February 23, 2021 • 28 mins
The NTSB issues its final report on the probable cause of the helicopter crash and makes recommendations to prevent another one like it from happening again. We learn more about the Mamba Sports Academy, the intended destination of the group aboard the flight. And we meet Gianna Bryant's teammate.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:08):
February nine, members of the National Transportation Safety Board meant
to review the results of the investigation into the crash
of the Sikorski s s B. Even good pilots can
end up in bad situations, and just because something is
legal doesn't mean that it's always safe. I'm Steve Gregory,
and this is the death and life of Kobe Bryant.
(00:34):
Robert Sumwalt is the chair of the NTSB. He convened
the members of the board, Bruce Landsburg, Michael Graham, Thomas Chapman,
and Jennifer hammondy Hamandy was the board member on scene
with a go team in Calabasas the day after the crash.
The report contains more than sixteen hundred pages of documents
and evidence related to the investigation. The hearing also includes
(00:56):
members of the NTSB staff, which sit through the entire
hearing to answer questions from board members. Now, I will
introduce the staff for today's meeting. Unless otherwise noted. The
staff members are from the Office of Aviation Safety. Dana Schultz,
the director for the Office Office of Aviation Safety, Bill English,
Investigator in Charge, Mike Richards, Meteorology Fabian Salazar, Operational Factors,
(01:24):
Dr Duan Civilian Human Performance Kathleen Silba, General Counsel for
the NTSP, Daulian Hatchett, Director for the Office of Safety,
Recommendations and Communications, Jim Ritter, Director for the Office of
Research and Engineering. Brian Soper Air Traffic Control, Chris Babcock
(01:45):
crash resistant flight recorder Systems from the Office of Research
and Engineering, Ban McKenny air Worthiness, Adam Horay Airworthiness, Nathan
Hoyt Safety Recommendations from the Office of Safety, recommen Dations
and Communications, greg Or Sorry Helicopter Maintenance and Visuals, and
Kathy Gania Report Writer and NTSB Board hearing is very
(02:09):
clinical and without emotion. The role of the board is
to establish a probable cause of an accident and offer
subsequent safety recommendations to prevent that type of accident from
ever happening again. Bill English was the lead investigator for
this incident and kicks off the hearing with his official
narrative on January at am Pacific Standard time. Sikorski seventy
(02:33):
B helicopter November seven, two Echo x Ray operated by
Island Express Helicopters collided with Hilly Terraine near the city
of Calabasas California. The pilot and eight passengers were fatally injured,
and the helicopter was destroyed by impact forces and fire.
The helicopter was not equipped with a flight data or
cockpit voice recorder, nor was it required to be. The
(02:55):
flight was an on demand charter operated under the provisions
of fourteen the Federal Regulations Part One to take the
passengers from John Wayne, Orange County Airport in Santa Ana, California,
to the Camario, California Airport for a basketball tournament. The
weather that morning included a widespread area of coastal clouds
associated with a marine layer, a stable humid air mass
(03:19):
about one to two thousand feet thick, often characterized by
stratus clouds at its top, and the potential for fog
formation in some areas below. There were no hazardous conditions
such as icing or thunderstorms. Mr Richards will have further
details on the meteorological factors in his presentation. The flight
was operated with a single pilot under visual flight rolls
(03:41):
or VFR, as Island Express was not authorized to conduct
passenger carrying flights under instrument flight rolls. This is typical
for helicopter charter operations. The pilot flying was Island Express.
His chief pilot, and he had been flying in the
area for ten years and had logged about the flight
to parted at nine oh seven and proceeded northwesterly across
(04:03):
the Los Angeles metropolitan area. At the pilot requested to
transit the Burbank Class Charlie air Space, but a TC
advised him to hold due to traffic. Weather in this
area was reported as cloud ceilings one thousand, one hundred
feet above ground level with visibility two and a half miles.
About eleven minutes later, a TC provided special VFR clearance
(04:26):
to proceed through the Burbank and Van Nuys airspace. Throughout
this segment of flight, the helicopter was maintaining an altitude
of about five hundred feet above ground level. As the
flight proceeded to the west out of the San Fernando
Valley area, a t C advised the pilot that they
would be too low for flight following and they should
contact Cameo Tower as they got closer. The pilot acknowledged,
(04:49):
and the helicopter proceeded to the west, following US or
out one on one toward an area of rising terrain
at a speed of about one hundred and forty knots.
About four minutes later, the pilot contacted a TC again
and advised them that he was intending to climb to
go above the cloud layers. A surveillance camera near the
one oh one captured the helicopter about this time. The
(05:13):
helicopter had been flying about three hundred and fifty feet
above ground level, but during the transmission to a TC,
began climbing at a rate of about fifteen hundred feet
per minute while generally following the one oh one in
a slight left turn. During radio communications with a TC,
the helicopter climbed through an altitude of two thousand feet
above sea level, or about hundred feet above ground level,
(05:35):
by which point it was highly unlikely for the pilot
to be able to maintain visual ground contact. The climb
reached a maximum altitude of about two thousand, four hundred
feet above sea level. As the helicopter continued a left
turn diverging from the highway. The controller asked the pilot's intentions,
and he said he was climbing to four thousand feet. However,
(05:57):
by that time the helicopter was in a tightening left
turn and descending rapidly. This maneuver is consistent with a
pilot experiencing spatial disorientation in limited visibility conditions. The helicopter
impacted hilly Terraine on a generally northeasterly bearing at a
high speed and decent rate. From here, all the subject
matter experts offer their respective narratives. One of the more
(06:18):
interesting perspectives comes from Dr duan civilian, an expert on
human performance and aviation. I will discuss the following human
performance issues in this accident, pilot decision making, spatial disorientation,
and safety management systems. Several factors may have influenced the
(06:38):
pilot to place pressure on himself to complete the flight.
For example, the pilot was preferred and trusted by the client,
as was Island Express. The pilot likely took pride in
these positions of trust with both the client and with
Island Express. The pilot had a good relationship with the
client and likely did not want to disappoint him by
(06:59):
not completing the like this kind of self induced pressure
can adversely affect pilot decision making and judgment. However, there
was no evidence that Island Expressed or the client placed
pressure on the pilot to accept the chartered flight request,
or complete the flight in adverse weather. The pilot's flight
(07:21):
in i AMC was inconsistent with his demonstrated judgment and
decision making. Although conditions were deteriorating en route, an alternative
course of action was not acted upon by the pilot.
The pilots continuation of the flight despite deteriorating weather conditions
was representative planned continuation bias, which strengthens as the pilot
(07:44):
gets closer to the destination. The pilot statement to the
air traffic control is that he was initiating. The climb
occurred about two seconds after the helicopter enter the clouds.
Data show the climb started at a rate about per minute,
accompanied by a gradual left bank to the left, generally
following the US one on one as the helicopter continue
(08:06):
climbing into the cloud layer. The pious loss of visual
references would have required him to transition to the flight
instruments to maintain awareness of the helicopter's attitude and track
the inner ear since his balance and orientation. We're flying
an aircraft and there's a lack of outside visual references,
(08:28):
our inner ear can give us a false sense of
orientation because our inner ear cannot distinguish between accelerations and tilt.
If a pilot cannot see outside visual references, he must
rely on flight instruments. When there are no outside visual references,
the pilot is more susceptible to inner ear illusions. One
(08:50):
common illusion that can trigger pilot's perception into believing he
is flying straight and level but he is in a
steady turn is called the leans. During the climb, and
I amc the helicopter earned a steady left turn, conducive
for the pilot to experience the lanes. The vestibular system
(09:11):
will usually detect initial rolling and turning movement. However, once
the aircraft is stabilized in a steady rate of turn
and angle of bank, the vestibular system will catch up
with the aircraft and the pilot can believe that the
aircraft is straight and leveled when it is not. Helicopter
was in a left bank rapid climb. It's bank increased
(09:35):
and it entered a tighter left turn that diverged away
from US one on one. The increasing bank would exacerbate
the aspects of the lanes. The result of descent and
acceleration were conducive for the pilot to experience a semidographic
illusion in which he would incorrectly perceive that the helicopter
(09:56):
was climbing when it was descending. The pilot was either
not referencing the helicopter's instruments or having difficulty interpreting or
believing them due to the compelling vestibular illusions, and he
did not successfully recover the helicopter coming up. NTSP board
(10:17):
members began questioning investigators. It becomes clear where the blame's
gonna land, and we talk with a teammate of Gianna
Bryant's about their time together. As the death and life
of Kobe Bryant continues, members of the NTSB have gathered
(10:52):
to discuss the investigation into the crash of the Sikorski
s B and it's time for board members to ask
the ntsb s own investigators and subject matter experts about
details of the twelve month investigation. At one point, board
member Michael Graham focused on pilot are as abyans training.
(11:12):
Graham seemed concerned it's a bayan's decision to fly into
the clouds using only visual flight rules or VFR. The
pilot should initiate a straight ahead climb. Straight ahead controlled
climb to an altitude that will provide obstructive clearance in
the area of operation. Did he climb straight ahead in
that case when he penetrated the weather, No, sir, the
(11:35):
climb was initiated in a subtle left turn. Following the
subtle left turn, so he didn't follow his training. Do
you feel he he committed to the instruments? In this case,
the path and behavior of the helicopter is not consistent
with committing to the instruments. Exactly. I agree with you
wholeheartedly there. So um, yeah, I'm just concerned about all
(11:59):
this as as a as a fellow aviator. He didn't
even follow the training, so I see, my time's about up.
I just say, you know, as long as we continue
to have VFR only helicopters continuing to flirt with marginal
weather and sometimes sub marginal weather um of low altitudes,
(12:19):
low ceilings, limited visibility, unfortunately, a certain percentage of them
will stray into inavert in I amc and unfortunately a
certain percentage of them will not come out alive. Remember,
Tom Chapman has a different concerns. Certainly, it could be
that self induced pressure played a role, and it's reasonable
to discuss that as a possibility. Would you please elaborate
(12:43):
on the findings of the investigation on this point. The
relationship between the pilot and the client had turned into
a friendship over the years, that the client allowed the
pilot to fly his children UH without him being present,
and that that type of relationship that they had was
(13:08):
very close. And when we look at human factor psychology,
we look at the decisions that people make based off
of the perception of a situation UH, and in this case,
the the pilot as he was flying en route, these
(13:28):
types of this this type of relationship that he had
with the client can UH leads to self induced pressure
during the portion of the flight, and so that is
why it's the objective evidence from the interviews that helped
us understand that relationship and the effect that it can
(13:48):
have on pilot decision making. UH. The investigation Also, investigation
also indicates that the phenomenon of planned continuation bias was
a factor contributing to the pile decision to continue the flight.
Is planned continuation bias dependent on an element of self
induced pressure? So, in other words, is it possible there
(14:09):
could have been planned continuation bias without any self induced
pressure of the type that you've described. Well, in this case,
it was both self induced pressure and planning continuation bias
UH and the plan continuation bias UH. Portion of it
was the pilot continuing the flight despite changing conditions. Board
(14:32):
member Jennifer Hammond he was at the crash site and
her first round of questioning had more to do with
risk assessment. She's been asking the chief investigator about a
checklist at the beginning of the flight. But then she summarizes,
I guess what I'm asking is why wasn't there an
alternative plan? An alternative plan and could have helped? At
the time at eight thirty seven, he had a conversation
(14:54):
with O C that said that mapped. He pointed to
a map that said he planned to go north to
Rogers Stadium in Los Angeles, around Burbank and follow State
Route one eighteen. At some point after Van Nye he enters,
I MC around and you and I discussed this ninety
four and seconds sometime between there and nine and ten seconds.
(15:19):
That's thirty five seconds. I mean, that's not a lot
of time. And so would you why wouldn't you have
wouldn't it have helped if you had an alternative plan
in mind rather than a quick decision making yes, ma'am
coming up. The board makes its final determination and we
meet a teammate of Gianna Bryant's. As the death in
(15:42):
life of Kobe Bryant continues for about four hours, members
(16:02):
of the NTSB did rounds of Q and A s
with investigators. Then it was time to present the final report.
The National Transportation Safety Board determines that the probable cause
of this 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
(16:25):
to the accident was the pilot's likely self induced pressure
and the pilot's plan continued continuation bias, which adversely affected
his decision making. And Island Express Helicopters inadequate review and
oversight of its safety management process, and, as with all
NTSB hearings, safety recommendations follow. As a result of this investigation,
(16:49):
staff proposes the following four new safety recommendations due to
the Federal Aviation Administration. One, require the use of appropriate
simulation devices during initial and recurrent pilot training for Title
fourteen Code of Federal Regulations, Part one thirty five Helicopter
(17:09):
Operations two convene a multidisciplinary panel of aircraft performance, human factors,
and aircraft operations specialists to evaluate spatial disorientation simulation technologies
to determine which applications are most effective for training pilots
to recognize the onset of spatial disorientation and successfully mitigated,
(17:34):
and to two Island Express Helicopters, Inc. Three participate in
the Federal Aviation Administration's Safety Management System Voluntary program, and
number four install flight data recording devices capable of supporting
a flight data Monitoring FDM program on each helicopter in
your fleet. Now it's time for Chairman Bob some Walt
(17:56):
to call for a vote. No further discussions or Vice
Chairman Landsburg. Your vote is I shareman votes. I remember Hamedymember,
Hamedy votes, Remember Graham Imber Graham votes on. Remember Chapman,
I remember Chapman votes on. The chairman votes. Uh. The
report has been adopted as revised unanimously. Minutes after the hearing,
(18:19):
some Walt takes questions from the media in a virtual
press conference. Stephen Gregory, thank you, Chairman. Stone Walt, You
have made these statements all throughout, not only hearing it
with my colleague here about good pilots make bad decisions.
You talked about Island Express being a potential I'm safe operator,
after all, they were the ones that this crash happened with. Also,
(18:41):
you talked about the previous owners of the helicopter had
CFR but Island Express did not. It was almost sort
of this subtle hint along the way that you were
you were sending out messages to either Part one thirty
five operators or to Island Express that they're this. There
was a series of bad choices along the way. Is
that correct? I think so. As you pointed out, they
(19:04):
had a flight data recorder when they received the helicopter,
they removed the I'm sorry as a CVR. Maybe it
was an FDR. They'll have to look which wasn't It
was a it was a cockpit MORS recorder. They removed
it when they got the got the helicopter. Uh. I
personally believe that you can certainly operate a helicopter like
(19:27):
this single pilot, and you can do it very safely
until something happens, like you inadvertently flying to the clouds,
or until your pilot gets distracted and something happens. So
I feel like UM has mentioned in the board meeting,
the oil and gas industry has pretty much exclusively gone
(19:51):
to two pilot operations in aircraft of this of this
similar size. UM. Why are they doing that, UM to
enhance the safety margin? And I feel like, uh, that's
a question. That I have this same exact helicopter, same
exact ship. UM. When Chevron used it, they had to
(20:12):
have to two pilots. UM. Wonder while Island Express did
not elect to operate that way when they were chartering
to other clients. There are a lot of corporate operators
that I've checked with over the last few weeks that
operate this same type of aircraft exclusively with two pilots. Again,
(20:33):
the previous owner of this preview of this helicopter always
operated with two pilots. I want to make darn sure
that somebody doesn't think that I'm blaming the client for
electing not to operate with two pilots. UM. I think
that sometimes the consumers. I want the consumers to be
(20:54):
aware and just because something is legal doesn't mean that
it's always safe. At Mamba Sports, Academy. We embraced the
Mamba mentally on the morning of the accident. The Mamba
Sports Academy was the intended destination for Bryant, Bryant's daughter, Gianna,
Gianna's two teammates and parents of her teammates, as well
(21:17):
as the girls assistant coach. Mamba Sports Academy is where
we evolved and have fun. I did know G first
time I met her. She was really nice. Isabella Escribano
says she was one of G's teammates and recalls how
she became a member of the Mamba Sports Academy. I
started playing for Team Mamba by well the Lakers assistant
(21:40):
coach Phil Handy. He invited me to a workout and
with j R. Smith and basically Kobe saw that video
me working out with NBA player, which no ordinary eleven
and ten year old would work out with the NBA player,
And to me, it was really surprising and you like
(22:02):
you never like you never see like a girl working
out with NBA player. Phil trained Kobe and he knew
Kobe physically and um he basically asked Phil and said
how old is this girl and what great is she?
And invited over to practice with us, I go over
(22:22):
and this is my first time meeting Kobe Bryant. Like ever,
I never met him. I never took a picture with
him because actually my first time meeting him, and it
was just he looked kind of like a god to me,
like a Hercules, and it was just so cool meeting him,
Um and just being right next to him was just
a blessing. The first practice, Gigi, his daughter Gianna was
(22:47):
on the eighth grade girls team and I was a
sixth grader, which was a big difference an age gap,
but um, he had another girl was sixth sixth grade,
and he wanted to make a se a great team,
and he wanted me to play for a seventh grade team.
So basically I was just going to practice with the
eighth graders until we started playing basket, like when we
(23:10):
started playing art, like when we started getting into our
actual tournaments. But interacting with him was such a blessing
getting advice from him. Um. I remember the first time
I met him, he told me, Um, brick by brick,
which meant is that you can't build your house and
one day it's gonna take day by day. And he
(23:31):
told me it's like cutting down a tree. It's going
to take piece by piece by piece, and just like
hearing those words is like okay. So he wants me
to take it day by day and he wants me
to like take my time learning all the all of
like this knowledge he's giving me, says. She remembers where
she was and what she was doing the morning she
heard about the helicopter crash. Me and my brother were
(23:53):
at Target. The game didn't start until like thirty minutes later,
and we were right there, like literally, I'm gonna say,
twelve minutes, fifteen minutes from the sports Accati. My brother
gets a call from as one of his friends and says,
did you hear the news? My brother's like, what news.
He's like, cold, we just crashed his helicopter. My brother
starts crying and I'm like, why are you crying? And
(24:14):
he says that your coach just died. I wasn't shocked.
I didn't like I didn't start crying until we got there.
The whole team. Like if you saw, if you were
in like the room where the team was, you would
have like like burst of tears because the girls were
like literally crying so much. It was just really sad
(24:34):
to be in there, and that's when I started like
thinking to myself, wait, did he really die or is
this like fake? Like I didn't know if it was
a dream or not or reality. To me, it wasn't real.
I don't feel like it's still real. And then later
on we found out that you was in there and
our teammates were in there as well. I was younger
(24:55):
than Gianna, but that didn't stop them from hanging out
on and off the court. First time I met her,
she was really nice. She introduced me, she asked where
I lived. Day by day. I started like talking to her,
getting to know her a little bit more. Um, she
actually is the reason why I got onto TikTok. And
I was like, let's TikTok and she's like, oh, you
(25:15):
don't know what TikTok is. And I did my first,
I think, my first dancing TikTok with her. Um, it
was really cool. I was like really serious in the
in the video, but there's a reason I didn't know,
like what the dance was. We had to do I
think three times that video. She was really nice. She
was a really kind girl. The stuff I could tell
(25:36):
you about g G is she was really determined she
really wanted to be better. Yeah, and she really loved basketball.
When we would practice together, you know, like when we
got on the court, we're like, we're not friends anymore,
but when we're off the court, we are friends. So
you know, I would put my effort in, She'll put
her effort in. Looking back now, Arbano says she was
(25:59):
truly blessed be coached by Kobe Bryant. It's like the
best feeling, like nobody, no, no coach is better than
Kobe Bryant. To me, having a coach Kobe Bryant, you
can never say that you had Kobe Bryant as your coach.
I was just so blessed to be coached by Kobe
Bryan because I knew I was gonna learn so much
from him, and I was gonna know so much knowledge.
And I was like, I remember, he told me that
(26:21):
he didn't want me to be the number one eleven
year old. He wanted me to be the number one
fifteen sixteen year old, and he wanted me to like
progress every day. What he was trying to do is
that woman's sports, well, woman's sports is a big deal,
but woman's basketball isn't really a big deal. It's more
than the men's game. What he was trying to do
(26:43):
is make the woman's game more expand and he was
trying to make the woman's game more big. And I
felt like that was just like the best feeling that
Kobe Bryant was trying to get girls out there that
are good, that girls could play basketball, and that girls
are like fun to walk. And I feel like he
wanted to do that. He wanted to expand the girls
(27:04):
use the basketball, and um, after he was gone, I
wanted to finish that job for him. The Sports Academy
opened in It was Decemberen that Kobe Bryant announced the
renaming of the facility to the Mamba Sports Academy. Four
months after the tragic accident, the academy's CEO, Chad Faulkner
would announce that they would drop the name Mamba and
(27:26):
simply go back to the original name of the Sports Academy.
Faulkner said, out of respect for Bryant, our beliefs and
thoughts are Kobe is one of one. Mamba is one
of one. Coming up in episode six, you know, it's
(27:47):
it's really emotional some of these murals that I see
and still see to this day, Bryant would become an
inspiration in the most unlikely ways, and still to come
in future episodes Bryant's quiet and unknown contributions to charity.
The Death and Life of Kobe Bryant is a production
of k FI News at iHeartMedia, Los Angeles for the
iHeart podcast network.
February nine, members of the National Transportation Safety Board meant
to review the results of the investigation into the crash
of the Sikorski s s B. Even good pilots can
end up in bad situations, and just because something is
legal doesn't mean that it's always safe. I'm Steve Gregory,
and this is the death and life of Kobe Bryant.
(00:34):
Robert Sumwalt is the chair of the NTSB. He convened
the members of the board, Bruce Landsburg, Michael Graham, Thomas Chapman,
and Jennifer hammondy Hamandy was the board member on scene
with a go team in Calabasas the day after the crash.
The report contains more than sixteen hundred pages of documents
and evidence related to the investigation. The hearing also includes
(00:56):
members of the NTSB staff, which sit through the entire
hearing to answer questions from board members. Now, I will
introduce the staff for today's meeting. Unless otherwise noted. The
staff members are from the Office of Aviation Safety. Dana Schultz,
the director for the Office Office of Aviation Safety, Bill English,
Investigator in Charge, Mike Richards, Meteorology Fabian Salazar, Operational Factors,
(01:24):
Dr Duan Civilian Human Performance Kathleen Silba, General Counsel for
the NTSP, Daulian Hatchett, Director for the Office of Safety,
Recommendations and Communications, Jim Ritter, Director for the Office of
Research and Engineering. Brian Soper Air Traffic Control, Chris Babcock
(01:45):
crash resistant flight recorder Systems from the Office of Research
and Engineering, Ban McKenny air Worthiness, Adam Horay Airworthiness, Nathan
Hoyt Safety Recommendations from the Office of Safety, recommen Dations
and Communications, greg Or Sorry Helicopter Maintenance and Visuals, and
Kathy Gania Report Writer and NTSB Board hearing is very
(02:09):
clinical and without emotion. The role of the board is
to establish a probable cause of an accident and offer
subsequent safety recommendations to prevent that type of accident from
ever happening again. Bill English was the lead investigator for
this incident and kicks off the hearing with his official
narrative on January at am Pacific Standard time. Sikorski seventy
(02:33):
B helicopter November seven, two Echo x Ray operated by
Island Express Helicopters collided with Hilly Terraine near the city
of Calabasas California. The pilot and eight passengers were fatally injured,
and the helicopter was destroyed by impact forces and fire.
The helicopter was not equipped with a flight data or
cockpit voice recorder, nor was it required to be. The
(02:55):
flight was an on demand charter operated under the provisions
of fourteen the Federal Regulations Part One to take the
passengers from John Wayne, Orange County Airport in Santa Ana, California,
to the Camario, California Airport for a basketball tournament. The
weather that morning included a widespread area of coastal clouds
associated with a marine layer, a stable humid air mass
(03:19):
about one to two thousand feet thick, often characterized by
stratus clouds at its top, and the potential for fog
formation in some areas below. There were no hazardous conditions
such as icing or thunderstorms. Mr Richards will have further
details on the meteorological factors in his presentation. The flight
was operated with a single pilot under visual flight rolls
(03:41):
or VFR, as Island Express was not authorized to conduct
passenger carrying flights under instrument flight rolls. This is typical
for helicopter charter operations. The pilot flying was Island Express.
His chief pilot, and he had been flying in the
area for ten years and had logged about the flight
to parted at nine oh seven and proceeded northwesterly across
(04:03):
the Los Angeles metropolitan area. At the pilot requested to
transit the Burbank Class Charlie air Space, but a TC
advised him to hold due to traffic. Weather in this
area was reported as cloud ceilings one thousand, one hundred
feet above ground level with visibility two and a half miles.
About eleven minutes later, a TC provided special VFR clearance
(04:26):
to proceed through the Burbank and Van Nuys airspace. Throughout
this segment of flight, the helicopter was maintaining an altitude
of about five hundred feet above ground level. As the
flight proceeded to the west out of the San Fernando
Valley area, a t C advised the pilot that they
would be too low for flight following and they should
contact Cameo Tower as they got closer. The pilot acknowledged,
(04:49):
and the helicopter proceeded to the west, following US or
out one on one toward an area of rising terrain
at a speed of about one hundred and forty knots.
About four minutes later, the pilot contacted a TC again
and advised them that he was intending to climb to
go above the cloud layers. A surveillance camera near the
one oh one captured the helicopter about this time. The
(05:13):
helicopter had been flying about three hundred and fifty feet
above ground level, but during the transmission to a TC,
began climbing at a rate of about fifteen hundred feet
per minute while generally following the one oh one in
a slight left turn. During radio communications with a TC,
the helicopter climbed through an altitude of two thousand feet
above sea level, or about hundred feet above ground level,
(05:35):
by which point it was highly unlikely for the pilot
to be able to maintain visual ground contact. The climb
reached a maximum altitude of about two thousand, four hundred
feet above sea level. As the helicopter continued a left
turn diverging from the highway. The controller asked the pilot's intentions,
and he said he was climbing to four thousand feet. However,
(05:57):
by that time the helicopter was in a tightening left
turn and descending rapidly. This maneuver is consistent with a
pilot experiencing spatial disorientation in limited visibility conditions. The helicopter
impacted hilly Terraine on a generally northeasterly bearing at a
high speed and decent rate. From here, all the subject
matter experts offer their respective narratives. One of the more
(06:18):
interesting perspectives comes from Dr duan civilian, an expert on
human performance and aviation. I will discuss the following human
performance issues in this accident, pilot decision making, spatial disorientation,
and safety management systems. Several factors may have influenced the
(06:38):
pilot to place pressure on himself to complete the flight.
For example, the pilot was preferred and trusted by the client,
as was Island Express. The pilot likely took pride in
these positions of trust with both the client and with
Island Express. The pilot had a good relationship with the
client and likely did not want to disappoint him by
(06:59):
not completing the like this kind of self induced pressure
can adversely affect pilot decision making and judgment. However, there
was no evidence that Island Expressed or the client placed
pressure on the pilot to accept the chartered flight request,
or complete the flight in adverse weather. The pilot's flight
(07:21):
in i AMC was inconsistent with his demonstrated judgment and
decision making. Although conditions were deteriorating en route, an alternative
course of action was not acted upon by the pilot.
The pilots continuation of the flight despite deteriorating weather conditions
was representative planned continuation bias, which strengthens as the pilot
(07:44):
gets closer to the destination. The pilot statement to the
air traffic control is that he was initiating. The climb
occurred about two seconds after the helicopter enter the clouds.
Data show the climb started at a rate about per minute,
accompanied by a gradual left bank to the left, generally
following the US one on one as the helicopter continue
(08:06):
climbing into the cloud layer. The pious loss of visual
references would have required him to transition to the flight
instruments to maintain awareness of the helicopter's attitude and track
the inner ear since his balance and orientation. We're flying
an aircraft and there's a lack of outside visual references,
(08:28):
our inner ear can give us a false sense of
orientation because our inner ear cannot distinguish between accelerations and tilt.
If a pilot cannot see outside visual references, he must
rely on flight instruments. When there are no outside visual references,
the pilot is more susceptible to inner ear illusions. One
(08:50):
common illusion that can trigger pilot's perception into believing he
is flying straight and level but he is in a
steady turn is called the leans. During the climb, and
I amc the helicopter earned a steady left turn, conducive
for the pilot to experience the lanes. The vestibular system
(09:11):
will usually detect initial rolling and turning movement. However, once
the aircraft is stabilized in a steady rate of turn
and angle of bank, the vestibular system will catch up
with the aircraft and the pilot can believe that the
aircraft is straight and leveled when it is not. Helicopter
was in a left bank rapid climb. It's bank increased
(09:35):
and it entered a tighter left turn that diverged away
from US one on one. The increasing bank would exacerbate
the aspects of the lanes. The result of descent and
acceleration were conducive for the pilot to experience a semidographic
illusion in which he would incorrectly perceive that the helicopter
(09:56):
was climbing when it was descending. The pilot was either
not referencing the helicopter's instruments or having difficulty interpreting or
believing them due to the compelling vestibular illusions, and he
did not successfully recover the helicopter coming up. NTSP board
(10:17):
members began questioning investigators. It becomes clear where the blame's
gonna land, and we talk with a teammate of Gianna
Bryant's about their time together. As the death and life
of Kobe Bryant continues, members of the NTSB have gathered
(10:52):
to discuss the investigation into the crash of the Sikorski
s B and it's time for board members to ask
the ntsb s own investigators and subject matter experts about
details of the twelve month investigation. At one point, board
member Michael Graham focused on pilot are as abyans training.
(11:12):
Graham seemed concerned it's a bayan's decision to fly into
the clouds using only visual flight rules or VFR. The
pilot should initiate a straight ahead climb. Straight ahead controlled
climb to an altitude that will provide obstructive clearance in
the area of operation. Did he climb straight ahead in
that case when he penetrated the weather, No, sir, the
(11:35):
climb was initiated in a subtle left turn. Following the
subtle left turn, so he didn't follow his training. Do
you feel he he committed to the instruments? In this case,
the path and behavior of the helicopter is not consistent
with committing to the instruments. Exactly. I agree with you
wholeheartedly there. So um, yeah, I'm just concerned about all
(11:59):
this as as a as a fellow aviator. He didn't
even follow the training, so I see, my time's about up.
I just say, you know, as long as we continue
to have VFR only helicopters continuing to flirt with marginal
weather and sometimes sub marginal weather um of low altitudes,
(12:19):
low ceilings, limited visibility, unfortunately, a certain percentage of them
will stray into inavert in I amc and unfortunately a
certain percentage of them will not come out alive. Remember,
Tom Chapman has a different concerns. Certainly, it could be
that self induced pressure played a role, and it's reasonable
to discuss that as a possibility. Would you please elaborate
(12:43):
on the findings of the investigation on this point. The
relationship between the pilot and the client had turned into
a friendship over the years, that the client allowed the
pilot to fly his children UH without him being present,
and that that type of relationship that they had was
(13:08):
very close. And when we look at human factor psychology,
we look at the decisions that people make based off
of the perception of a situation UH, and in this case,
the the pilot as he was flying en route, these
(13:28):
types of this this type of relationship that he had
with the client can UH leads to self induced pressure
during the portion of the flight, and so that is
why it's the objective evidence from the interviews that helped
us understand that relationship and the effect that it can
(13:48):
have on pilot decision making. UH. The investigation Also, investigation
also indicates that the phenomenon of planned continuation bias was
a factor contributing to the pile decision to continue the flight.
Is planned continuation bias dependent on an element of self
induced pressure? So, in other words, is it possible there
(14:09):
could have been planned continuation bias without any self induced
pressure of the type that you've described. Well, in this case,
it was both self induced pressure and planning continuation bias
UH and the plan continuation bias UH. Portion of it
was the pilot continuing the flight despite changing conditions. Board
(14:32):
member Jennifer Hammond he was at the crash site and
her first round of questioning had more to do with
risk assessment. She's been asking the chief investigator about a
checklist at the beginning of the flight. But then she summarizes,
I guess what I'm asking is why wasn't there an
alternative plan? An alternative plan and could have helped? At
the time at eight thirty seven, he had a conversation
(14:54):
with O C that said that mapped. He pointed to
a map that said he planned to go north to
Rogers Stadium in Los Angeles, around Burbank and follow State
Route one eighteen. At some point after Van Nye he enters,
I MC around and you and I discussed this ninety
four and seconds sometime between there and nine and ten seconds.
(15:19):
That's thirty five seconds. I mean, that's not a lot
of time. And so would you why wouldn't you have
wouldn't it have helped if you had an alternative plan
in mind rather than a quick decision making yes, ma'am
coming up. The board makes its final determination and we
meet a teammate of Gianna Bryant's. As the death in
(15:42):
life of Kobe Bryant continues for about four hours, members
(16:02):
of the NTSB did rounds of Q and A s
with investigators. Then it was time to present the final report.
The National Transportation Safety Board determines that the probable cause
of this 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
(16:25):
to the accident was the pilot's likely self induced pressure
and the pilot's plan continued continuation bias, which adversely affected
his decision making. And Island Express Helicopters inadequate review and
oversight of its safety management process, and, as with all
NTSB hearings, safety recommendations follow. As a result of this investigation,
(16:49):
staff proposes the following four new safety recommendations due to
the Federal Aviation Administration. One, require the use of appropriate
simulation devices during initial and recurrent pilot training for Title
fourteen Code of Federal Regulations, Part one thirty five Helicopter
(17:09):
Operations two convene a multidisciplinary panel of aircraft performance, human factors,
and aircraft operations specialists to evaluate spatial disorientation simulation technologies
to determine which applications are most effective for training pilots
to recognize the onset of spatial disorientation and successfully mitigated,
(17:34):
and to two Island Express Helicopters, Inc. Three participate in
the Federal Aviation Administration's Safety Management System Voluntary program, and
number four install flight data recording devices capable of supporting
a flight data Monitoring FDM program on each helicopter in
your fleet. Now it's time for Chairman Bob some Walt
(17:56):
to call for a vote. No further discussions or Vice
Chairman Landsburg. Your vote is I shareman votes. I remember Hamedymember,
Hamedy votes, Remember Graham Imber Graham votes on. Remember Chapman,
I remember Chapman votes on. The chairman votes. Uh. The
report has been adopted as revised unanimously. Minutes after the hearing,
(18:19):
some Walt takes questions from the media in a virtual
press conference. Stephen Gregory, thank you, Chairman. Stone Walt, You
have made these statements all throughout, not only hearing it
with my colleague here about good pilots make bad decisions.
You talked about Island Express being a potential I'm safe operator,
after all, they were the ones that this crash happened with. Also,
(18:41):
you talked about the previous owners of the helicopter had
CFR but Island Express did not. It was almost sort
of this subtle hint along the way that you were
you were sending out messages to either Part one thirty
five operators or to Island Express that they're this. There
was a series of bad choices along the way. Is
that correct? I think so. As you pointed out, they
(19:04):
had a flight data recorder when they received the helicopter,
they removed the I'm sorry as a CVR. Maybe it
was an FDR. They'll have to look which wasn't It
was a it was a cockpit MORS recorder. They removed
it when they got the got the helicopter. Uh. I
personally believe that you can certainly operate a helicopter like
(19:27):
this single pilot, and you can do it very safely
until something happens, like you inadvertently flying to the clouds,
or until your pilot gets distracted and something happens. So
I feel like UM has mentioned in the board meeting,
the oil and gas industry has pretty much exclusively gone
(19:51):
to two pilot operations in aircraft of this of this
similar size. UM. Why are they doing that, UM to
enhance the safety margin? And I feel like, uh, that's
a question. That I have this same exact helicopter, same
exact ship. UM. When Chevron used it, they had to
(20:12):
have to two pilots. UM. Wonder while Island Express did
not elect to operate that way when they were chartering
to other clients. There are a lot of corporate operators
that I've checked with over the last few weeks that
operate this same type of aircraft exclusively with two pilots. Again,
(20:33):
the previous owner of this preview of this helicopter always
operated with two pilots. I want to make darn sure
that somebody doesn't think that I'm blaming the client for
electing not to operate with two pilots. UM. I think
that sometimes the consumers. I want the consumers to be
(20:54):
aware and just because something is legal doesn't mean that
it's always safe. At Mamba Sports, Academy. We embraced the
Mamba mentally on the morning of the accident. The Mamba
Sports Academy was the intended destination for Bryant, Bryant's daughter, Gianna,
Gianna's two teammates and parents of her teammates, as well
(21:17):
as the girls assistant coach. Mamba Sports Academy is where
we evolved and have fun. I did know G first
time I met her. She was really nice. Isabella Escribano
says she was one of G's teammates and recalls how
she became a member of the Mamba Sports Academy. I
started playing for Team Mamba by well the Lakers assistant
(21:40):
coach Phil Handy. He invited me to a workout and
with j R. Smith and basically Kobe saw that video
me working out with NBA player, which no ordinary eleven
and ten year old would work out with the NBA player,
And to me, it was really surprising and you like
(22:02):
you never like you never see like a girl working
out with NBA player. Phil trained Kobe and he knew
Kobe physically and um he basically asked Phil and said
how old is this girl and what great is she?
And invited over to practice with us, I go over
(22:22):
and this is my first time meeting Kobe Bryant. Like ever,
I never met him. I never took a picture with
him because actually my first time meeting him, and it
was just he looked kind of like a god to me,
like a Hercules, and it was just so cool meeting him,
Um and just being right next to him was just
a blessing. The first practice, Gigi, his daughter Gianna was
(22:47):
on the eighth grade girls team and I was a
sixth grader, which was a big difference an age gap,
but um, he had another girl was sixth sixth grade,
and he wanted to make a se a great team,
and he wanted me to play for a seventh grade team.
So basically I was just going to practice with the
eighth graders until we started playing basket, like when we
(23:10):
started playing art, like when we started getting into our
actual tournaments. But interacting with him was such a blessing
getting advice from him. Um. I remember the first time
I met him, he told me, Um, brick by brick,
which meant is that you can't build your house and
one day it's gonna take day by day. And he
(23:31):
told me it's like cutting down a tree. It's going
to take piece by piece by piece, and just like
hearing those words is like okay. So he wants me
to take it day by day and he wants me
to like take my time learning all the all of
like this knowledge he's giving me, says. She remembers where
she was and what she was doing the morning she
heard about the helicopter crash. Me and my brother were
(23:53):
at Target. The game didn't start until like thirty minutes later,
and we were right there, like literally, I'm gonna say,
twelve minutes, fifteen minutes from the sports Accati. My brother
gets a call from as one of his friends and says,
did you hear the news? My brother's like, what news.
He's like, cold, we just crashed his helicopter. My brother
starts crying and I'm like, why are you crying? And
(24:14):
he says that your coach just died. I wasn't shocked.
I didn't like I didn't start crying until we got there.
The whole team. Like if you saw, if you were
in like the room where the team was, you would
have like like burst of tears because the girls were
like literally crying so much. It was just really sad
(24:34):
to be in there, and that's when I started like
thinking to myself, wait, did he really die or is
this like fake? Like I didn't know if it was
a dream or not or reality. To me, it wasn't real.
I don't feel like it's still real. And then later
on we found out that you was in there and
our teammates were in there as well. I was younger
(24:55):
than Gianna, but that didn't stop them from hanging out
on and off the court. First time I met her,
she was really nice. She introduced me, she asked where
I lived. Day by day. I started like talking to her,
getting to know her a little bit more. Um, she
actually is the reason why I got onto TikTok. And
I was like, let's TikTok and she's like, oh, you
(25:15):
don't know what TikTok is. And I did my first,
I think, my first dancing TikTok with her. Um, it
was really cool. I was like really serious in the
in the video, but there's a reason I didn't know,
like what the dance was. We had to do I
think three times that video. She was really nice. She
was a really kind girl. The stuff I could tell
(25:36):
you about g G is she was really determined she
really wanted to be better. Yeah, and she really loved basketball.
When we would practice together, you know, like when we
got on the court, we're like, we're not friends anymore,
but when we're off the court, we are friends. So
you know, I would put my effort in, She'll put
her effort in. Looking back now, Arbano says she was
(25:59):
truly blessed be coached by Kobe Bryant. It's like the
best feeling, like nobody, no, no coach is better than
Kobe Bryant. To me, having a coach Kobe Bryant, you
can never say that you had Kobe Bryant as your coach.
I was just so blessed to be coached by Kobe
Bryan because I knew I was gonna learn so much
from him, and I was gonna know so much knowledge.
And I was like, I remember, he told me that
(26:21):
he didn't want me to be the number one eleven
year old. He wanted me to be the number one
fifteen sixteen year old, and he wanted me to like
progress every day. What he was trying to do is
that woman's sports, well, woman's sports is a big deal,
but woman's basketball isn't really a big deal. It's more
than the men's game. What he was trying to do
(26:43):
is make the woman's game more expand and he was
trying to make the woman's game more big. And I
felt like that was just like the best feeling that
Kobe Bryant was trying to get girls out there that
are good, that girls could play basketball, and that girls
are like fun to walk. And I feel like he
wanted to do that. He wanted to expand the girls
(27:04):
use the basketball, and um, after he was gone, I
wanted to finish that job for him. The Sports Academy
opened in It was Decemberen that Kobe Bryant announced the
renaming of the facility to the Mamba Sports Academy. Four
months after the tragic accident, the academy's CEO, Chad Faulkner
would announce that they would drop the name Mamba and
(27:26):
simply go back to the original name of the Sports Academy.
Faulkner said, out of respect for Bryant, our beliefs and
thoughts are Kobe is one of one. Mamba is one
of one. Coming up in episode six, you know, it's
(27:47):
it's really emotional some of these murals that I see
and still see to this day, Bryant would become an
inspiration in the most unlikely ways, and still to come
in future episodes Bryant's quiet and unknown contributions to charity.
The Death and Life of Kobe Bryant is a production
of k FI News at iHeartMedia, Los Angeles for the
iHeart podcast network.
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