The NTSB unanimously adopted on February 9 its determination that the probable cause of the crash on January 26, 2020, that killed all nine people aboard was the “pilot’s decision to continue flight under visual flight rules into instrument meteorological conditions,” leading to “spatial disorientation and loss of control.”
The board found that the absence of terrain awareness and warning technology on board the Sikorsky S–76B was not a factor because it would not have improved the likelihood of safely completing this flight. Zobayan lost control of the helicopter while attempting to climb above clouds, and crashed into a hillside in Calabasas, California, because he thought he was climbing when, in fact, the helicopter was descending rapidly.
Board members noted that this was a familiar scenario that has consistently claimed lives for decades despite efforts by government and industry to improve pilot training. Between 2010 and 2019, 184 fatal aircraft accidents, including 20 helicopter accidents, were caused by pilots becoming disoriented after inadvertent entry into instrument conditions.
“We are averaging one helicopter crash, VFR into instrument conditions, every six months for the last 10 years, so I guess the question I have to ask is, what part of ‘cloud’ … do pilots not understand?” said NTSB Vice Chairman Bruce Landsberg, expressing a frustration that appeared unanimous.
There is no way to replicate the disorienting effects of somatogravic illusions in simulators, board members and staff noted. Even full-motion simulators cannot realistically create the forces of acceleration during flight that act on the vestibular system and mislead pilots who lose visual references. Training in an aircraft with a view-limiting device also has limitations, including the ability to “peek” around the edges that can be difficult to resist, though it defeats the purpose of the exercise. This method also fails to realistically replicate how quickly visual references can disappear in real-world conditions.
Among the four new safety recommendations unanimously approved on February 9, the board called on the FAA to convene a multidisciplinary panel to evaluate emerging technologies such as virtual reality that could be incorporated into simulation training to better prepare pilots, including those who do not routinely fly on instruments, to ignore the misleading sensations that Zobayan must have experienced in the final moments of the flight.
The board found “inadequate review of and oversight of its safety management processes” by Island Express Helicopters Inc. was a contributing factor, along with
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