DCA20MA059

NTSB accident investigation · Sikorsky S76 · Calabasas, CA · January 26, 2020

Accident · FatalClass 1 · MajorFinal report
Date
January 26, 2020, 09:45 local (17:45 UTC)
Place
Calabasas, CA
Injuries
9 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N72EXSikorsky S76
Defining event
Enroute: VFR encounter with IMC
Weather
Instrument (IMC) · Day
Status
Completed · report February 9, 2021
Report
Board-adopted at Board Meeting · Board meeting February 9, 2021
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
20200126001589A
Case key
100863

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

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. 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.

Findings · 9

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotSikorsky S-76B: 2 casesAll aircraft: 9,295 casesProbable cause
Safety programs: adequacy of safety programOrganizational issues › Support/oversight/monitoring · OperatorSikorsky S-76B: 1 caseAll aircraft: 24 casesProbable cause
Air traffic/operating procEnvironmental issues › Operating environment · Compliance w/ procedureSikorsky S-76B: 1 caseAll aircraft: 13 cases
Ceiling/visibility/precip: cloudsEnvironmental issues › Conditions/weather/phenomena · Decision related to conditionSikorsky S-76B: 1 caseAll aircraft: 108 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Factual narrative

On January 26, 2020, about 0945 PST, a Sikorsky S76B helicopter, N72EX, crashed into hilly terrain near Calabasas, California. A post impact fire ensued and resulted in a brush fire. The eight passengers and one pilot onboard were fatally injured and the helicopter was destroyed. The helicopter was operated by Island Express Helicopters. Weather at Van Nuys airport, about 14 miles northeast of the site was reported as 1,100 feet overcast with 2 ½ miles visibility. The flight was operated under the provisions of 14 CFR Part 135 under visual flight rules from John Wayne Airport (KSNA), Santa Ana, California, to Camarillo Airport (KCMA), Camarillo, California. An Investigative Webpage is located at https://www.ntsb.gov/investigations/Pages/DCA20MA059.aspx.

Aircraft

Registration
N72EX
Reported as
Sikorsky S76 (B)
Category
Helicopter
Serial number
760379
Built
1991
Damage
Destroyed
Fire
On-Ground
Flight
Part 135
Operator
Island Express
Registered owner
Island Express Holding Corp
Airworthiness certificate
Standard, Normal
Departed
KSNA · Santa Ana, CA
Destination
KCMA · Camarillo, CA
Equipment
Auto-pilot, ADS-B

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
50
Injuries
Fatal
Certificate
Commercial
Instrument ratings
Helicopter
Medical
Class 2, With waivers/limitations
Toxicology
Performed
Flight hours
8,577 total · 1,250 in this make and model · 61 in the last 90 days · 15 in the last 30 days · 1.5 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
Calm
Visibility
2.5 statute miles
Lowest ceiling
1,100 ft overcast
Observed at
KVNY, 14 nm away

Docket · 53

The files NTSB released with the investigation on June 17, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.0 GB in all.

Operational factors and human performance group chairman factualItem 1 · PDF · 29 pages · 430 KBOps/hp attachment 1 interviews tocItem 2 · PDF · 2 pages · 36 KBOperational factors and human performance group interview official transcriptsItem 3 · ZIP · 2.2 MBOps/hp attachment 2 pilot's documentsItem 4 · PDF · 148 pages · 26.9 MBOps/hp attachment 4 flight planning documentsItem 5 · PDF · 26 pages · 5.1 MBMaintenance recordsItem 6 · PDF · 13 pages · 164 KBAircraft performance studyItem 7 · PDF · 13 pages · 3.2 MBDeleted--personal electronic devices - specialist's factual reportItem 8 · PDF · 9 pages · 772 KBErrata - personal electronic devices - specialist's factual reportItem 9 · PDF · 1 page · 13 KBAddendum - personal electronic device - specialist's factual reportItem 10 · PDF · 3 pages · 273 KBAddendum 2 - personal electronic device - specialist's factual reportItem 11 · PDF · 2 pages · 116 KBMeteorology factual reportItem 12 · PDF · 38 pages · 12.4 MBAttachment 1 to the meteorology factual reportItem 13 · PDF · 230 pages · 428 KBAttachment 2 to the meteorology factual reportItem 14 · PDF · 36 pages · 21.4 MBAttachment 3 to the meteorology factual reportItem 15 · PDF · 20 pages · 6.4 MBAttachment 4 to the meteorology factual reportItem 16 · PDF · 27 pages · 83 KBAttachment 5 to the meteorology factual reportItem 17 · PDF · 13 pages · 6.1 MBAttachment 6 to the meteorology factual reportItem 18 · PDF · 4 pages · 1.4 MBAttachment 7 to the meteorology factual reportItem 19 · PDF · 22 pages · 3.1 MBMeterology - baseball fields camera videosItem 20 · ZIP · 338 MBMeteorology - bloomsky videoItem 21 · MP4 · 1.9 MBMeteorology - city of calabasas videoItem 22 · ZIP · 130 MBMeteorology - dash cam videosItem 23 · ZIP · 268 MBMeteorology - sce camera video loopsItem 24 · ZIP · 300 MBMeteorology - video visibility studyItem 25 · PDF · 12 pages · 5.2 MBErrata 1 to the meteorology factual reportItem 26 · PDF · 2 pages · 16 KBAddendum 1 to the meteorology factual reportItem 27 · PDF · 4 pages · 608 KBAirworthiness group chairman's factual reportItem 28 · PDF · 15 pages · 8 photos · 1.2 MBAirworthiness group chairman's factual report - attachment 1-list of recovered avionicsItem 29 · PDF · 14 pages · 148 KBAirworthiness - UAS imagery reportItem 30 · PDF · 6 pages · 1.3 MBAirworthiness - UAS att 1 google earth kmzItem 31 · KMZ · 86.9 MBAirworthiness - UAS att 2 orthomosaic geotiffItem 32 · ZIP · 285 MBAirworthiness - UAS att 3 flight path videoItem 33 · MP4 · 446 MBAirworthiness - UAS att 4 panoramic photoItem 34 · JPG · 30.0 MBATC group chairman's factual reportItem 35 · PDF · 17 pages · 209 KBATC group chairman's factual report - attachment 1 - interview summariesItem 36 · PDF · 19 pages · 125 KBATC group chairman's factual report - attachment 2 - record of conversationItem 37 · PDF · 12 pages · 3.9 MBATC group chairman's factual report - attachment 3 - partial ATC communication transcriptItem 38 · PDF · 6 pages · 150 KBATC group chairman's factual report - attachment 4 - flight track graphicsItem 39 · PDF · 4 pages · 1.9 MBErrata - ATC group chairman's factual report - attachment 5 - ADS-B data - ccItem 40 · PDF · 1 page · 105 KBATC group chairman's factual report - attachment 5 - ADS-B data - ccItem 41 · CSV · 970 KBPowerplants group chairman's factual reportItem 42 · PDF · 27 pages · 59 photos · 3.0 MBTechnical review master errata sheetItem 43 · PDF · 2 pages · 104 KBMaterials laboratory factual reportItem 44 · PDF · 40 pages · 44 photos · 6.0 MBFMS data extraction reportItem 45 · PDF · 29 pages · 136 KBParty submission - island expressItem 46 · PDF · 9 pages · 7.1 MBParty submission - SikorskyItem 47 · PDF · 9 pages · 484 KBRelease of aircraft wreckage, NTSB form 6120.15Item 48 · PDF · 1 page · 733 KBOps/human performance attach #6 sms updated redactionItem 49 · PDF · 215 pages · 15.0 MBOps/human performance emails attach #7 updated redactionItem 50 · PDF · 26 pages · 800 KBOps/human performance attachment text messages attachment #5Item 51 · PDF · 24 pages · 1.5 MBOps/human performance attachment island express documents attachment #3 redacted updatedItem 52 · PDF · 59 pages · 6.6 MBFAA emails regarding 135 operator numbersItem 53 · PDF · 3 pages · 195 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.