messing with transponders or talking to ATC can wait until you're stable. They most they'll get from me is "123, standby".

 

[GRG55]

Perhaps you are correct, but one would think he should not have list control. Maybe it was a long time since he was imc..??

I'm thinking the same thing. Given his employer was VFR only could be a very long time had passed since last time in actual IMC.

And that's specifically what I was referring to. the so-called "split second decision" discussion is all speculation. It never should have come down to a split second decision.

Arent all decisions "split second". The second immediately prior you haven't yet made a decision. The second after the decision' already been made.

 

[MauleSkinner]

re: distracted pushing Ident button,
I used to fly a C421 that had an ident button mounted on the yoke opposite the auto pilot disconnect switch, trim, and transmit button.
The a/c had been based In, and operated under a European equivalent to FAR Part 135 for more than two decades.
I don’t know if it was a European requirement, but I thought it was a novel idea.

An ident button on the yoke is actually a requirement for at least some single-pilot jet operations

 

[MauleSkinner]

Arent all decisions "split second". The second immediately prior you haven't yet made a decision. The second after the decision' already been made.

It's all a matter of perspective. Sort of like the veteran Navy pilot who had his first ejection after 20 years of flying when a cat shot went bad. He was asked when he made the decision to eject, and he responded, "About 20 years ago."

 

[Bell206]

Well, when you're pushing to get there and suddenly you're in IMC, there's no discontinuing the flight at that point.

I think the correct take away is that entry to IMC immediately becomes about aviate

I think you missed the point. The correct take away is that all his training and company procedures directed him not to leave the Van Nuys area while en-route. Once he proceeded beyond his training and procedures limits it becomes immaterial at that point what caused him to fly into the ground. After all that is the whole point to training and required procedures to prevent that result. Right?

 

[Doc Holliday]

I observed the outcome.

As part of my job, I conduct training, not in aviation, but I understanding training. When I train someone and they go out and do it wrong, something is wrong with 1) my training delivery, 2) my training content, 3) my evaluation of the student, or 4) the student's engagement. As the trainer, even that last one is up to me and if the student isn't engaged, then I have to know that and fail to give them credit.

Bottom line, when the student performs the task correctly, the training was done right. When the student makes an error, the training was wrong.

The trained response, according to the Avweb video, is to level the airframe, slow the aircraft and execute a climb. I believe they got that from the Island Express training manual, which was probably at least edited by the pilot since he was the company check airman.

Instead, the pilot made a descending turn to the left until he contacted the ground. What I observe is 1) he did not properly execute the described training, 2) there is no way he was referencing his instruments OR he was task saturated and couldn't process what he was seeing and 3) you seem very aggressively insulted that I believe the cause of an IMC CFIT crash is bad recovery training. But the bottom line is, if the pilot had done what the Island Express training said to do then he would have recovered.

Bottom line is you don’t have the background or experience to be pontificating on a subject you know nothing about.

Not insulted here whatsoever, however when an armchair quarterback decides he knows more than the professionals and he can attempt to BS his way in subject matter of no expertise, I’m going to point that out.

He obviously passed his training, and he obviously passed the mandated 135.293 checkride to enable him to operate. You erroneously claim fault with a training program you know absolutely nothing about, operations in an aircraft you know absolutely nothing about, in flight conditions you know absolutely nothing about.

You refuse to accept the PIC, for whatever reason, decided to throw out training and procedures and proceed on his own, then try to place the blame on the training.

 

[bflynn]

Bottom line is you don’t have the background or experience to be pontificating on a subject you know nothing about.

I see. You're operating from the standpoint that because I don't fly helicopters, that I I'm not qualified to determine that the pilot didn't follow his training.

Did you watch the Avweb video? Did you read the NTSB report? The training and correct recovery method was covered in there, the method the pilot was supposed to have used. Everyone who watched the video knows what he should have done. Everyone knows what actually happened. The two don't match. Ergo, the pilot did not execute what he was trained to do.

So tell me - because there was training on what the pilot was to do, because we know what that training was, and because we know the pilot didn't execute the trained procedure correctly...why can we not say there was a training problem?

 

[bflynn]

I think you missed the point. The correct take away is that all his training and company procedures directed him not to leave the Van Nuys area while en-route. Once he proceeded beyond his training and procedures limits it becomes immaterial at that point what caused him to fly into the ground. After all that is the whole point to training and required procedures to prevent that result. Right?

So, you're saying there were additional training faults on ADM that I'm not addressing. I don't disagree with that, but my focus is on how an IFR rated pilot lost control and failed to do what was necessary to keep himself and his passengers alive.

 

[MauleSkinner]

So tell me - because there was training on what the pilot was to do, because we know what that training was, and because we know the pilot didn't execute the trained procedure correctly...why can we not say there was a training problem?

So, you're saying there were additional training faults on ADM that I'm not addressing. I don't disagree with that, but my focus is on how an IFR rated pilot lost control and failed to do what was necessary to keep himself and his passengers alive.

Who would you imagine conducted the training that the accident pilot went against?

 

[Doc Holliday]

I see. You're operating from the standpoint that because I don't fly helicopters, that I I'm not qualified to determine that the pilot didn't follow his training.

Did you watch the Avweb video? Did you read the NTSB report? The training and correct recovery method was covered in there, the method the pilot was supposed to have used. Everyone who watched the video knows what he should have done. Everyone knows what actually happened. The two don't match. Ergo, the pilot did not execute what he was trained to do.

So tell me - because there was training on what the pilot was to do, because we know what that training was, and because we know the pilot didn't execute the trained procedure correctly...why can we not say there was a training problem?

The PIC in question did not go IIMC. He went past a point in which his training told him to turn around. At that point for whatever reason he decided to go against what he was trained. Why we will never know.

He then proceeded to improvise with scud running.

 

[Bell206]

So, you're saying there were additional training faults on ADM that I'm not addressing.

No. The pilot made a conscious decision NOT to follow his existing training when he crossed the Van Nuys area and proceeded toward his destination. This has zero to do with the actual training he received because he purposely ignored it.

failed to do what was necessary to keep himself and his passengers alive.

And that would have been to land at Van Nuys or return to John Wayne. Period. Which would have been in accordance with his existing training and company procedures.

my focus is on how an IFR rated pilot lost control

That's the easy part. He got his Instrument ticket in 2007, hired on at Island in 2011, had 68.2 hours simulated instrument time and zero instrument proficiency checks (135.297) in his Island records, i.e., he hadn't flown IFR in at least 10 years. That part of the equation is no different than the airplane accidents posted on PoA every week.

 

[weilke]

This wasn't a 'split second' decision. By the time he was heading into a wall of fog at 140kts with a pass in front of him, multiple bad decisions had already been made.

Anyone familiar with LA road traffic. What would the drive time from Van Nuys to the sports venue have been at that time of the day ? Based on road mileage, it would have been 32min instead of 17min (from Camarillo), but I understand this is highly dependent on the time of day.

 

[bflynn]

LA traffic would have been about 2 hours between the two points.