What Can we Learn From This Fatal S-76 Accident in California?

This accident still makes a lot of pilots uncomfortable.

Not because it’s complicated, or hard to understand, but because it’s a scenario we’ve seen play out time and time again in the rotary industry… 💥

This wasn’t a technical issue. It was a perfectly serviceable helicopter, with an experienced pilot, on a route and in an aircraft he knew well, but on a day with marginal weather conditions.

The helicopter ended up in a rapidly descending left turn in Instrument Meteorological Conditions (IMC), and crashed into terrain in Calabasas, California. The crash resulted in the tragic death of all 9 people onboard, including famous basketball player Kobe Bryant.

Let’s go over what happened, why it happened, and what we can learn from this.

💥 Accident Overview

On 26 January 2020, around 09:07 Pacific standard time, a Sikorsky S-76B helicopter (N72EX), operated by Island Express Helicopters Inc. departed VFR from John Wayne Airport-Orange County (SNA), Santa Ana, California.

Its destination was Camarillo Airport (CMA), Camarillo, California (about 24 miles west of the accident site).

After departing SNA, the helicopter mainly flew at altitudes between 400 to 600 ft AGL (above ground level), always remaining below 1,700 ft AMSL (above mean sea level).

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At 09:20:14, 8.5 miles southeast of Bob Hope Airport (BUR), the pilot requested special VFR clearance through the BUR airspace.

Air Traffic Control (ATC) requested the pilot to hold outside the airspace due to traffic. After a few holds, the helicopter progressed through controlled airspace without any issues:

At the start of the transit, ATC advised the pilot of the following weather conditions:

🔸 Overcast ceiling at 1,100 ft AGL

🔸 Visibility of 2.5 miles (4.5 km) with haze

🔸 Cloud tops at 2,400 ft msl.

After transiting BUR airspace, the helicopter started following the US101 westbound. This picture was taken at 09:44:20 by CCTV cameras from the US101:

At 09:44:34 (about 2 minutes before the accident), the helicopter was still flying west at an altitude of about 1,370 ft msl (450 ft agl) over US Route 101 (US 101), and rising terrain.

The pilot announced to air traffic control that he was initiating a climb to get the helicopter “above the cloud layers,” and the helicopter immediately began climbing at a rate of about 1,500 ft per minute.

At about the same time, the helicopter began a gradual left turn, and its flight path generally continued to follow the US 101 road.

About 36 seconds later and while still climbing, the helicopter began to turn more tightly to the left, and its flight path diverged from its overflight of US 101.

The helicopter reached an altitude of about 2,370 ft msl (about 1,600 ft agl) at 09:45:15 and then began to descend rapidly while in a left turn.

At 09:45:17 (during the descent), the air traffic controller asked the pilot to “say intentions,” and the pilot replied that he was “climbing to 4,000 ft”.

A witness near the accident site heard the helicopter, then saw it emerge from the bottom of the cloud layer in a left-banked descent about 1 or 2 seconds before impact.

About 3 minutes after impact, a ground witness managed to capture an image of the accident site:

The helicopter was destroyed, and all 9 occupants were fatally injured.

🔎 Investigation Findings

So what did the investigation reveal?

The investigation team was able to confirm that this accident included:

🔸 No mechanical failures.

🔸 No medical issues.

🔸 No drugs, alcohol, or fatigue.

🔸 No evidence of direct pressure from the company or client

So what happened? The report states:

“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.”

And:

“Contributing to the accident was the pilot’s likely self-induced pressure and the pilot’s plan continuation bias, which adversely affected his decision-making, and Island Express Helicopters Inc.’s inadequate review and oversight of its safety management processes.”

The weather risk was underestimated

The pilot completed a flight risk assessment earlier that morning and it came out as “low risk.”

However, the updated weather before departure would have triggered a higher level of scrutiny and required an alternate plan. That reassessment didn’t happen, partly because it wasn’t clear that it had to.

The pilot did mention to the air charter broker before departing that his intension was to go ‘up and around” the weather.

The NTSB said:

“There was no record that the pilot obtained a formal preflight weather briefing for the accident flight either directly from the flight services provider, through his ForeFlight application, or from a third-party vendor.”

The NTSB also noted the benefits of a mandatory Safety Management System, which would have helped prevent a situation like this.

The problem with flights like these around unconventional terrain is what one of the weather service forecasters told the NTSB as well:

“The area it was approaching at that time often had cloud ceilings and visibilities that were lower than the areas to the east when regional weather conditions like those that existed on the day of the accident were present.”

The helicopter inadvertently entered IMC, causing Spatial Disorientation

By the time the decision to climb was made, the aircraft was already entering cloud. The pilot didn’t slow down, manoeuvre away, or land.

The NTSB concluded:

“The pilot’s poor decision to fly at an excessive airspeed for the weather conditions was inconsistent with his adverse-weather-avoidance training and reduced the time available for him to choose an alternative course of action to avoid entering IMC.”

We’ve covered IIMC in the past, which remains a very large contributor to helicopter incidents and accidents:

Inadvertent IMC: Are you Truly Prepared?

Climbing rapidly into cloud while turning removed all external visual references. This created the perfect conditions for vestibular illusions and spatial disorientation, which quickly led to loss of control.

A decision to continue flight in degrading conditions

The NTSB noted that continuing into deteriorating weather didn’t match his usual judgement. They concluded it was likely driven by self-induced pressure, no clear Plan B, and classic plan continuation bias, especially as the destination got closer.

The report notes:

“At the time that the flight began entering IMC, it was only about 25 miles from CMA (the destination), which had been reporting weather conditions above the basic VFR minimums since before the accident flight departed.”

And:

“With plan continuation bias, the closer the pilot gets to the destination, the stronger the bias becomes (Woods 2020,10).”

We’ve covered plan continuation bias and it’s insidious effects on flight safety before, as it is still such a common occurrence:

The Trap of Plan Continuation Bias

There was no evidence of external pressure

This one is always a little tricky to determine, as its almost impossible to provide accurate and objective evidence of what company cultures are like, and how pilot minds are influenced overall.

However, the NTSB notes there was:

🔸 No pressure from the company

🔸 No pressure from the client

🔸 No pressure from the broker

It concludes it was likely internal pressure (the hardest kind to recognise).

Also, this begs the question what are the influences within a culture that increase or reduce a pilots internal pressure?

Lots of variances here depending on the culture you find yourself in.

The NTSB report did mention some ‘influences’, such as:

🔸 The pilot was the client’s preferred pilot, who trusted him to fly his children

🔸 The pilot likely did not want to disappoint the client by not completing the flight

We’ve covered how tricky commercial pressure can be to detect and address here:

Let’s Talk About Commercial Pressure in Aviation

💡 What Can we Learn From This?

Some new, and some age old takeaways from this horrible accident:

Marginal VFR is often borrowed time

Flying just under the cloud, just legal, just comfortable enough, is not a stable place to be.

It works right up until something changes. There’s no room for anything to go sideways.

Terrain rises. Visibility drops. Workload spikes. Options disappear. Ask any HEMS pilot trying to get to a dying patient.

This flight is a classic example of margin slowly getting thinner until there was nothing left. If your plan relies on everything staying the same, it isn’t really a plan.

Have options, ask what-ifs, and be aware of plan continuation bias when you get closer to your destination.

“Let’s just climb above it” requires planning and mental preparation

Climbing feels like action. Like you’re taking control of the situation.

But if you’re already close to cloud, and not fully set up for instruments, that climb can remove your last escape route in seconds if you haven’t planned and prepared yourself properly.

We don’t publish all our Notes from the Cockpit (like this one) publicly, some are shared only by email. Get the next one sent straight to your inbox ⤵️

In this accident, the moment visual references disappeared, the helicopter entered a situation where time, orientation, and control were all working against the pilot.

From there, recovery options ran out very quickly.

IIMC Remains a Huge Threat to Helicopter Pilots

This is one of the most uncomfortable lessons.

We keep seeing that even experienced instrument qualified pilots can suffer startle effect and other threats from an unplanned entry into IMC.

By the time you enter clouds inadvertently, any decision that follows is now reactive, not proactive.

If you’re asking yourself whether it’s time to change the plan, there is a good chance the weather has probably already won that argument.

The most powerful pressure often comes from ourselves

There was no pressure from the company. No pressure from the client. No one telling the pilot to push on. The pressure came from within:

The pilot wanted to make it work, to deliver, to succeed and complete the task. Saying no can be way easier said than done, as we’ve covered here:

The Crucial Skill of Saying No as a Pilot

Self induced pressure is quiet, convincing, and incredibly hard to spot or be aware of, especially when the destination is close and the route is familiar.

Experience doesn’t make you immune, it can make traps harder to see

This pilot was experienced, current, trained, and respected.

And yet, plan continuation bias still crept in. Familiarity still reduced caution. Confidence potentially shortened re-assessment.

Experience doesn’t remove human factors, we still deal with the same traps and biases that without awareness, can be even stronger when we’ve flown for a long time.

💭 Conclusion

Crashes like these always hit differently, because marginal VFR conditions are one of the most common threats for helicopter operations.

A flight that started out feeling “doable.” Weather that was legal, but uncomfortable.

A familiar route. A capable pilot. A helicopter that was working exactly as it should, but with less and less margin.

Nothing here jumps out as objectively reckless. Most of the decisions make sense when you look at them in isolation. And that’s the scary part. Because this is exactly how a lot of helicopter accidents start, not with one big mistake, but with a series of small, debatable ones that slowly box you in.

You can find the NTSB report here.