MAMBA

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 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, 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 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

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 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 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 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 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

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 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, 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 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, 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, 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 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 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 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 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 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 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, 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 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

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 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 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

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 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. 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

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 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, 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 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

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 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

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 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 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 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. 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 life of Kobe Bryant continues for about four hours, members 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 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, 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 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, 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 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, 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, 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 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 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 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

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, 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 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 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

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 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 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 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 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 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 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 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 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 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 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 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

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 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 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 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 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 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.