Sikorsky S76Island Express
Calabasas, CA, USA · 2020-01-26·N72EX
What happened
NTSB summary, verbatimOn January 26, 2020, about 0945 PST, a Sikorsky S76B helicopter, N72EX, crashed into hilly terrain near Calabasas, California. A post impact fire ensued and resulted in a brush fire. The eight passengers and one pilot onboard were fatally injured and the helicopter was destroyed. The helicopter was operated by Island Express Helicopters. Weather at Van Nuys airport, about 14 miles northeast of the site was reported as 1,100 feet overcast with 2 ½ miles visibility. The flight was operated under the provisions of 14 CFR Part 135 under visual flight rules from John Wayne Airport (KSNA), Santa Ana, California, to Camarillo Airport (KCMA), Camarillo, California. An Investigative Webpage is located at https://www.ntsb.gov/investigations/Pages/DCA20MA059.aspx.
Photographs
1the aircraft, and what the investigators foundProbable cause
the Board's determinationThe 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 to the accident was the pilot’s likely self-induced pressure and the pilot’s plan continuation bias, which adversely affected his decision-making, and Island Express Helicopters Inc.’s inadequate review and oversight of its safety management processes.
Occurrence sequence
3 stepsNTSB coding · CICTT taxonomy- 1 · EnrouteVFR encounter with IMCdefining event
- 2 · EnrouteLoss of control in flight
- 3 · EnrouteCollision with terr/obj (non-CFIT)
Findings
6 causal · 3 contributing- CAUSEPersonnel issues › Action/decision › Info processing/decision › Decision making/judgment — Pilot
- CAUSEPersonnel issues › Psychological › Perception/orientation/illusion › Spatial disorientation — Pilot
- CAUSEPersonnel issues › Task performance › Use of equip/info › Aircraft control — Pilot
- CAUSEPersonnel issues › Psychological › Personality/attitude › Motivation/respond to pressure — Pilot
- CAUSEOrganizational issues › Support/oversight/monitoring › Safety programs › Adequacy of safety program — Operator
- CAUSEEnvironmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip › Clouds — Decision related to condition
- FACTOREnvironmental issues › Operating environment › Air traffic/operating proc — Compliance w/ procedure
- FACTORAircraft › Aircraft systems › Indicating/recording systems › Data recorders (flight/maint) — Not installed/available
- FACTORPersonnel issues › Task performance › Communication (personnel) › Lack of communication — ATC personnel
Safety recommendations
4 issuedwhat changed because of this accidentTO THE FEDERAL AVIATION ADMINISTRATION: Require the use of appropriate simulation devices during initial and recurrent pilot training for Title 14 Code of Federal Regulations Part 135 helicopter operations to provide scenario-based training that addresses the decision-making, skills, and procedures needed to recognize and respond to changing weather conditions in flight, identify and apply mitigation strategies for avoiding adverse weather, practice the transition to the use of flight instruments to reduce the risk of spatial disorientation, and maintain awareness of a variety of influences that can adversely affect pilot decision-making.
TO THE FEDERAL AVIATION ADMINISTRATION: 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 mitigate it, and make public a report on the committee’s findings.
TO ISLAND EXPRESS HELICOPTERS INC.: Participate in the Federal Aviation Administration’s Safety Management System Voluntary Program.
TO ISLAND EXPRESS HELICOPTERS, INC.: Install flight data recording devices capable of supporting a flight data monitoring (FDM) program on each helicopter in your fleet and establish an FDM program that reviews all available data sources to identify deviations from established norms and procedures as well as other potential safety issues.