From the outset it looked to me as though the Kobe Bryant crash was a simple case of “continued VFR into IMC” — a crash caused by a pilot wandering into clouds and fog and losing control of the helicopter and crashing. The NTSB’s update seems to confirm just that.   Here are the four important points from the update:

A photograph of the helicopter seems to show it entering clouds.

The pilot was on a visual flight rules (or “VFR”) flight. On a VFR flight, the pilot is supposed to control the helicopter by looking out the window rather than by looking at the helicopter’s instruments.   So, on a VFR flight, the  pilot must stay out of fog and clouds.  Yet the photo shows Kobe’s helicopter flying into clouds (“IMC,” or “instrument meteorological conditions”), or at least flying on the ragged edge of acceptable visibility.

The pilot’s last communication is consistent with his being inside the clouds and trying to escape them.

The last communication air traffic control received from the pilot was that he was climbing to 4000 feet — well above his cruising altitude.  That suggests that the pilot was attempting to get out of the foggy conditions by climbing above them.

The aircraft’s flight path was consistent with the pilot’s losing control of the helicopter while in the clouds. 

The update notes that:

the aircraft was climbing along a course aligned with Highway 101. . .  reached 2,300 feet msl (approximately 1,500 feet above the highway, which lies below the surrounding terrain) and began a left turn. Eight seconds later, the aircraft began descending and the left turn continued. The descent rate increased to over 4,000 feet per minute (fpm), ground speed reached 160 knots.”

Translation: the helicopter climbed, then started a turn, then suddenly went out of control and tumbled out of the sky.

Nothing was mechanically wrong with the helicopter.

The update notes that there didn’t appear to be anything wrong with the helicopter and it was producing power at impact.

In short, the crash appears to be a classic case of loss of control following improper VFR flight into IMC.

Some folks are saying that the helicopter should have had a terrain awareness warning system to let the pilot know where the hillside was.  It wouldn’t have helped.  The pilot crashed because he flew into IMC and lost control.  Not because he hit a hillside that he could not see.

Helicopters come to grief all too often after encountering clouds or fog. In fact, it seems that it was an encounter with low clouds that lead to the fatal Safari Helicopter Crash on Kauai just a few weeks ago.

Fog can lead to a helicopter crash in two ways. First, the pilot can, upon encountering clouds, lose track of the horizon. Once that happens, the pilot may not know which way is up. The disoriented pilot will soon lose control of the helicopter and crash.

Second, once in the clouds, the pilot may maintain control of the helicopter only to collide with terrain he cannot see – or cannot see until it is too late. The type of accident is called “controlled flight into terrain,” or CFIT.

CFIT accidents are especially common in conditions such as those that Bryant’s helicopter encountered. The pilot, trying to stay beneath the clouds, may be forced lower and lower. Or, he may be forced away from the road or valley that marked his intended flight path towards the hills that surround that flight path. Suddenly, the pilot finds himself face-to-face with rising terrain.  A CFIT in the making.

If the pilot sees the terrain in time, the only way to avoid it may be to turn into the clouds or fog he was seeking to avoid. It’s possible that is just what Kobe Bryant’s pilot did, as radar tracking shows the aircraft climbing suddenly. After all, once in the clouds, climbing is the pilot’s best hope for avoiding terrain he cannot see. But, of course, once in the clouds, it is all too easy to become disoriented, lose control of the aircraft, and crash.

Why didn’t Bryant’s pilot just fly by instruments? Flying by instruments, especially in a helicopter, is a difficult, technical endeavor. It’s not enough for the pilot to hold an instrument rating. For a pilot to legally fly on an instrument flight plan, the helicopter must be specially equipped and the pilot must be current on all instrument procedures, having completed a minimum number of recent instrument flights. Finally, when flying on instruments the pilot must follow an inconvenient and often circuitous routing, contend with holding patterns, and follow the instructions of an air traffic controller. In short, flying visually is often quicker and easier.

So, what might the pilot have done here? He could have simply stayed on the ground. After all, he knew when he took off that the weather was marginal, as he needed a “special VFR” clearance to depart the airport.  Or, if he was instrument-current and the aircraft properly equipped, he could have filed an instrument flight plan. Failing that, once he encountered fog or clouds on route, he could have returned to the airport. Finally, if the weather had closed in behind him, precluding a safe return, he could have considered the helicopter pilot’s mantra – “land and live.”

The NTSB won’t come out with its conclusion as to the cause of the crash for months if not years. But from what we know now, it sure looks like “continued VFR into IMC,” which is the NTSB’s phrase for flying visually into conditions of poor visibility.

This video shows what can happen when a helicopter presses on into clouds or fog.  (Warning – disturbing.)

 

A passenger boarded a United flight from Rome to San Francisco. He asked for food. The flight attendant refused. The two exchanged words. Eventually, another flight attendant heard the argument and brought the passenger some crackers. The passenger ate the crackers, took his seat, and went to sleep.

While the passenger slept, the flight attendant convinced the pilot to land the plane. The pilot diverted to Belfast. On landing, the flight attendant reported to the local police that the passenger threatened the safety of the flight. The report was false. Nonetheless, the Belfast police detained the passenger for ten months. They locked him up with convicted murders and other violent criminals before putting him on trial for “endangering the safety of a flight.”

United sent its crew to testify against the passenger. The jury determined that the flight attendant’s testimony was false and quickly acquitted the passenger who was, at long last, permitted to return home.

We brought a malicious prosecution lawsuit against United on the passenger’s behalf. A federal judge Oakland dismissed the suit, agreeing with United that the Montreal Convention — the international treaty governing airline’s liability for injuries occurring on international flights – immunized United from any liability. We appealed. We argued that the Montreal Convention addresses only an airline’s liability for conduct occurring during the flight itself. The flight attendant’s false testimony that lead to the malicious prosecution action occurred 10 months after the flight had landed.

The federal court of appeal for the ninth circuit agreed, reversed the trial judge’s ruling and reinstated the passenger’s case.

Read the Appellate Court opinion.

 

 

Of course it’s too early to know why the Safari Helicopters AStar crashed this week, killing all aboard. But it sure looks like a long line of other Hawai’ian tour crashes that fall under the category “Controlled Flight Into Terrain,” or CFIT for short.

Hawai’i is subject to “microclimates.” The weather can be fine at the

Safari Helicopters AStar

helicopter’s point of departure, but the pilot can encounter clouds, rain or fog along the route. The pilot then has a choice. He can turn around and disappoint the tourists on board. Or he can press on a bit, deviating around the clouds and fog as necessary.

The plan works fine until it’s time to return to base. If the usual path is blocked by the deteriorating weather, the pilot must improvise, cutting across terrain with which he may not be familiar. If the helicopter flies into the clouds, the pilot will become disoriented, he will lose control and crash. So he will try to stay below the clouds, a practice often called “scud-running.”

Scud running can turn lethal when either the cloud deck drops suddenly or the ground rises, causing the aircraft to fly into the terrain feature at a high rate of speed.

Other CFIT accidents I’ve written about:

Blue Hawaiian Helicopter Crash: Photo Tells the (Same Old) Story?

Ella Lake, Alaska Crash Looks Like Another CFIT Accident

SkyLife HEMS Crash and Weather

Senator Stevens Crash Looking Like “Controlled Flight Into Terrain”

 

The first thing Boeing does when sued for a crash on foreign soil is try to get those lawsuits moved out of the US and into the foreign countries.  In the case of the 737 Max cases, it means trying to move them to Indonesia and Ethiopia.  If Boeing’s successful, the cases would be virtually worthless and the families would get next to nothing.

The legal doctrine that Boeing relies on is called forum non conveniens. I’ve written about Boeing’s “FNC” strategy most recently here.   And then I gave an interview explaining the strategy to Business Insider reporter Sinead Baker in London, who published an article in June.  She took particular note of my comment that “having a trial in another country with a different legal culture, and less scope for close scrutiny of Boeing, would render the case worthless.”

Last week Boeing’s CEO, Dennis Muilenburg, testified before Congress.  When asked whether Boeing was seeking to move the cases out of the country, the best he could come up with was “Congressman, I can’t comment on that.  I’m just not familiar with the details of that. . . I don’t know the answer.”

Representative Peter De Fazio, the committee chairman, was incredulous.  He hammered the CEO. The Congressman pointed to the Business Insider article, and specifically referred to my comments about the cases being “worthless” in another country.

This took me 30 seconds with Google search.  June 13th, Business Insider. . . And you don’t that that’s happening?”

Read the transcript or watch the exchange at the Business Insider follow-up article.

The National Transportation Board investigates every general aviation accident.  It chalks up the vast majority to pilot error. But half the time, it’s just wrong.

The trouble’s that, in investigating an accident, the NTSB refuses to consult with the pilot’s family or the family’s experts. Rather, it invites into the investigation only other potentially responsible parties–usually the manufacturers of the plane and the plane’s engine–seeking their technical “expertise.” That introduces into the investigation an inherent conflict of interest. It’s no wonder that the NTSB ends up blaming the pilot more often than not.

I’ve written about the inherent conflict of interest for years.  And certainly I’ve had cases where the NTSB determined that the crash was the result of pilot error, but I proved in court the NTSB was just plain wrong.

Now a new film, Invisible Sky, challenges the NTSB’s work in connection with a general aviation crash that killed an opera singer and four of her friends.  I’m told the film takes the NTSB head on.  Click on the image to watch the trailer.

Invisible Sky

The FAA is too cozy with the manufacturers it is supposed to regulate.  I’ve been writing about that since 2009.  The press is just now becoming interested, asking how the FAA ever allowed the 737 Max to be certified.

What does that have to do with a helicopter case and a murder investigation?

In 2001, an Assistant US Attorney, Tom Wales, was shot and killed in his Seattle home.  Wales had prosecuted a case involving a Bell Helicopter — an odd case which seemed to benefit no one but Bell.  Wales’ murder was as mysterious as the Bell case he was prosecuting.  There has never been an arrest.  Rod Rosenstein said a few months ago that the murder investigation is still active, and there’s a $1.5 million reward for information.

The murder case is a subject of a popular podcast, “Somebody, Somewhere.”  The investigative reporters, former federal prosecutor and CNN producer David Payne, along with his colleague from CNN, Jody Gottlieb, have been re-examining the evidence since 2018, despite a request from the FBI that they cease and desist.  The popular podcast’s twelfth and final episode leads to a Bell Helicopter case I handled just before Wales was shot.  If the evidence is authentic, it suggests that it’s not just the FAA who the aviation manufacturers have in their pocket.

The highly-rated series is a must-listen for anyone interested in the aviation industry, even if you’ve never listened to a podcast before.

Podcast Uncovers Aviation Industry Influence Over Government Agencies – Season 1, Episode 1

 

 

 

 

Families of both Ethiopian Airlines Flight 302 and Lion Air Flight 610 have sued Boeing in Cook County, Illinois. To win, the families need prove only that a defect in the design of the Boeing 737 Max contributed to the crashes.  But first they have to convince the judges that their cases should be heard in this country and not in either Indonesia or Ethiopia, where the crashes occurred. Of course, if the Cook County courts decide to send the cases to the countries where the crashes occurred, its unlikely the families will ever receive meaningful compensation. Neither the Ethiopian nor Indonesian legal systems allow for meaningful monetary compensation in death cases, at least as compared to the legal system in the US.

So how will the Cook County judges decide whether to allow the cases to proceed in the US, or to instead send them away? The courts will look to the doctrine of forum non conveniens, a common doctrine in aviation cases which allows a judge to send a case to the country where the crash occurred if the judge decides the foreign country is a more appropriate place for the case to proceed.

In deciding whether to keep the case or send it away, the courts will seek guidance from an Illinois appellate case entitled Ellis v. AAR.  Like these cases, Ellis involved the crash of a Boeing 737, but in the Philippines. I represented 31 families from that crash and the issue of forum non conveniens was, of course, hotly contested. Ultimately, we won the forum non conveniens battle and went on to win settlements for all the families. Had we lost on forum non conveniens and the had the court sent the cases to the Philippines, the families would have been turned turned away without any compensation at all.

Under the Ellis case, some of the factors a court should consider in deciding whether to keep a crash case in the United States or send it to the country in which the crash occurred are as follows:

1. Which country would be most convenient for the witnesses?
2. In which country would it be easier to access the relevant evidence?
3. Where would it be easiest to subpoena unwilling witnesses?
4. In which country would it be the least costly to have witnesses attend trial?
5. In which country is it easiest to view the crash site, if necessary?

In Ellis, we convinced the court that, on balance, consideration of these factors weighed in favor of hearing the case in the US and not the country in which the crash occurred. Of note was that the crash site had no evidentiary value because it had been paved over shortly after the crash. Thus there was no reason for a jury to see it.

Boeing will argue that, unlike the Ellis case, these cases should be sent back to the countries in which the crashes occurred. First, Boeing will argue that only the foreign courts can decide the cases in their entirety. That’s because Boeing will blame the foreign airlines, their pilots and their mechanics, but the Cook County courts cannot force those parties to come to the US for trial. Boeing, on the other hand, will volunteer to submit to the jurisdiction of the foreign courts, making those courts the only ones where “complete relief” can be afforded. Boeing will further argue that crucial evidence, such as the aircraft flight data recorders, cockpit voice recorders, and various aircraft parts are in the foreign countries and it’s not likely those countries will allow the evidence to be shipped here.

The families will argue that most of Boeing’s engineers are in Chicago, right down the street from the courthouse, as are the reams of documents involved in the aircraft certification. Moreover, the evidence from the flight data recorders will soon be extracted and reduced to written form which can be easily copied and transmitted to the US. Further, getting to the bottom of what caused these crashes is of vital interest to the United States because the 737 Max aircraft will once again fly in this country.

Judges are allowed wide discretion in ruling on forum non conveniens motions.  That means that, whatever the trial judges decide, it will be difficult if not impossible to reverse the decisions on appeal.

Normally, the FAA cannot be sued for doing a bad job certifying an aircraft as safe. But in the case of the 737 Max, things might be different.

As a general rule, the FAA cannot be sued as long as, in certifying the aircraft as safe, it was exercising its “discretion.” The United States Supreme Court discussed the “discretionary function defense” in a case called United States v. Varig Airlines. In that case, 124 people died on board a Boeing 707 due to an inflight fire. The fire was the result of a lavatory that did not satisfy applicable safety regulations. The families sued the FAA for wrongful death, alleging that the FAA was negligent in certifying the aircraft as safe when, in fact, it wasn’t safe at all. Specifically, the FAA didn’t even review the defective lavatory design, instead simply “spot checking” the design work of Boeing. The Supreme Court ruled that in only spot-checking Boeing’s design work, the FAA was exercising its discretion and thus could not be sued.

[T]he acts of FAA employees in executing the “spot-check” program in accordance with agency directives are protected by the discretionary function exception . . . The FAA employees who conducted compliance reviews of the aircraft involved in this case were specifically empowered to make policy judgments regarding the degree of confidence that might reasonably be placed in a given manufacturer, the need to maximize compliance with FAA regulations, and the efficient allocation of agency resources. In administering the “spot-check” program, these FAA engineers and inspectors necessarily took certain calculated risks, but those risks were encountered for the advancement of a governmental purpose and pursuant to the specific grant of authority in the regulations and operating manuals. Under such circumstances, the FAA’s alleged negligence in failing to check certain specific items in the course of certificating a particular aircraft falls squarely within the discretionary function exception . . .

The case of the Boeing 737 Max, however, is different.  The FAA didn’t even spot-check Boeing’s work. Rather, it farmed out its job to Boeing itself.  Some courts hold that the government can’t assert the “discretionary function” defense when it completely abdicates its responsibility. In short, the FAA can’t argue it had the “discretion” not to do its job, and to instead hope that someone else does it. As the court explained in Whisnant v. United States, 

While the government has discretion to decide how to carry out its responsibility to maintain safe and healthy premises, it does not have discretion to abdicate its responsibility in this regard.   When it does so, the discretionary function exception cannot shield the government from . . . . liability for its negligent conduct.

Of course, the FAA’s practice of allowing Boeing to self-certify its design seems to be an complete abdication of its responsibilities and, in fact, is now under scrutiny by the Department of Justice, among others. So the question for the families of Ethiopian Airlines Flight 302 is whether this situation is more like Varig or Whisnant?

Both the Department of Justice and Transportation Department’s inspector general are investigating the FAA’s approval of the Boeing 737 Max and, in particular, the aircraft’s anti-stall system known as MCAS.

The FAA is supposed to ensure that Boeing aircraft are safe. Investigators want to know:

  • Are the FAA and Boeing too cozy?
  • Is the FAA’s oversight is too lax?
  • Is it true that the FAA didn’t actually certify the Max’s anti-stall system as safe but instead allowed Boeing to certify the system itself? Wouldn’t that be a conflict of interest?

Perhaps the real question is why these questions are being asked only now.

It was almost 10 years ago that the FAA abdicated its certification responsibilities and granted to Boeing the power to certify its own products. I questioned then whether that was in the best interests of safety.

Beginning August 31, the FAA will allow Boeing to self-certify its designs. The FAA will not even do the rubber stamping — Boeing employees will do that too. According to the Seattle Times, “the new system increases the authority of the in-house inspectors directly managed by Boeing, allowing them to review new designs, oversee testing to ensure the products meet all applicable standards, and sign off on certification.”

Then, in 2013, Boeing’s new 787s began to catch fire. The problem seemed to be Boeing’s new batteries. The NTSB investigated, and raised the same questions that I had a few years earlier. NTSB Chair Deborah Hersman hinted that maybe, just maybe, the FAA isn’t doing its job:

This is an issue when you have a regulator with limited resources. . .You can delegate some of the action, but you can’t delegate responsibility.”

No one seemed to listen. In fact, the FAA, for its part, began to allow manufacturers to certify even more of their own products. In fact, by 2017, the FAA outsourced 90% of all aircraft certification work to the manufacturers themselves.

The FAA is supposed to oversee aircraft manufacturers to ensure that the aircraft they produce are safe for the flying public. They can’t do that if they leave it to manufacturers to police themselves. Yet, that’s what they’ve done since 2009.

Is it any wonder that we’re where we are now?