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Safety Spotlight: Lessons from a tragedySafety Spotlight: Lessons from a tragedy

Speculation versus hard truths

Don’t speculate. This is a common rebuke directed at those discussing a recent aviation accident, and it’s been drilled into our culture. We’ve learned that the root cause of an accident can be quite different than what may seem obvious. It’s a sensible posture that has kept us (and some public agencies) from acting on erroneous theories with ineffective or even counterproductive remedies. Often, though, the “don’t speculate” principle is misapplied to mute all discussion until an investigation is fully complete, thereby delaying an opportunity to reinforce important learning.

Speculation is forming a theory without firm evidence. A person who happens to see an airplane crash near a runway is speculating when he or she says, “The aircraft must have stalled.” It’s not speculation to piece together known facts such as weather, winds, aircraft state, flight path, and air traffic control communications, and deduce a likely cause. The distinction is important. Informed analysis based on facts and experience can be helpful in emphasizing lessons learned while the event is still fresh.

The helicopter crash that killed nine people, including L.A. Lakers basketball star Kobe Bryant, is a case in point. The NTSB advised it would be more than a year before the investigation is complete (absurd, but the NTSB has recently promised reforms to reduce investigation timelines). Meanwhile, enough facts have been determined to ascertain what likely happened and summarize lessons learned that are beneficial for pilots to consider now.

According to investigators, the Sikorsky S–76 was flown by a single, experienced pilot under VFR per the operator’s Part 135 limitations. The pilot departed in marginal VFR conditions over flat terrain, traversed busy airspace, and—in worsening weather and visibility—followed a prominent highway into rising terrain. He climbed to avoid a cloud layer, began a left turn, and then made a sharp descent that peaked at 4,000 fpm. A witness observed the helicopter emerge from the mist descending at high speed and roll sharply left a few seconds prior to ground impact. NTSB experts found no evidence of engine or flight control problems. It’s not speculation to deduce that this is likely a spatial disorientation accident. Several lessons from this tragedy will remain relevant, regardless of additional findings.

1. Flying VFR into instrument meteorological conditions is dangerous, regardless of your experience and ratings. A third of these accidents happen to experienced, IFR-rated pilots and they are usually lethal. Falter into IMC and you are likely to die.

2. The gray area between flying on instruments and flying by visual reference is far more challenging than just flying on instruments. This hybrid arena, often borne of indecision, can provoke visual illusions. Pilots anxious to gain visual context can convince themselves of visual recognition that isn’t present. The consequences are exacerbated at low altitude by reduced opportunity to recover.

3. Low visibility in hilly terrain is especially treacherous. False horizons from multiple illusory effects can occur. Tiers of sloping cloud decks against rolling, layered hillsides are insidiously disorienting. Lights from cars, houses, or other sources can add to a misperception of aircraft attitude. Recognition is slow and often too late.

4. Fog, and in particular coastal fog, is unpredictable and can move in dense waves. Fog hinders depth perception, so it’s difficult to determine where it gets worse. It can seem tolerable, then thicken quickly into hard IMC.

5. Flights, conditions, and decisions must be assessed more conservatively when operating single pilot. There is no one to cross-check a decision, and no help to alleviate task saturation, an especially perilous state when operating a helicopter at low altitude in hilly terrain with limited visibility amid busy airspace. This flight was extraordinarily demanding for a single pilot.

6. The most important decision pilots will ever make is made every time they fly, and that is whether or not to fly. We often talk of advancing skills in terms of knowledge and stick-and-rudder skills. We rarely think of advancing our skills relative to decision making, yet pilot decision making is a part of most fatal accidents. Decision-making skills need just as much work and continued development as stick-and-rudder skills. It only takes one lapse in judgment on one flight for a tragic ending.

We don’t need to wait a year or more (actually, 22 months on average) for the NTSB to finish its full investigation to emphasize some important lessons from the tragedy in Calabasas, California. It’s not speculation to analyze an abundance of facts, determine what likely happened—with a caveat that we’re not completely sure—and emphasize promptly some important lessons that may prevent a future tragedy.

Email [email protected]

Richard McSpadden

Executive Director of AOPA Air Safety Institute
Richard McSpadden lead’s AOPA’s ASI, committed to reducing General Aviation mishaps by providing free educational resources and supporting initiatives that improve General Aviation safety and grow the pilot population.

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