The REAL Kobe Bryant Story that the Crash Investigation Ignored! N72EX

A gorgeous Sikorsky S76 is flying over the Ventura Freeway, otherwise known as Highway 101 just north of Los Angeles, California, as it transports 8 passengers to a sporting event in Thousand Oaks, CA when they suddenly encounter low clouds just as they begin flying over the city of Calabasas,CA.  The pilot attempts to climb over these clouds and as he finally emerges from the clouds, they have actually turned all the way around and are now pointed directly at the ground and descending at an extremely high rate of speed.   There is no time to react and this helicopter is destroyed on impact, killing the pilot, and all 8 of the passengers on board. 

You may have heard about this one before as this helicopter was carrying Kobe Bryant and consumed the national and international news cycle for quite a while a couple years ago.  Not only did this tragedy claim the lives of 9 people, including three children, but there was a trial that just concluded a couple months ago, nearly 3 years after the accident, due to law enforcement and fire personnel inappropriately sharing graphic pictures of the bodies of the victims on this helicopter. 

We put a lot of trust in the media, and even to our investigatory boards such as the National Transportation Safety Board (NTSB).  But, in every story I write about, I find that the media missed the mark by a mile and that the NTSB made some assumptions that were based on their gut and past experiences as opposed to actual science.  Well, this case is no different.  When scientists publish studies in journals, we also might not have perfect conclusions or perfect results.  But, we must disclose those imperfections in a section of the study called limitations so that the reader can be as informed as possible about how we might have come to such a conclusion and what limitations are important.  I think the media and the NTSB could benefit from doing the same thing.

Normally with a crash investigation like this, the identity of the passenger or passengers really would be irrelevant to the overall investigation.  I understand that Kobe Bryant was a celebrity and a very influential person to millions of people but that is not why I am mentioning him by name in this story.  I am mentioning him because the NTSB points out the relationship that Kobe had with the accident pilot.  Likewise, the business structure that existed between multiple companies does come into play in this story and so, too, do other celebrity names that I'll discuss later in the story.

This helicopter is flying from Orange County up to Thousand Oaks, CA.  They fly north in pretty clear weather while they are south of the mountains, up and around Burbank and Van Nuys airports, and then transition into the valley on the north side of the Santa Monica mountains.  The pilot encounters clouds, tries to climb up out of them, becomes spatially disoriented, and eventually flies the helicopter directly into the ground killing everyone on board.  When you look at the stories in the mainstream media you will see that what I just told you is the gist of most of the story along with the fact that the helicopter company may have had a poor safety culture.  But, as is usually the case, there is far more to the story. 

Let’s try and clear up why Kobe was on this particular helicopter in the first place.  Kobe lived south of Los Angeles down in Orange County, but he also had a strong working relationship with, what at the time was called the Mamba Sports Academy, in Thousand Oaks, CA.  Not only did Kobe host NBA and WNBA workouts at the Mamba Sports Academy but he also coached his own 13-year old daughter’s AAU girls basketball team at the same facility.  L.A. has some of the worst traffic in the world and to add on top of that, Thousand Oaks is separated from L.A. by a forty mile stretch of the Santa Monica Mountains. Being that Kobe lived in Orange County, this would be nearly a two-hour drive each way.  So, like many celebrities and people with his kind of money, he hired a service to do his transportation for him.  But, he didn't hire them all on his own - he actually started his own company called Kobe, Inc. back in 2014 to handle all of the business dealings and this included all of Kobe’s transportation. The transportation service that Kobe, Inc. began talks with is called OC Helicopters out of Orange County and these talks began back in 2012 and 2013.  OC helicopters is a Part 135 operator who can fly on demand charter flights, day or night, only VFR, meaning only when the weather is good enough to look out the window and fly safely.  Weather minimums for VFR can vary but in the type of airspace they were flying in on the accident day, they would need 3 miles visibility and 1,000 foot ceilings for clouds.  This can be more strict with some operators and there are some exceptions to the rule such as when a pilot requests what’s called special VFR or SVFR.  SVFR are special visual flight rules that may be granted to an aircraft that is already flying in VFR conditions and then the conditions change where VFR can no longer be maintained.  If the pilot is flying through certain congested areas or around airports they may request SVFR from air traffic control or the closest airport tower in order to continue their flight in these areas.  This is a very important point that we’ll come back to later in this story.

OC helicopters was able to charter flights and were authorized to fly a single helicopter being the Eurocopter EC120.  At the time, they only had the one helicopter and two employees for the company.  Back in 2012, Kobe, Inc. approached OC helicopters and wanted to forge a relationship to fly Kobe and any of his family and associates around the southern California area.  Kobe was by no means a stranger to helicopters and it was well-known that he would fly on helicopters from his home in Orange County to every home game.  He even had his Nike Kobe 6 shoes with a colorway called ‘helicopter.’  He once gave an interview in GQ magazine where he detailed the reasons for this being that he could spend more time with his family.  Kobe would actually wake up, work out at home, take his kids to school, fly down to the Staples Center, practice, work, do media stuff and then take the helicopter home and get back in time to hit the carpool line and pick up his kids.  Even though his wife told him she would pick up the kids from school, Kobe insisted on doing it and said “No no no i wanna do that,,,because you have road trips and times where you don't see your kids so every chance I get to see them and spend time with them, even if it's 20 minutes in the car, I want that.”  Man, I feel that sentiment completely.  But even then, Kobe wouldn't just fly with anyone - there were some strict stipulations that had to be in place.  The helicopter had to be dual engine, and there had to be a heavy security vetting process for pilots.  After pilots were vetted it was only these pilots that could fly Kobe, Inc. associates.  Now, it was not unusual for OC helicopters to broker flights when they received a request that they could not support such as flying 8 people or needing an aircraft that was dual engine, neither of which their EC120 would support.  So, OC would broker these flights with Island Express helicopters, the operator actually flying this helicopter.  There was actually no written agreement between the two companies but when Kobe would request a flight, OC would contact Island Express and arrange for all of the travel including the ground transport to and from the airport and also a backup ground transportation plan just in case the helicopter flight was canceled due to weather.  Anytime Kobe wanted a flight, all of those involved would create a group text to organize everything and this included the pilot for Island Express, the OC helicopters employee and even his limo drivers.  Now, remember that Kobe was able to vet all of the pilots and would only fly with four approved pilots from Island Express with his favorite one being the accident pilot, Ara Zobayan. 

Ara Zobayan was a 50-year-old male who lived in Huntington Beach, CA and was hired nearly 9 years earlier in 2011.  He held a private pilot rotorwing certificate from 2001 and he gained his commercial rotorwing and instrument rotorwing rating in 2007 as well as his flight instructor and ground instructor in 2008.  He held a 2nd class medical certificate with only limitations being that he needed to wear glasses or contacts.  He was experienced in the Robinson R22 and R44, the Schweizer S300, Bell 206, AS350, and of course the Sikorsky S76B.  He had a total of 8,577 total flight hours which is a massive amount of time in a helicopter and he also had 1,250 hours in the S76.  Much of his initial hours were flown offshore with only 400 of his hours being at night with 75 hours on instruments.  This basically means that Ara was a SUPER-experienced pilot, but only during the day and only in visual conditions.  Ara was the chief pilot for Island Express and was extremely well-liked and well-respected amongst the other employees and line pilots. 

Island Express helicopters is a privately owned company and were issued their first VFR certificate back in 1988.  They have 25 employees and a total of 6 pilots.  They were authorized to conduct charter flights for paying customers under their Part 135 certificate day or night,,,,,but ONLY VFR.  At the time of the accident they had 6 helicopters with 3 AS350s and 3 Sikorsky S76s.  Yes, even though they have these beautiful S76s that could easily be certified for IFR, they were still a VFR only company.  What does that mean?  Well, as I have mentioned in previous stories, flights conducted under visual flight rules, or VFR, can only be done during visual meteorological conditions otherwise known as VMC.  In very simple terms, if you are flying under visual flight rules, you can only fly the aircraft in visual conditions meaning that it is clear enough outside to see a few miles away and that the clouds are at least 1,000 feet off the ground.  But, there is another set of conditions called IMC, or instrument meteorological conditions.  In order to fly in IMC, the aircraft must be certified for instrument flight rules, or IFR, and the pilot must be rated for IFR.  There are many ways to fly IFR which include things like ILS approaches, ADF, VORs, or GPS, but the main point is that in order to fly IFR the aircraft has to have all of the proper technology and equipment and be certified and so, too, does the pilot (rated).  And yes you can also fly IFR in VMC.  You can fly IFR anywhere.  But you can only fly VFR in VMC.  To tell you how serious this is, if you are flying VFR and suddenly find yourself, inadvertently, in IMC then you need to declare an emergency and contact air traffic control, or ATC, for assistance.  But if you do it on purpose it could be against the law and it is a HUGE problem.  So, why did Island Express not get the S76 IFR rated?  I could only speculate but I would imagine it was simply a business decision.  Getting the aircraft IFR rated would have a cost, as would require training all of their pilots.  It is something that Island Express could have done but they were certainly not required to do so.  For instance, the overwhelming majority of medical helicopters in the U.S. are not certified for IFR flights and complete the majority of their flights as VFR and only in visual conditions. 

Now, let’s take a look at this amazing helicopter.  This was a Sikorsky S76B model built in 1991 with a total of 4,717 hours on the airframe.  This is a big medium-sized helicopter with twin Pratt & Whitney PT6B-36A engines.  The S76 could be configured to carry up to 13 passengers but was set up in an executive configuration seating 8 passengers in the back.  It has retractable landing gear and a very high-tech 4-axis autopilot system (more about this part later).  The instrumentation was fully IFR capable and was not equipped, nor was it required to be equipped, with a cockpit voice or flight data recorder.  It actually did have a Fairchild Cockpit voice recorder when first delivered to Island Express but, as permitted by the FAA, was subsequently removed. 

Many of the photos you've probably seen show Kobe in front of this helicopter while it was temporarily wrapped in this cool black look with the Nike logo and Kobe’s trademarked “black mamba” logo, but the helicopter was not outfitted like this on the accident day and instead was painted white with blue and teal stripes.  It was this very helicopter that Kobe took to his final home game on April 13, 2016 where he destroyed the Utah Jazz with 60 points and scored the game winning shot. 

On the accident day Kobe had charted this flight with OC helicopters, who then brokered the flight with Island Express to fly from John Wayne airport in Orange County to Camarillo airport on the other side of the Santa Monica mountains.  Kobe was taking his 13-year-old daughter, Gianna, to a girls basketball tournament at the Mamba Sports Academy up in Thousand Oaks.   A 14-year-old teammate of Gianna’s named Alyssa was also on board, as was her mother Keri and her father John.  Also on board was another teammate, 13-year-old Payton, her mother Sarah, and one of the assistant coaches to the girls basketball team, Christina.  The planning for this flight began the previous day and is all documented in text messages between the pilot Ara, Kobe’s drivers, and executives with OC helicopters and Island Express.  The text messages show that the previous day they flew the exact same flight out to Mamba Sports Academy.  At about 5:30 pm the previous evening they do discuss the weather for the next day’s flight and acknowledge that the weather could be an issue and they will have to confirm the next morning.  The next morning the pilot confirms at 7:30 a.m. that the weather is looking okay and they are finalizing arrangements for the flight as he files a company VFR flight plan.  There are many different ways for pilots to check weather.  They can look at radar depictions, satellite, review other pilot reports, look at AIRMETS and they can even use the HEMS tool which was originally designed to assist medical helicopters by easily color coding geographical areas into VFR, marginal VFR, IFR, and even mountain obscuration.  At the time of the accident the HEMS tool was showing nearly the entire flight path as either marginal VFR or IFR.  If this was a medical flight and the aircraft was not certified for IFR flights, there is no way that they would have taken this flight and it would have been declined instantly.  But, there is no evidence to show that the pilot accessed this HEMS tool.  He did have a weather app on his iPad mini and on his iPhone called Foreflight which is perfectly common for pilots to use.  And, the data did show that the pilot’s phone and iPad did hit the servers of Foreflight at 7:31 a.m. and 8:02 a.m. prior to the flight but there was not any evidence to show that the pilot actually received any weather briefing from this app and it was unknown whether he utilized other sources for weather prior to the accident flight.  Likewise, you can also see that the National Weather Service's AIRMET advisory was showing the accident area was IFR and had conditions for mountain obscuration, meaning you could not see the mountains.  But , like I said, there is no evidence to show what sources the pilot used to check weather.  He was very experienced in this area and had been flying through these same mountains for many years.  Local meteorologists have stated that the accident area included valleys and elevation changes that did make for slightly colder temperatures and that it was normal for pilots to expect to have worse visibilities and worse cloud ceilings in this area.

Either way, the pilot files his company VFR flight plan with plans to fly north from John Wayne Airport, and follow just to the east of downtown L.A., just past Dodgers Stadium and then once into Glendale to contact Burbank Airport for instructions on how to proceed west towards Camarillo over HWY 101.  The relative humidity was near 100 percent through most of the valley that morning.   There are also many ALERTWildefire cameras that are placed on tops of the Santa Monica mountains facing to the north.  Right around the time of the accident there was a heavy cloud layer in the valley and there were even some baseball field cameras to the north that were facing south, directly at the accident site, showing how cloudy the conditions are.  And, just a few moments before the crash occurred you can see the helicopter flying along the 101 over a construction site and then disappearing into the clouds.  

You might be thinking “why didn't they just take the shortest route and fly over the water and around to the west??  Or, why didn't they just fly over the mountain tops?  The mountain tops are only 3,100 feet high, and helicopters can certainly fly far above that, especially the S76.  Well, Island Express did have authorization to fly over water as they routinely flew out to Catalina Island and even did offshore oil operations.  But to fly offshore, the helicopters have to have floats for flying over the water and they also have to worry about designated traffic patterns.  In an area as congested as Los Angeles, helicopters cannot really fly just anywhere.  There are many big airports with lots of commercial traffic flying in and out and one of them being LAX.  To stay low enough and get around LAX they would have to fly out over the water quite a bit which just adds another level of risk that is unnecessary when you can fly over land and it would have made the flight simply too long.  Flying over the mountains also would have been a risk.  There are commercial flight patterns that fly over those mountains and given the forecasts they definitely would not have been able to fly over the mountains as they then would have been flying on top of the clouds which would put them into instrument conditions where they would have needed IFR clearances and approvals.  So, the only way to get to Camarillo, at least on this day, was to fly along the previously mentioned pathway and to stay below the cloud layer.

In very simple terms you really have two main types of air traffic controllers - those that work in the towers that you see at airports, and those that are not at the airports and work in dark rooms staring at radar and computer screens all day.  They are both air traffic controllers but the ones that are working in the towers at airports are mainly called tower controllers and the ones in the dark computer room are called radar controllers.  Each big airport has a number of controllers working in the tower who are basically responsible for controlling the traffic on the ground at the airport and also in the air within a certain distance AROUND the airport which is usually around 5 nautical miles, and they typically have to be able to see the aircraft visually.  They have to be able to lay eyes on what they are controlling.  But even though they should be able to see you, they also have their own radar and will be tracking any aircraft in their airspace via this radar.  They know who each aircraft is by having them SQUAWK a 4-digit identifier code from their aircraft’s transponder which basically lets them know who you are when they see you on their radar screen. The controller will tell the pilot to SQUAWK and then give them 4 numbers which the pilot then enters into their transponder which then shows up on the controller’s radar with the same 4 numbers.  Think of it like when you get a text message where you need to confirm a number for some online account.  SQUAWKING just confirms to the controllers that the little blip on their screen matches who they are looking at and who they are talking to.  These tower controllers at the airport are not only responsible for taxiing, takeoffs, and landings, but they are also responsible to have two-way radio contact with any aircraft that is transitioning through that roughly 5-mile radius around their airport.  That means if you are flying in a helicopter and want to fly within 5 miles of a controlled airspace around an airport, you must make radio contact with the tower of the airport and the tower controllers will provide the pilot with clearance and instructions on how to safely navigate around the airport in order to avoid incoming and outgoing aircraft.   But, and this is very important, if you are not flying in controlled airspace you are under no obligation to be talking to anyone on the radio and if you are flying VFR you can pretty much fly your route without talking to anyone on the radio at all.  You also normally would not SQUAWK anything as no one would be seeing you SQUAWK since you are not being tracked by radar.  And, 99% of helicopter flights, including EMS and charter flights, are operated this way.  As long as they are not in an airport’s controlled space they can fly their flight plan with no further radio communication.  So what is radar control for?  Well, remember that they are not at the airport and have no visual contact with aircraft and only see aircraft on their radar screens.  But more importantly, while they may be able to “see” aircraft on their radar that are flying low, they are typically not paying attention to them at all.  The radar controllers are really only paying attention to the aircraft that have filed IFR plans and are flying at high altitudes or are doing approaches and departures.  The radar controllers keep these airliners separated by a certain distance front to back but also by a certain distance vertically and basically organize and line aircraft up as they start approaches and departures from airports.  And, as these aircraft fly along they are being passed off from one set of controllers to the next.  In short, for a basic airliner, they would start their flight talking to the airport tower, then talk to departure, then talk to center, then approach, and then another tower at the next airport.

But helicopters flying around cities?  They would not be doing this.  Again, they are REQUIRED to be talking to airport towers if they are in their airspace but otherwise are not required to talk to radar control, and typically they do not do so, except in a few instances.  One of them being if they have declared an emergency, and another one being if they have requested flight following.

Well, what is flight following?  Flight following is when a pilot is flying in uncontrolled airspace under VFR conditions and then specifically calls up radar control on their radio and asks for flight following. Flight following is considered an additional service by radar control and once flight following is initiated, the controller will monitor the radar of the aircraft to “observe and note deviations from its authorized flight path, airway, or route.”  In other words, this service will ensure that the pilot has a radar controller watching him on radar who will keep them apprised of other traffic targets that could be a threat and also to provide safety alerts about terrain or other obstructions that could be a threat.  According to the air traffic control handbook, this “additional service is not optional on part of the controller, but rather is required when the work situation permits.”  This means that as long as the controller is not overloaded with separating other IFR traffic, that they are required to help and provide this service.  A

And finally, we need to understand how these controllers utilize checklists.  When one controller gets up from their chair to take a break or be relieved by an oncoming controller, there are required processes for this that are listed in the air traffic control handbook under their standard operating procedure for “transfer of position responsibility”  which outlines a “step-by-step process for conducting a position relief briefing and transferring position responsibility from one specialist to another.”  The oncoming controller is first to “follow the checklist” and part of this checklist is to fully brief the oncoming controller on things like “traffic, items of special interest, anything out of the ordinary, and a brief communication status of all known aircraft.”  All of this should be done while they are both “plugged in” to their control station for several minutes and ensuring that there are no surprises for that oncoming controller.  The last piece to know about radar controllers is that there is a process for confirming that you are being tracked by radar.  Once they tell you to SQUAWK you know they are tracking you, and then when they are no longer tracking you they have to say that radar services are now terminated so that the pilot knows they are on their own or that they need to get radar services from the next airport or from a radar controller. 

When the pilot departed John Wayne airport he had VFR conditions and was flying in pretty good weather.  They continued north and passed downtown Los Angeles, then Dodger Stadium, then into Glendale at about 800 feet above the ground.  Once into Glendale, the pilot contacted Burbank Airport tower and requested to transition through their airspace.  Burbank reports that they are IFR at this time and that they have just had a SkyWest commercial airliner do a go-around during their approach to runway 8.  A go-around is when pilots decide to abort their landing and go around and try again.  Pilots plan for a go-around on every single approach during every single landing and there are planned procedures for such an event.  Go-arounds do happen every day around the world but it happens a very low percentage of the time.  Anything can trigger a go around.  It could be a safety reason. It could be poor visibility or it could be just a gut feeling that the pilot has.  Either way when a go around is called out, the aircraft aborts their landing.  When the accident pilot requested to transition through Burbank airspace he was told about the go-around by the SkyWest plane, he was told that Burbank was IFR, and was also told that the next airspace he was going to fly through, Van Nuys Airport, was also IFR, and he was finally told that he would need to hold outside of the airspace for several minutes while the tower dealt with the go around by SkyWest as well as several other waiting departures and arrivals.  The pilot is also told that the last reported cloud tops in the area were at 2,400 feet.  Kobe's helicopter is now circling over Glendale outside of Burbank airspace for about 12 minutes.  At this point, I think most would agree that the signs were there that this flight should have been aborted.  Burbank is showing IFR.  Van Nuys is showing IFR.  And. if they are all IFR it is only going to be worse once the aircraft gets into the valley near Calabasas.  But, onward they continued. 

It is very common, especially in southern California for designated helicopter routes to follow large ground freeways.  They are easy to see from the air and can always have a guarantee that there will be no terrain above them and the L.A. area is no exception.  So, once Burbank clears the helicopter, they tell the pilot to SQUAWK 0235 and to follow interstate 5 to the north and fly around Van Nuys Airport, following the 118, due to Van Nuys having several departures taking off to the south.  The Burbank controller then coordinates this transition with a Van Nuys controller, terminates radar contact with the helicopter, and advises them to contact Van Nuys tower. 

The pilot then does call Van Nuys tower and requests that special VFR transition clearance we talked about earlier.  He requests SVFR because Van Nuys is showing that they are IFR but the pilot is telling the tower that he is actually in VFR conditions.  Vans Nuys approves this transition request and instructs the pilot to start turning southwest of the airport and start heading towards the 101 where he would transition to the west towards Camarillo.  The Van Nuys controller then asks the pilot if he wants to talk to SoCAL which is the southern California radar controllers, remember, they are the ones sitting in the dark room looking at radar depictions.  Remember, he does not HAVE to talk to the radar controllers.  But he chooses to anyway, probably because he might be foreseeing that he would like their assistance with navigating through the valley on his way to Camarillo. 

It is now 9:40 a.m. and now that the pilot is out of the airspace of both airports he contacts SoCal and tells them that he is transitioning to the west and headed towards Camarillo.  SoCal asks if he is going to stay that low the whole way to Camarillo and the pilot responds in the affirmative.  Now this is where things go awry. The SOCAL controller then advised the pilot that he is too low and would lose radar and radio contact with him at that altitude and to just squawk VFR until he can call the next airport which is Camarillo.  Now, this controller does not even give the pilot a chance to request flight following, which he is certainly about to do, and tells him is probably going to lose him so just forget about our services and just SQUAWK this and then talk to Camarillo when you get there.  The only time that ATC really would be able to deny this request is if they were overloaded with separating other IFR traffic.  But, in post accident interviews with the controllers, they all acknowledged that they were not very busy at the time.  Just three minutes after this communication this controller was done with his shift and a position relief briefing took place at 9:43 a.m.

Just two minutes later at 9:45 a.m. the pilot calls back and says that he is going to start a climb and go above the cloud layers and also says that he is going to stay with SoCal meaning he wants to stay in contact.  Now, remember, 1 of 2 things is taking place here, either the pilot is completely breaking the law and purposely flying into instrument conditions without an IFR flight plan or, he is having an emergency. But, if he is having an emergency, he should have declared a mayday and said so - but he did not. 

When the pilot makes this communication about attempting to climb above the clouds, remember the Burbank tower told him the cloud tops were at 2,400 feet, it took the controller 9 seconds to respond.  Why did it take so long?  Probably because we now have a new controller sitting at the station and it is 100% obvious that he was caught way off guard by this communication from the pilot and he asks the pilot for his location to which the pilot provides it.  The controller then asks the pilot to “ident.”  This means the pilot needs to look over to his left to his transponder and hit the "ident" button which will confirm the SQUAWK code which the pilot acknowledged.  The pilot is now SQUAWKing 1200 which means that he is flying under VFR.  But he only SQUAWKED 1200 because that is what the controller told him to do.  At this point, the helicopter is in a nice steady climb with a slight leftward turn.  This leftward turn appears to coincide with the 101 freeway below and they climb 1,000 feet in just 36 seconds.  The ident comes through appropriately on the controller’s side who then asks the pilot if he was requesting flight following and the pilot responded affirmative.  The controller then asks the pilot to state his intentions to which the pilot said he was trying to climb to 4,000 feet to which the controller again responded with “what are you going to do when you get there?”

The pilot did not respond and there were no further transmissions from the helicopter.  The flight tracking shows that once the controller started asking the questions and giving some commands, that nice leftward turn turned into a massive left hand turn that eventually caused the aircraft to be pointed almost directly at the ground.  At this point the pilot has now become spatially disoriented where the sensation in his brain is telling him that he is upright, even though he is leaned extremely over to the left.  In fact, at the very moment that the pilot said he was trying to climb to 4,000 feet, he was already pointed at the ground and was traveling at over 200 mph straight towards the ground.  The aircraft then continued to descend at a rapid rate of speed and impacted the side of the mountain where the aircraft wreckage was spread out over several hundred feet.  While there was a post impact fire, and contrary to several reports, none of the passengers suffered any thermal injuries and they were all killed by the traumatic force of the crash.  There was actually a mountain biker up on this mountain who witnessed the entire end of this flight stating that he could hear the helicopter and then it emerged out of nowhere through the bottom of the clouds and crashed just a couple hundred feet from where he was standing with debris being scattered and then a few moments later, there was an eruption of fire. 

The controller attempted several more times to reach the helicopter and was never able to do so.  He did NOT report this lack of communication to his supervisor and it wasn’t until about 1 hour later that SoCAL was informed by the owner of the helicopter that it was looking for its location and that the sheriff’s department had reported a helicopter crash. 

So, what in the world was the issue with the communication here?  Well, it is clear to me that the pilot found himself in inadvertent IMC or IIMC, but failed to declare an emergency.  Instead he was vague in his communications and simply told the controller that he was climbing to 4,000 feet.  But it is also possible and probably very likely based on the radio transmissions, that the pilot thought he was receiving flight following and may have been very confused when he was told to SQUAWK 1200 which is a VFR code, and then heard the confusion in the controller’s voice as if he wasn't even aware that his helicopter existed.  Why did he sound like that?  Because he WASN’T aware.  In post accident interviews, it was shown that when the first SoCAL controller left his post and was relieved by the new controller that they did not follow the checklist as required and that they did not sit together for a few minutes to review what was going on.  The offgoing controller, in my opinion, seemed dismissive and did not want to flight follow this helicopter and it seemed like the accident pilot was an inconvenience to him, and therefore he told him to just stick to a VFR flight and then never told the oncoming controller that he even existed.  So then when the oncoming controller hears the pilot on the radio he is extremely confused, it takes him 9 seconds to respond and then he still tries to verify who he is talking to and what exactly the situation is.  In order to do so he has to ask the pilot who he is, where he is, to ident, and then ask what his intentions are and what exactly he plans to do when the pilot reaches 4,000 feet.  In hindsight, it was clear that the pilot thought he was getting flight following and then was having an emergency, but he didn't confirm the flight following and he never declared an emergency.  But, it is very possible that had the offgoing controller given a proper relief report to the oncoming controller, that this oncoming controller would have been looking out for terrain and bad weather for this helicopter instead of not even knowing he was there.  The controllers acknowledged during interviews that even though many helicopters fly this route, that they do not get a lot of helicopters that call them for assistance.  When asked about VFR conditions in this area the offgoing controller even stated “I would not know because we do not talk to VFR aircraft that remain low, we still were not even really talking to this guy, so no.”  Well what about losing contact with the helicopter? The controllers also noted that since he was SQUAWKing 1200 as a VFR flight that they did not need to report the pilot as lost radar or comms because they didn't even feel that they were really tracking him.  So, even though this helicopter crashed while talking to the radar controllers, the controllers did not report the loss of communications to anyone. 

Remember that this pilot was doing a nice easy climb when he first entered the IMC and it wasn't until the controller made several requests and commands that the pilot started to become disoriented.  This is most likely due to stress overload which would have contributed to an overall lack of situational awareness.  The pilot was probably facing forward focusing on his flight but then had to turn his head to ident as the controller requested. There are supporting studies that show that when a pilot is flying in IMC that even a slight turn to tune a channel on their radio can be enough to induce an illusion and lead to spatial disorientation.  To add to this he is also tasked with answering the radio.  Even in a study that I published recently we have found that in high dynamic situations stress can lead to tunnel vision which then leads to poor situational awareness which is exactly what happened in this situation. 

Of note, if you remember that the cloud tops were listed at 2,400 feet, well the data shows that the pilot made it to 2,370 feet, just 30 feet short of the cloud tops when he was asked to ident which very possibly could have led to a coriolis effect which ultimately leads to spatial disorientation.  In short, human beings have no way of telling the difference between gravity and acceleration forces unless there is some visual reference to aid them.  In these cases, the pilot needs to rely on their instruments in order to avoid such disorientation.  The pilot needed to fly by his instruments, climb out of the clouds, and then receive vectors from ATC to a safe landing area.  He also should have activated his auto-pilot, at least by holding altitude or heading, and also to slow down, but for some unknown reason, he did neither.  But he didn't declare an emergency, the controllers weren't even paying attention to him, when he did call for help, the controllers were confused, and then finally the controllers most likely made things worse by adding lots of workload to an already stressful situation. 

There was obviously a full investigation completed by the NTSB.  Typically, with the fatal helicopter crashes that I have reported on, the final report can take up to several years to be finalized and published.  But, in this case the final report was published just 4 and a half months after the accident.  I have never seen a helicopter crash investigation with such detail and the use of all available resources as this one.  I mean they x-rayed just about every single bulb they could on the instrument panel of this aircraft.  They did a thorough forensic analyses of the engines and transmissions.  They even were able to recover every single iPhone, iPad, Apple Watch, and a Samsung Galaxy phone, and performed a detailed analyses on each of them as well.  In the end, there was absolutely nothing wrong with the helicopter, any of the instruments, the engines and transmission were fine, and there was no meaningful evidence on any of the personal electronic devices. 

In the end, the NTSB found 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 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.”

Yes, the pilot had many opportunities to abort this flight and chose not to and was probably suffering a bit of get-there-itis, otherwise known as plan continuation bias, yes that's a real thing :-).

I have an extremely hard time seeing how the NTSB could conclude that contributing factors were the pilot’s ‘likely’ self-induced pressure and the inadequate review and oversight of Island Express helicopters safety management processes.  In the supporting paperwork as well as in the 4-hour public NTSB board meeting for this incident, the NTSB tries to say that because this pilot had such a close relationship with Kobe that he didn't want to let him down, leading to this self-induced pressure to complete the flight.  It is very difficult, if not impossible, to determine if this was the case.  This pilot, as well as other pilots at Island Express helicopters, regularly flew affluent and famous people.  There were many canceled flights in just the few months leading up to this accident which shows a history that Island Express was more than willing to cancel flights and lose revenue from other celebrities such as Lil dicky, Los Angeles Clippers star, Kawhi Leonard, and even Kylie Jenner.  All of these canceled flights were lost revenue.

During the board meeting you can even hear NTSB board members press the issue and question how this conclusion could be made.  When pressed, the NTSB human factors investigator who came to this conclusion even repeatedly said that the relationship “may” have contributed.  Well, if it may have contributed it also may not have contributed.  That is not how science works and I am a bit disappointed that the NTSB included this as a contributing factor in their conclusions as there is absolutely no way to prove this was the case. 

In reviewing all of the practices and documentation of Island Express it certainly appears to me that they implemented and embraced a just culture and a safety culture.  They held safety meetings.  They had a reporting system.  They canceled flights.  They put their pilots through training on get-there-itis.  And more importantly, they even participated in a safety management system or SMS.  An SMS is a “top-down, organization-wide approach to managing safety risk and assuring the effectiveness of safety risk controls. It includes systematic procedures, practices, and policies for the management of safety risk.”  There are over 1,900 part 135 operators in the United states.  And out of those 1,900 there are only 17 of them with fully accepted SMS.   That does not mean that the other 1,883 operators are NOT safe.  Forming an SMS is a major undertaking both logistically and financially. As we’ll see later on, the NTSB took major exception to the fact that Island Express did not have a fully accepted SMS with the FAA.  But they even note that an SMS is not required by the FAA and the overwhelming majority of air operators do NOT have an SMS.  Yet, the NTSB even states that “Had Island Express’ SMS been required by the FAA, it would have been subject to FAA oversight to inspect the SMS for alignment with FAA objectives and to provide feedback to help the company implement the entire program.”  Well, this may be true, but from what I found, there was nothing wrong with Island Express’ SMS in the first place.  The only documentation that shows me any real issue with Island Express’ SMS is the fact that their CEO was not very involved in it.  Yes, in the FAA’s SMS, this is a requirement but even though Island Express didn't have this, I see no connection between the CEO’s lack of involvement, and this crash.  Just because there is a crash, albeit a bad one like this, does not mean that the entire company is unsafe.  Every major airline in the U.S. has had some form of fatal incident and I don't think anyone would say that ANY of them are unsafe.  During the NTSB meeting, you can hear the lead investigator of this accident seems to disagree with the NTSB chairman on this very issue.  The fact of the matter is that this accident was caused by two things, the pilot’s poor decision to continue into an area where IFR was forecast and likely, and a total miscommunication between the pilot and radar controllers, including the radar controller’s deviation from standard operating procedure while relieving a controller. 

I know that the FAA will soon be requiring an SMS for all Part 135 operators and this is bound to ruffle a lot of feathers across the entire industry.   Maybe it is needed and maybe it is not.  SMS is quite in-depth and complicated and the financial and political ramifications of requiring such a mandate is huge.  Is it possible that the NTSB will seize any opportunity to push SMS?  Yes, I am sure it is possible.  Did that happen in this case?  I don't know.  Maybe.  Either way, I am not saying an SMS is bad.  In fact, I am sure they are really good and do a lot to improve the safety culture.  But just because you have an SMS doesn't mean that your company is safe.  I worked at a helicopter EMS service that had an SMS, and there were plenty of safety issues. Again, not a bad thing to implement an SMS - I just don't see the connection between an SMS and the cause of this particular accident.  Why?  Because the research did not appear to show that Island Express had a poor safety culture, a lack of a just culture, or was an otherwise unsafe operator.  In fact, Sikorsky, the manufacturer of the helicopter, also did their own independent investigation of this incident and they concluded “that the probable cause of this accident was spatial disorientation of the pilot, and subsequent loss of control following entry into instrument meteorological conditions.”  I think it is important to point out that Sikorsky makes no mention of self-induced pressure on the pilot or any problems with Island Express’ SMS.

But either way, the NTSB made absolutely no mention about the air traffic controller miscommunications or their failure to follow the rules as laid out in their own handbook. The only way I even found out about the miscommunication was by reading through every single interview transcript and there is the data plain as day - the pilot requested flight following, and even though the controllers were obligated to provide it, they punted it and refused the request because of a possibility of losing radar contact since the helicopter was so low.  Then, they did not follow their checklist when relieving one of the controllers leading to the accident controller having absolutely no clue what was happening when the pilot communicated that he was climbing up through the clouds to 4,000 feet.  This pilot would have had no way to know that the first controller he was talking to was relieved and that no one knew he was there or was watching him.  This all led to massive task overload, stress, tunnel vision, spatial disorientation, all ultimately leading to the crash and the deaths of all 9 of these people.  And with the exception of the spatial disorientation, none of this was in the NTSB's final report or probable cause.  

And, as if all of this wasn't bad enough, when the first responders showed up to respond to this accident on the ground, several of them took many pictures of the dead bodies and random body parts, and then shared them inappropriately afterwards.  Now, when it comes to taking pictures of scenes, here’s what I can tell you - as a paramedic, the big concern with photographing any scene, traumatic or medical, is violating the federal law known as HIPAA.  In short, this law is really about health insurance but it also says that no private medical information can be shared without the patient’s consent unless it is relevant to continued patient care.  This is why you have to sign that patient privacy paperwork every time you go to the doctor or dentist or the hospital.  Without this consent, nothing can legally be shared, including photos.  And the fines from HIPAA are serious.   But - in the grand scheme of things, HIPAA does not apply here as these photos were not taken by paramedics in the course of patient care, they were taken by the sheriff’s department and by the fire department.  Why would they be taking photos? Well, there were 9 deaths and lots of property damage so law enforcement would certainly have reason to take official photos.  For the fire department, I see absolutely no reason why they would need to take pictures but their defense was that they took the photos for PIO, or public information purposes.  And, in the grand scheme of things, whether or not I agree with them taking the photos in the first place is actually irrelevant,  the problem is that they shared them inappropriately.  Kobe’s wife, Vanessa Bryant, filed a lawsuit several months after the accident due to the fire department and sheriff’s department sharing graphic photos of the bodies of Kobe and their daughter, Gianna.  One of the firefighters was a Los Angeles County fire captain who was attending a cocktail hour at the radio and television news association golden mike awards just a few weeks after the crash when the captain, and his wife, called people over to their area to laugh and show pictures of Kobe’s body with another L.A. County captain even stating “I can’t believe I just looked at Kobe’s burnt up body and now I’m about to eat.”  And on top of that, a Sheriff's deputy also took pictures, on his personal cell phone, and then texted and AirDropped them to several other deputies and at least one unnamed and unknown firefighter.  One of the deputies who received the photos then visited a local bar and showed the photos, in great detail, to the bartender.  That lawsuit eventually went to trial which took place just a few months ago with a verdict coming on August 25, 2022 with the jury awarding $31 million in damages with $16 million going to Vanessa Bryant and $15 million going to Chris Chester whose wife and daughter also died in the crash. 

Now, this story is filled with tragedy from beginning to end.  Everyone involved with the actual flight seemed like good people with good intentions, but, man, there were some poor decisions made by several people. 

This pilot was clearly experienced.   But, as is all too often the case, complacency got the best of him.  Not because he didn't care.  And not because he was a terrible pilot.  But because his plan continuation bias continued to tell him that he could somehow beat the weather.  But complacency also caused the offgoing radar controller to assume that this flight did not need his flight following services.  He assumed they would be too low for radar and radio comms - and they were not.  And then, when getting relieved by another controller, failed to tell that relief about this helicopter, where they were, and where they were going.  And by not communicating this appropriately, or using the required checklist, the ongoing controller had no clue this helicopter was even on his screen and therefore was not able to provide any form of flight following or provide any alerts to worsening weather, terrain, or erratic flight patterns. 

And finally, there were some absolutely terrible decisions made by the Los Angeles County Sheriff's department as well as the Los Angeles County Fire Department.  Multiple deputies and firefighters took photos that they probably should not have taken, and then against any and all reasoning and common sense, shared them inappropriately for their own personal and selfish gain. 

What would have prevented this crash?  Having an IFR certified aircraft and IFR rated pilot.  Clouds shouldn't be the defining factor as to whether or not passengers live or die.  Private pilots want to fly VFR and take the risks, well this is America, do what you want.  Paying customers, whether it was Kobe and his family and friends on this flight, or medical and trauma patients on a medical helicopter, do not understand VFR and IFR.  They just know and have an expectation that their flight crew is going to get them safely from point A to point B, just like you do when you get on a commercial flight.  The accident pilot’s brother even argued in court that Kobe and the other passengers knew the risk when getting on this helicopter.  Did he?  Did these Coaches and parents?  Did these 3 children know?  When you go skydiving you know the risks of doing so.  You have to sign waivers after being told that the parachute might not open and you might die.  But, you understand the risks so you sign the document and you jump anyway.  Passengers aboard an aircraft that is flying under Part 135 do NOT know the risks.  They do not know that clouds could kill them.  How would they know?  Yes, accidents can happen.  But they hardly ever happen and this is why we call them incidents or collisions and not accidents.  Incidents are preventable.  Accidents are not. 

There are plenty of private helicopter companies that are IFR capable and fly IFR flights all day and night - and plenty of air medical that are as well.  It is a cost.  But it is a cost that drastically raises the safety of any flight.  Same, too, goes for dual pilots.  Yes, spatial disorientation has been documented in IIMC cases with dual pilots, but, even the NTSB has recommended and noted that dual pilots would be an amazing safeguard in preventing IIMC events from occurring. 

The last thing I will say in terms of the cause that has been argued is that this helicopter did not have a helicopter terrain awareness system otherwise known as TAWS.  Now, why I find it absolutely unbelievable that this helicopter did not have this major safety device, which is now required on all EMS helicopters, I do not see how this could have prevented the crash.  TAWS is designed to alert the pilot of terrain and obstacles to prevent them from having a controlled flight into terrain.  Controlled flight into terrain is not what happened in this case.  With Kobe’s crash, the pilot was so disoriented he didn't know which way was up.  Had he heard a loud TAWS warning he would most likely have been confused by it or simply ignored it altogether. 

I am sad for Kobe and the other 8 people who lost their lives on this helicopter, including the pilot.  I am sad for the family and friends of those on board. But, the lessons learned here are invaluable.  Every day, the helicopter industry gets safer and safer.  And that increased safety usually comes by way of learning from the past mistakes.  I hope that any pilots who read this can value the danger of IIMC, that the controllers stick to their checklists, and that the deputies and firefighters of southern California keep their phones in their pockets on these scenes.

Leave a comment