Incident: Helicopter Crash Due to Lack of Instrument Flight Certification

Published Date: 2020-01-31

Postmortem Analysis
Timeline 1. The software failure incident involving the helicopter crash that killed Kobe Bryant and eight others happened on a Sunday, as mentioned in Article 94293. 2. Published on 2020-01-31 08:00:00+00:00. 3. The incident occurred on Sunday, January 26, 2020.
System The software failure incident mentioned in the news article did not involve a specific software system failure. Therefore, the answer is 'unknown'.
Responsible Organization 1. Island Express Helicopters - The charter company owning the helicopter that crashed, not certified for conditions requiring pilots to use cockpit instruments [94293]. 2. Federal Aviation Administration (FAA) - Responsible for certifying companies for instrument flights and ensuring compliance with regulations [94293]. 3. Sikorsky - The manufacturer of the helicopter, urged customers to install a critical warning system missing from the crashed helicopter [94293]. 4. National Transportation Safety Board (NTSB) - Currently reviewing the company's certifications and investigating the cause of the accident [94293].
Impacted Organization 1. Island Express Helicopters [94293]
Software Causes 1. The software cause of the failure incident was the absence of the vital software, the terrain awareness and warning system (TAWS), on the Sikorsky S-76B helicopter that crashed, which is designed to send a warning when a collision appears imminent [94293]. 2. The lack of certification for instrument flights by Island Express Helicopters also contributed to the failure incident as it limited the pilot's ability to navigate through the clouds using instrument flight rules (IFR) [94293].
Non-software Causes 1. The charter company, Island Express Helicopters, was not certified to fly in conditions that require pilots to only use cockpit instruments, leading to the pilot not having legal authority for the specific flight due to lack of necessary Federal Aviation Administration certification [94293]. 2. The helicopter, a Sikorsky S-76B, was not equipped with vital software, the terrain awareness and warning system (TAWS), that alerts pilots when aircraft are too close to the ground [94293]. 3. The pilot, Ara Zobayan, was flying in deteriorating visibility conditions due to heavy fog, and there were concerns about whether he flew beyond the boundaries of good judgment and whether pressure to transport his VIP client, Kobe Bryant, played a role in the crash [94293].
Impacts 1. The software failure incident, in this case, the lack of the terrain awareness and warning system (TAWS) on the Sikorsky S-76B helicopter, potentially contributed to the crash that killed Kobe Bryant, his daughter, and seven others [94293]. 2. The absence of the TAWS on the helicopter raised concerns about whether the warning system could have prevented the crash and highlighted the debate over the merits of such warning systems in helicopters [94293]. 3. The National Transportation Safety Board (NTSB) criticized federal regulators for not mandating the installation of TAWS on helicopters with six or more passenger seats, despite the NTSB's recommendation over a decade ago [94293]. 4. The failure to have the TAWS installed on the helicopter led to questions about the safety enhancements available and the trade-off between safety and potential nuisance alarms [94293]. 5. The incident prompted discussions among regulators, pilots, and aviation experts about the necessity of TAWS on helicopters and the potential risks of flying without such critical warning systems [94293].
Preventions 1. Installing the terrain awareness and warning system (TAWS) on the Sikorsky S-76B helicopter could have potentially prevented the crash. The TAWS is designed to send a warning when a collision appears imminent, and its absence on Bryant's chopper was highlighted as a critical missing software feature [94293]. 2. Ensuring that the necessary software for alerting pilots when aircraft are too close to the ground is equipped on the helicopter could have helped prevent the crash [94293].
Fixes 1. Installing the critical warning system, Terrain Awareness and Warning System (TAWS), on helicopters like the Sikorsky S-76B used by Island Express Helicopters could help prevent similar incidents in the future. The absence of TAWS on the helicopter involved in the crash was highlighted as a critical factor in the incident [94293]. 2. Mandating the installation of TAWS on helicopters with six or more passenger seats, as recommended by the National Transportation Safety Board (NTSB) over a decade ago, could enhance safety measures and potentially prevent crashes like the one involving Kobe Bryant's helicopter [94293].
References 1. National Transportation Safety Board officials 2. Investigator Carol Hogan 3. Island Express Helicopters 4. Sikorsky (helicopter manufacturer) 5. Former safety manager at the company, Kurt Deetz 6. Owner of Group 3 Aviation, Claudia Lowry 7. Manufacturer of the helicopter, Sikorsky 8. Brian Alexander, helicopter pilot and aviation lawyer 9. Peter Goelz, former managing director of the NTSB 10. Bill English, investigator in charge of the NTSB's Major Investigations Division 11. Jerry Kidrick, retired Army colonel and aviation instructor at Embry-Riddle Aeronautical University [94293]

Software Taxonomy of Faults

Category Option Rationale
Recurring one_organization, multiple_organization (a) The software failure incident having happened again at one_organization: - Island Express Helicopters, the company that owned the Sikorsky S-76B helicopter that crashed and killed Kobe Bryant, had previously faced a fatal crash incident in May 2008 involving its Eurocopter AS-350 helicopter. The crash was attributed to a fatigue fracture in the turbine blade, resulting in the death of the pilot, an employee, and a local school teacher [94293]. (b) The software failure incident having happened again at multiple_organization: - The National Transportation Safety Board (NTSB) criticized federal regulators for not mandating the installation of the terrain awareness and warning system (TAWS) on helicopters with six or more passenger seats, despite recommending it over a decade ago. This lack of implementation was highlighted in the crash involving Kobe Bryant's Sikorsky helicopter, where the TAWS was missing. The NTSB had previously recommended such systems after a fatal crash in 2004 involving a Sikorsky S-76A in the Gulf of Mexico [94293].
Phase (Design/Operation) design, operation (a) The software failure incident related to the design phase: - The helicopter that crashed, killing Kobe Bryant and eight others, was not equipped with vital software, the terrain awareness and warning system (TAWS), that alerts pilots when aircraft are too close to the ground [94293]. - Investigators revealed that the TAWS, which is designed to send a warning when a collision appears imminent, had not been installed on Bryant's helicopter [94293]. - National Transportation Safety Board officials criticized federal regulators for not carrying out the NTSB's recommendation over a decade ago to mandate such equipment on helicopters with six or more passenger seats [94293]. (b) The software failure incident related to the operation phase: - The pilot in the crash, Ara Zobayan, had been climbing out of the clouds when the chartered aircraft went into a sudden and terrifying 1,200-foot descent that lasted nearly a minute [94293]. - Zobayan asked for and received permission from air traffic controllers to proceed in the fog before the crash occurred [94293]. - The pilot's decision to proceed in deteriorating visibility has raised questions about whether he flew beyond the boundaries of good judgment and whether pressure to get his superstar client where he wanted to go played a role in the crash [94293].
Boundary (Internal/External) within_system, outside_system (a) within_system: The software failure incident related to the helicopter crash that killed Kobe Bryant was within the system. The helicopter involved in the crash was not equipped with vital software, specifically the terrain awareness and warning system (TAWS), which is designed to send a warning when a collision appears imminent. Investigators revealed that the TAWS was missing from Bryant's chopper, and it was criticized that such equipment should have been installed on the aircraft [94293]. (b) outside_system: The contributing factors that originated from outside the system in this software failure incident include the weather conditions and the lack of necessary Federal Aviation Administration certification for the charter company to fly in conditions that require pilots to only use cockpit instruments. The pilot was given special visual flight rules (SVFR) clearance to fly in less-than-optimal weather conditions, and the company's lack of certification for instrument flights raised questions about why the pilot didn't file an instrument flight plan that would have enabled him to navigate through the clouds [94293].
Nature (Human/Non-human) unknown (a) The software failure incident occurring due to non-human actions: The software failure incident in the article is not directly related to non-human actions. The primary cause of the helicopter crash that killed Kobe Bryant and others was not a software failure but rather a combination of factors such as poor visibility, weather conditions, and the pilot's decision-making process. The absence of a vital software system, the terrain awareness and warning system (TAWS), on the helicopter was highlighted as a potential contributing factor, but it was not the primary cause of the crash [94293]. (b) The software failure incident occurring due to human actions: The software failure incident in the article is not directly related to human actions causing a software failure. The crash was primarily attributed to factors such as the pilot's decision-making, weather conditions, and operational limitations of the charter company. While the absence of the TAWS system was mentioned as a potential contributing factor, it was not explicitly stated that human actions led to a software failure in this incident [94293].
Dimension (Hardware/Software) software (a) The articles do not provide information about a software failure incident occurring due to hardware issues. (b) The software failure incident in the articles is related to the missing vital software, the Terrain Awareness and Warning System (TAWS), on the Sikorsky S-76B helicopter that crashed, killing Kobe Bryant and eight others [94293]. The absence of this critical software, which is designed to send warnings when a collision appears imminent, was highlighted as a contributing factor in the crash. Additionally, the National Transportation Safety Board criticized federal regulators for not mandating the installation of TAWS on helicopters with six or more passenger seats, emphasizing the importance of such software in enhancing safety measures.
Objective (Malicious/Non-malicious) non-malicious (a) The articles do not mention any malicious software failure incident related to the helicopter crash that killed Kobe Bryant and eight others. (b) The non-malicious software failure incident related to the crash was the absence of a vital software system called the terrain awareness and warning system (TAWS) on the Sikorsky S-76B helicopter. The TAWS is designed to send a warning when a collision appears imminent, but it was not installed on Bryant's chopper [94293]. The absence of this critical software system could have potentially contributed to the crash.
Intent (Poor/Accidental Decisions) poor_decisions, accidental_decisions (a) The software failure incident related to poor decisions: - The pilot, Ara Zobayan, made a poor decision to proceed with the flight in deteriorating visibility despite heavy fog [94293]. - Island Express Helicopters, the company that owned the helicopter, was not certified to fly in conditions that require pilots to only use cockpit instruments, which contributed to the poor decision-making process [94293]. (b) The software failure incident related to accidental decisions: - The lack of certification for instrument flights by Island Express Helicopters may have led to accidental decisions made by the pilot, Ara Zobayan, as he may not have been experienced in instrumental flying due to the company's operating limitations [94293].
Capability (Incompetence/Accidental) accidental (a) The software failure incident occurring due to development incompetence: The article does not mention any software failure incident occurring due to development incompetence. (b) The software failure incident occurring accidentally: The software failure incident in the article occurred accidentally due to various factors such as the lack of necessary Federal Aviation Administration certification for the charter company to operate under instrument flight rules, the absence of a vital software system (terrain awareness and warning system) that alerts pilots when aircraft are too close to the ground not being installed on the helicopter, and the pilot's decision to proceed in deteriorating visibility despite heavy fog, which led to the crash [94293].
Duration unknown The articles do not provide information about a software failure incident related to the duration of the failure being permanent or temporary.
Behaviour crash, omission, value (a) crash: The software failure incident in the news article can be categorized as a crash. The helicopter crashed into a hillside due to a sudden and terrifying 1,200-foot descent that lasted nearly a minute, resulting in the loss of all nine people on board [94293]. (b) omission: The software failure incident can also be categorized as an omission. The helicopter was not equipped with vital software, the terrain awareness and warning system (TAWS), that alerts pilots when aircraft are too close to the ground. This omission of the critical warning system could have potentially contributed to the crash [94293]. (d) value: The software failure incident can be categorized as a value failure. The missing TAWS system, which was not installed on the helicopter, could have provided critical warnings to the pilot and potentially prevented the crash. The failure to have this system installed on the aircraft was highlighted as a significant issue by investigators [94293].

IoT System Layer

Layer Option Rationale
Perception None None
Communication None None
Application None None

Other Details

Category Option Rationale
Consequence death (a) death: People lost their lives due to the software failure The consequence of the software failure incident in the news article is the tragic loss of lives. The software failure, in this case, the absence of the vital terrain awareness and warning system (TAWS) on the Sikorsky S-76B helicopter, contributed to the crash that resulted in the deaths of Kobe Bryant, his daughter Gianna, the pilot Ara Zobayan, and six other passengers [94293].
Domain transportation The software failure incident reported in the news articles is related to the transportation industry. The failed system was intended to support the transportation of people and things, specifically in the context of helicopter operations conducted by Island Express Helicopters. The incident involved a Sikorsky S-76B helicopter that crashed in California, resulting in the tragic deaths of Kobe Bryant, his daughter, and seven others [94293]. The helicopter lacked vital software, specifically the terrain awareness and warning system (TAWS), which is designed to alert pilots when an aircraft is too close to the ground [94293]. The absence of this critical software system may have contributed to the crash. Additionally, the articles mention that the pilot of the helicopter was not certified to fly in conditions that required the use of cockpit instruments, highlighting a deficiency in the operational capabilities of the company and the pilot [94293]. The pilot, Ara Zobayan, was only licensed for visual flight rules and did not have the necessary Federal Aviation Administration certification for the specific flight that ended in the tragic crash [94293]. This lack of certification and the absence of essential software systems point to failures within the transportation industry, particularly in ensuring the safety and compliance of helicopter operations.

Sources

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