NTSB · Safety Recommendation
Safety Recommendation A-21-005
Recommendation
TO 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.
Safety Issue and Context
This report discusses the January 26, 2020, accident involving a Sikorsky S-76B helicopter, N72EX, being operated by Island Express Helicopters Inc. as a Title 14 Code of Federal Regulations (CFR) Part 135 on-demand flight, that crashed into terrain in Calabasas, California. The pilot and the eight passengers died.
Safety issues identified in this report include the pilot’s preflight weather and flight risk planning, the flight’s entry into instrument meteorological conditions and the pilot’s inadequate adverse weather avoidance, the pilot’s spatial disorientation, influences on the pilot’s decision to continue the flight into adverse weather, Island Express’ incomplete implementation of its safety management system (SMS), the benefits of a mandatory SMS, the benefits of flight simulation devices for pilot training in adverse weather avoidance, the benefits of a flight data monitoring program, and the value of crash-resistant flight recorder systems in preventing future accidents.
As a result of this investigation, the National Transportation Safety Board makes two new safety recommendations each to the Federal Aviation Administration and Island Express.
Response History
May 23, 2024 · NTSB Correspondence · FAA
We note that the Air Carrier Training Aviation Rulemaking Committee’s (ACT ARC’s) Spatial Disorientation Training Workgroup has completed its research and that you are reviewing its recommendations, which include 23-1, Simulation Training Devices Suitable for Spatial Disorientation Training, and 23-2, Part 135 Helicopter Operations Spatial Disorientation Training. Pending our review of a plan for requiring the recommended initial and recurrent training, Safety Recommendation A-21-5 remains classified OPEN-- ACCEPTABLE RESPONSE.
We also note that the ACT ARC evaluated spatial disorientation simulation technologies and that this information is included in its submission ACT ARC Recommendation 23-1, which is available on your website. We believe these actions satisfy the intent of Safety Recommendation A-21-6, which is classified Closed—Acceptable Action.
September 15, 2023 · Recipient Response · FAA
-From Kathryn B. Thomson, Deputy Administrator: The Air Carrier Training Aviation Rulemaking Committee (ACT ARC) approved two recommendations submitted by its Spatial Disorientation Training Workgroup during the January 25-26, 2023, ACT ARC Meeting. The Federal Aviation Administration (FAA) received these recommendations, which include:
1) ACT ARC Recommendation 23-1, Simulation Training Devices Suitable for Spatial Disorientation Training, which is available at the following website: https://www.faa.gov/about/office_org/headquarters_offices/avs/offices/afx/afs/afs200/afs280/ act_arc/act_arc_reco/ACT_ARC_Rec_23-1_Simulation_Training
2) ACT ARC Recommendation 23-2,