Pilot, safety expert, consultant, and aviation journalist Stuart “Kipp” Lau writes about flight safety and airmanship for AIN.

Contributor - Safety

Stuart “Kipp” Lau

The fallout from a fatal helicopter crash in 2020 that killed a pilot and eight occupants continues as the FAA now recommends spatial disorientation training for pilots operating under Part 91, 91K, and/or 135. Spatial disorientation was a probable cause of this high-profile accident, according to the NTSB. The recent FAA action closes a formal NTSB recommendation to enhance spatial disorientation training for business aviation pilots.
On Jan. 26, 2020, a <a href="https://www.ainonline.com/aviation-news/business-aviation/2021-02-26/ainsight-just-land">Sikorsky S-76B crashed</a> short of its planned destination of Camarillo Airport (KCMA) in Southern California. The crash killed the pilot, as well as Kobe Bryant, his daughter, and six family friends.
This accident wasn’t surprising, but it was preventable. It was the typical set-up that included scud running, inadvertent flight into IMC, spatial disorientation, loss of control, and a tragic loss of life.
The aircraft departed John Wayne Airport (KSNA) in Santa Ana under a special VFR clearance and flew toward Camarillo at 400 to 600 feet agl into progressively deteriorating weather conditions. The minimum flight altitude per the company’s flight ops manual was 300 feet agl.
As the helicopter neared Burbank (KBUR), the pilot was asked to hold outside of Class C airspace due to traffic, while awaiting another special VFR clearance. KBUR and the neighboring Van Nuys Airport (KVNY) were IFR, reporting 2.5 miles of visibility and 1,100-foot ceiling.
Clearing KBUR and KVNY airspace, the helicopter followed a path along U.S. Route 101 toward rising terrain. After a few brief interactions with the SoCal approach, the pilot announced that he was going to climb above the cloud layer. The helicopter climbed at 1,500 fpm, began a tight turn to the left, and then descended rapidly before hitting the ground. Within seconds of entering IMC, the pilot became disoriented, lost control of the aircraft, and crashed.
Included in the <a href="https://data.ntsb.gov/Docket?ProjectID=100863">NTSB docket</a> is a performance study and human performance report. These reports outline some very real human performance limitations backed by sound science that should keep any non-instrument-rated pilot out of the clouds. The report highlights the many vulnerabilities of the human body to spatial disorientation.
NTSB Recommendation and FAA Action
Published in February 2021, the NTSB final report included Safety Recommendation A-21-006 to the FAA: “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 mitigate it, and make public a report on the committee’s findings.”
Following this recommendation, the agency acknowledged NTSB accident investigation data showing that pilot spatial disorientation is a contributing factor in many accidents. The FAA said, “Spatial disorientation occurs when a pilot’s perception of direction of flight is not consistent with reality, often due to the lack of visual references or conflicting signals from the body’s sensory system.”
FAA established two separate groups to evaluate simulator technologies and training programs for pilots to effectively recognize and mitigate spatial disorientation. The work of these groups concluded during the first half of 2023.
The recently published FAA <a href="https://www.faa.gov/other_visit/aviation_industry/airline_operators/airline_safety/info/all_infos/InFO26003.pdf">Information for Operations (InFO) 26003</a>, recommending spatial disorientation training for Part 91, 91K, and 135 operators, is a direct result of the work from these two groups. “To reduce the possibility of spatial disorientation accidents in the future, the FAA recommends that operators and training providers incorporate spatial disorientation training into their operations,” the FAA said.
To accomplish this, “the FAA recommends a greater focus on spatial disorientation training beyond the scope of current guidelines. Spatial disorientation training should emphasize avoidance of conditions where spatial disorientation can occur, as well as recognition of onset and recovery from spatial disorientation events.”
Furthermore, the FAA stated, “Spatial disorientation training should include the types of training, training methods, and special emphasis areas.” According to the agency, this can be accomplished using scenario-based training and maneuver-based training in simulators (full-flight and spatial disorientation) or in-flight on aircraft. It must also include ground school and recurrent training.
Final Thoughts
Following the Kobe Bryant crash, NTSB investigators focused on the following safety issues: pilot preflight; weather and flight risk planning; entry into IMC and the pilot’s inadequate weather avoidance; spatial disorientation; the pilot’s decision to continue into adverse weather; the company’s inadequate implementation of a safety management system; and other topics related to system safety.
To be honest, it was all bad, and this crash was preventable. On that day, that helicopter and that pilot should have never left KSNA.
Improved aeronautical decision-making would have helped the pilot make better decisions during the preflight planning process (i.e., delay the flight) and offered alternatives (turn around, land somewhere safe) while en route to the destination. Within an effective SMS, the use of a flight risk assessment tool, proper safety risk management, and better support for the pilot almost certainly would have changed the outcome.
The FAA’s suggestion that business aviation pilots undergo spatial disorientation training is commendable and marks an important initial move. It’s a tragedy that it took a high-profile crash to move the needle on this much-needed training.
Spatial disorientation is a contributor to loss of control in-flight (LOC-I) accidents. LOC-I is the leading cause of fatalities in aviation. Airlines throughout the world have mitigated the LOC-I threat—which includes spatial disorientation—by implementing comprehensive upset prevention and recovery training (UPRT) programs.
Mandating comprehensive UPRT programs for Part 91, 91K, and/or 135 operators could be more effective than merely recommending spatial disorientation training.

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