Error Chains and SMS

Crash After Encounter with Instrument Meteorological  Conditions During Takeoff from Remote Landing Site 

New Mexico State Police  Agusta S.p.A. A‐109E, N606SP 

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Near Santa Fe, New Mexico  June 9, 2009 

Accident Report NTSB/AAR-11/04

PB2011-910404

National Transportation Safety Board

NTSB/AAR-11/04 PB2011-910404

Notation 8306 Adopted May 24, 2011

Aircraft Accident Report Crash After Encounter with Instrument Meteorological Conditions During Takeoff from Remote Landing Site

New Mexico State Police Agusta S.p.A. A-109E, N606SP

Near Santa Fe, New Mexico June 9, 2009

National Transportation Safety Board

490 L’Enfant Plaza, S.W. Washington, D.C. 20594

National Transportation Safety Board. 2011. Crash After Encounter with Instrument Meteorological Conditions During Takeoff from Remote Landing Site, New Mexico State Police Agusta S.p.A. A-109E, N606SP, Near Santa Fe, New Mexico, June 9, 2009. Aircraft Accident Report NTSB/AAR-11/04. Washington, DC. Abstract: This accident report discusses the June 9, 2009, accident involving an Agusta S.p.A. A-109E helicopter, N606SP, which impacted terrain following visual flight rules flight into instrument meteorological conditions near Santa Fe, New Mexico. The commercial pilot and one passenger were fatally injured; a highway patrol officer who was acting as a spotter during the accident flight was seriously injured. The entire aircraft was substantially damaged. The helicopter was registered to the New Mexico Department of Public Safety and operated by the New Mexico State Police (NMSP) on a public search and rescue mission under the provisions of 14 Code of Federal Regulations Part 91 without a flight plan. The safety issues discussed in this report include the pilot’s decision-making, flight and duty times and rest periods, NMSP staffing, safety management system programs and risk assessments, communications between the NMSP pilots and volunteer search and rescue organization personnel, instrument flying, and flight-following equipment. The National Transportation Safety Board (NTSB) is an independent federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The NTSB makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Internet at <http://www.ntsb.gov>. Other information about available publications also may be obtained from the website or by contacting: National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, SW Washington, DC 20594 (800) 877-6799 or (202) 314-6551 NTSB publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2011-910404 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000 The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of NTSB reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

NTSB Aircraft Accident Report

Contents Figures …………………………………………………………………………………………………………………………. iv 

Abbreviations and Acronyms ………………………………………………………………………………………….v 

Executive Summary …………………………………………………………………………………………………….. vii 

1. Factual Information …………………………………………………………………………………………………….1  1.1  History of Flight ………………………………………………………………………………………………………..1  1.2  Injuries to Persons ……………………………………………………………………………………………………10  1.3  Damage to Aircraft …………………………………………………………………………………………………..10  1.4  Other Damage ………………………………………………………………………………………………………….10  1.5  Personnel Information ………………………………………………………………………………………………10 

1.5.1  The Pilot ………………………………………………………………………………………………………..10  1.5.1.1  Professional Background…………………………………………………………………….10  1.5.1.2  Pilot Personal Background and Medical History ……………………………………14  1.5.1.3  Pilot Schedule and Duties …………………………………………………………………..15  1.5.1.4  Pilot Recent and 72-Hour History ………………………………………………………..16 

1.5.2  The Spotter …………………………………………………………………………………………………….17  1.6  Aircraft Information …………………………………………………………………………………………………18 

1.6.1  General Information ………………………………………………………………………………………..18  1.6.2  Helicopter Seating and Restraints ……………………………………………………………………..19 

1.7  Meteorological Information ………………………………………………………………………………………20  1.7.1  General ………………………………………………………………………………………………………….20  1.7.2  Local Airport Weather Information …………………………………………………………………..21  1.7.3  Local Witness Reports …………………………………………………………………………………….21 

1.8  Aids to Navigation ……………………………………………………………………………………………………21  1.9  Communications ………………………………………………………………………………………………………22  1.10 Airport Information ………………………………………………………………………………………………….22  1.11 Flight Recorders ………………………………………………………………………………………………………22  1.12 Wreckage and Impact Information ……………………………………………………………………………..22 

1.12.1  Seats and Restraints ……………………………………………………………………………………….23  1.12.1.1  Pilot Seat (Right Front) and Restraint System ……………………………………..23  1.12.1.2  Aft, Forward-Facing Passenger Seats and Restraint Systems …………………23 

1.13 Medical and Pathological Information ………………………………………………………………………..23  1.14 Fire …………………………………………………………………………………………………………………………24  1.15 Survival Aspects ………………………………………………………………………………………………………25 

1.15.1 Postaccident Search and Rescue Efforts …………………………………………………………….25  1.16 Tests and Research …………………………………………………………………………………………………..27 

1.16.1 Emergency Locator Transmitter’s Distress Signal Information …………………………….27  1.16.2 Radar Study ……………………………………………………………………………………………………27 

1.17 Organizational and Management Information ……………………………………………………………..28  1.17.1  NMSP Aviation Section—General Information …………………………………………………28  1.17.2  NMSP Aviation Section Personnel and Chain of Command………………………………..28 

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1.17.3 Aviation Section Policies, Procedures, and Practices …………………………………………..29  1.17.3.1  Flight Operations and Training ………………………………………………………….29  1.17.3.2  Pilot Flight and Duty Time ………………………………………………………………..30  1.17.3.3  SAR Helicopter Support Information …………………………………………………31 

1.17.3.3.1  Prelaunch Decision-Making …………………………………………………….. 31  1.17.3.3.2  Risk Management During SAR Missions ………………………………….. 32 

1.17.3.4  Crew Staffing and Equipment Practices ………………………………………………33  1.17.4 NMSP Aviation Section Staffing ………………………………………………………………………33  1.17.5  Postaccident NMSP Actions ……………………………………………………………………………34 

1.18 Additional Information ……………………………………………………………………………………………..35  1.18.1  New Mexico Search and Rescue Act and Plan …………………………………………………..35  1.18.2 Public Aircraft Operations ……………………………………………………………………………….36  1.18.3  Airborne Law Enforcement Association Standards …………………………………………….37  1.18.4  Safety Management System Programs ……………………………………………………………..38  1.18.5  Previously Issued Safety Recommendations ……………………………………………………..39 

1.18.5.1  Pilot Flight and Duty Time and Rest Period Limitations ……………………….39  1.18.5.2  Safety Management Systems …………………………………………………………….40  1.18.5.3  Risk Management and Assessment …………………………………………………….41  1.18.5.4  Flight Following and Dispatch Procedures ………………………………………….42  1.18.5.5  Helicopter Pilot Training for Inadvertent Encounters with IMC …………….43  1.18.5.6  FAA Oversight of Public Operations ………………………………………………….44 

2. Analysis …………………………………………………………………………………………………………………….45  2.1 General …………………………………………………………………………………………………………………….45  2.2  Pilot Decision-Making ……………………………………………………………………………………………..46 

2.2.1  Decision to Launch on the Mission …………………………………………………………………..46  2.2.2  Decision-Making During the Mission ……………………………………………………………….48 

2.3  Factors Affecting the Pilot’s Decision-Making …………………………………………………………….50  2.3.1   Fatigue…………………………………………………………………………………………………………..51  2.3.2   Self-Induced Pressure ……………………………………………………………………………………..53  2.3.3   Situational Stress …………………………………………………………………………………………….53  2.3.4  Summary of Factors Affecting the Pilot’s Decision-Making ………………………………..54 

2.4  Organizational Issues ……………………………………………………………………………………………….54  2.4.1  Risk Assessments and Safety Management Systems ……………………………………………54  2.4.2  NMSP Flight and Duty Time, Rest Period Limitations, and Staffing …………………….57 

2.5  Relationship with the Volunteer Search and Rescue Organization ………………………………….59  2.6  Instrument Flying …………………………………………………………………………………………………….60  2.7  Emergency Locating Equipment ………………………………………………………………………………..61 

3. Conclusions ……………………………………………………………………………………………………………….63  3.1  Findings ………………………………………………………………………………………………………………….63  3.2  Probable Cause ………………………………………………………………………………………………………..65 

4. Recommendations ……………………………………………………………………………………………………..66 

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5. Appendixes ……………………………………………………………………………………………………………….68  Appendix A: Investigation and Public Hearing …………………………………………………………………..68 Appendix B: NMSP Aviation Section “Policies and Procedures” Document ………………………….69 

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Figures Figure 1. Google Earth map showing pertinent helicopter radar data and other points of interest near the accident site. ………………………………………………………………………………………………………. 6 

Figure 2. View of the accident location. ……………………………………………………………………………. 7 

Figure 3. Aerial photograph showing the main fuselage wreckage location, circled in red, on the west side of the lake. ……………………………………………………………………………………………………….. 8 

Figure 4. Photograph showing the helicopter main fuselage wreckage. …………………………………. 9 

Figure 5. Photograph at ground view looking from the helicopter main fuselage wreckage location in a southerly direction up the ridge that the accident helicopter rolled down. ……………. 9 

Figure 6. Preaccident photograph of the accident helicopter. ……………………………………………… 18 

Figure 7. Google Earth image with a blue line showing the likely route that the SAR ground team took from the SAR IB (E) to the helicopter main wreckage location (C). ……………………… 26 

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Abbreviations and Acronyms AC advisory circular

AFRCC U.S. Air Force Rescue Coordination Center

agl above ground level

ALEA Airborne Law Enforcement Association

ATC air traffic control

ATP airline transport pilot

AXX Angel Fire Airport

CFR Code of Federal Regulations

DPS Department of Public Safety

ELT emergency locator transmitter

EMS emergency medical services

FAA Federal Aviation Administration

FLIR forward-looking infrared

FSDO flight standards district office

G One G is equivalent to the acceleration caused by the Earth’s gravity (32.174 feet per second squared)

GPS global positioning system

HEMS helicopter emergency medical services

IACP International Association of Chiefs of Police

IB incident base

IFR instrument flight rules

IMC instrument meteorological conditions

METAR meteorological aerodrome report

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NTSB Aircraft Accident Report

MHz megahertz

msl mean sea level

MSP Maryland State Police

NASAO National Association of State Aviation Officials

nm nautical miles

NMSP New Mexico State Police

NOAA National Oceanic and Atmospheric Administration

NPRM notice of proposed rulemaking

NTSB National Transportation Safety Board

NWS National Weather Service

OCC operations control center

PIC pilot-in-command

PIO public information officer

PLB personal emergency locator beacon

SAF Santa Fe Municipal Airport

SAR search and rescue

SARSAT Search and Rescue Satellite-Aided Tracking

SIGMET significant meteorological information

SMS safety management system

SOP standard operating procedure

TAF terminal aerodrome forecast

USFS U.S. Forest Service

VFR visual flight rules

VMC visual meteorological conditions

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Executive Summary On June 9, 2009, about 2135 mountain daylight time, an Agusta S.p.A. A-109E

helicopter, N606SP, impacted terrain following visual flight rules flight into instrument meteorological conditions near Santa Fe, New Mexico. The commercial pilot and one passenger were fatally injured; a highway patrol officer who was acting as a spotter during the accident flight was seriously injured. The entire aircraft was substantially damaged. The helicopter was registered to the New Mexico Department of Public Safety and operated by the New Mexico State Police (NMSP) on a public search and rescue mission under the provisions of 14 Code of Federal Regulations Part 91 without a flight plan. The helicopter departed its home base at Santa Fe Municipal Airport, Santa Fe, New Mexico, about 1850 in visual meteorological conditions; instrument meteorological conditions prevailed when the helicopter departed the remote landing site about 2132.

The National Transportation Safety Board determines that the probable cause of this accident was the pilot’s decision to take off from a remote, mountainous landing site in dark (moonless) night, windy, instrument meteorological conditions. Contributing to the accident were an organizational culture that prioritized mission execution over aviation safety and the pilot’s fatigue, self-induced pressure to conduct the flight, and situational stress. Also contributing to the accident were deficiencies in the NMSP aviation section’s safety-related policies, including lack of a requirement for a risk assessment at any point during the mission; inadequate pilot staffing; lack of an effective fatigue management program for pilots; and inadequate procedures and equipment to ensure effective communication between airborne and ground personnel during search and rescue missions.

The safety issues discussed in this report include the pilot’s decision-making, flight and duty times and rest periods, NMSP staffing, safety management system programs and risk assessments, communications between the NMSP pilots and volunteer search and rescue organization personnel, instrument flying, and flight-following equipment.

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1. Factual Information

1.1 History of Flight

On June 9, 2009, about 2135 mountain daylight time,1 an Agusta2 S.p.A. A-109E helicopter, N606SP, impacted terrain following visual flight rules (VFR) flight into instrument meteorological conditions (IMC) near Santa Fe, New Mexico. The commercial pilot and one passenger were fatally injured; a highway patrol officer who was acting as a spotter during the accident flight was seriously injured. The entire aircraft was substantially damaged. The helicopter was registered to the New Mexico Department of Public Safety (DPS) and operated by the New Mexico State Police (NMSP) on a public search and rescue (SAR) mission under the provisions of 14 Code of Federal Regulations (CFR) Part 91 without a flight plan. The helicopter departed its home base at Santa Fe Municipal Airport (SAF), Santa Fe, New Mexico, about 1850 in visual meteorological conditions (VMC); IMC prevailed when the helicopter departed the remote landing site about 2132.

The mission was initiated after a lost hiker used her cellular telephone to call 911, and the 911 operator transferred the call to an NMSP dispatcher about 1646.3 The hiker, who was a citizen of Japan, had difficulty communicating in English. However, during her initial and subsequent telephone calls, she told the dispatcher that she had become separated from her hiking companion (her boyfriend) and was lost in the Pecos Wilderness Area about 20 miles northeast of Santa Fe and was feeling very cold.4 The local district shift supervisor, who was present in the dispatch office, asked an NMSP patrol officer to initiate a SAR effort, and the patrol officer asked the dispatcher to notify the volunteer New Mexico SAR command, which the dispatcher did about 1715.5

While the SAR command was organizing the SAR effort, a district sergeant (the outgoing police shift supervisor) made the decision to have the dispatcher contact the accident pilot and ask him to initiate an aerial search for the lost hiker. Because there were no roads into the search area, ground SAR teams would have to hike in, which would delay the rescue. The outgoing shift supervisor stated that he believed that a more immediate helicopter SAR effort was needed.6 In the meantime, ground SAR personnel began to set up the incident base (IB) at a local ski resort; it was later determined that the IB was about 4 nautical miles (nm) from the hiker’s location. Per the sergeant’s instructions, the dispatcher called the accident pilot and, about 1756, put him on

1 All times in this report are mountain daylight time based on a 24-hour clock. 2 Agusta and Westland signed a joint venture agreement in 2001. In 2004, Finmeccania acquired a 50 percent

stake in the combined company. Agusta is now known as AgustaWestland. 3 Times are based on NMSP dispatch recordings, unless otherwise noted. The NMSP dispatch times are

corrected for an error of about 24 minutes. 4 The lost hiker had only a light jacket and no cold-weather survival gear. 5 For additional information regarding New Mexico SAR operations, see section 1.18.1. 6 Postaccident interviews indicated that, during the decision to launch the helicopter on the SAR mission,

several state police personnel expressed their concern that the hiker would not have been able to survive on the mountain overnight because she lacked warm clothing and other survival equipment.

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the line with the incoming police shift supervisor to discuss the proposed mission. According to NMSP dispatch recordings, the shift supervisor asked the pilot if he “[felt] like going up again” to support the SAR effort and described the general location of the search. Initially, the pilot responded that it was too windy to fly in the described area at that time of day, but he offered to fly the mission at first light or during the night (using night vision goggles) if the winds were calmer. The shift supervisor accepted the pilot’s decision, and they ended the telephone call. About 1800, the accident pilot called the dispatcher to further discuss the proposed mission. He indicated to the dispatcher that he had just checked the winds, and he thought that he probably could fly the helicopter to look for the hiker.

The accident pilot (who was the dispatcher’s husband) was the chief pilot for the NMSP’s aviation section and had already worked a full 8-hour shift (including three previous flights) that day. Postaccident interviews indicated that he contacted the other full-time NMSP aviation section helicopter pilot about flying the mission; when the other pilot was unavailable, the accident pilot accepted the mission himself.

The dispatcher stated that she connected the accident pilot with the patrol officer who had been designated as the mission initiator. The patrol officer requested and received the accident pilot’s permission to ride in the helicopter and act as spotter during the search. The patrol officer/spotter then photocopied a topographical map of the search area, gathered SAR-related paperwork (including contact numbers for SAR personnel), and drove to SAF to meet the accident pilot.

The spotter stated that he arrived at SAF and found the accident pilot already in the hangar office. According to the spotter, the pilot told him to “take all [his] gear off” because it was too bulky for him to wear in the cockpit. As a result, the spotter removed his uniform shirt, bulletproof vest, and other police equipment and stowed them in the hangar. The spotter stated that the pilot performed a preflight inspection of the helicopter, gave the spotter a safety briefing, and helped him fasten his safety harness. The spotter said the pilot warned him that it could be windy and/or bumpy in the mountains; he did not recall the pilot saying anything else about the weather or mentioning any other safety-related concerns about the flight. The spotter stated that it was warm7 and sunny and not very windy when they took off from SAF about 1850. There were few clouds, and there was little turbulence on the way to the search area (which was at a much higher elevation; the lake near which the hiker and her companion were hiking was located at 11,700 feet mean sea level [msl])8.

About 1851, the pilot radioed the dispatcher to indicate that he and the spotter had departed SAF and that they were en route to the search area. According to dispatch records, the pilot and spotter searched for the lost hiker for more than 1 hour and coordinated with the dispatcher (who was speaking with the hiker on her cellular telephone) to help identify the

7 The National Weather Service daily summary indicated that the high temperature at SAF at 1853 (about

3 minutes after the helicopter departed SAF) was 68° F. 8 Unless otherwise indicated, all altitudes in this report are msl. SAF, the helicopter’s departure point, was

located about 20 miles southwest of the landing site at an elevation of 6,348 feet.

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hiker’s location.9 Although the hiker told the dispatcher that she was able to hear the helicopter operating nearby relatively early during the search, she was unable to provide much information that could help narrow the search (such as describing her position relative to the sun, nearby landmarks, or terrain features). She told the dispatcher that she was in a small clearing surrounded by trees and could not identify any landmarks.

About 1927, the pilot advised the dispatcher, “We’re dealing with a lot of wind up here…not to worry because we’re going to hang out until we get eyes on [the hiker] and go from there.” About 15 minutes later, the hiker told the dispatcher that the helicopter was directly above her; the dispatcher relayed this information to the pilot, who then relayed the helicopter’s latitude and longitude coordinates back to the dispatcher. The pilot descended, flew in the vicinity of those coordinates, and continued searching until he and the spotter made visual contact with the hiker, which occurred about 2010.10 After locating the hiker, the pilot stated, “all we need to do now is find a place to land… .” About 2 minutes later, the pilot asked the dispatcher if the hiker was ambulatory, stating that the closest place he would be able to land was about 0.5 mile uphill from her. Initially, because the hiker was not physically injured, the dispatcher responded that the hiker was ambulatory. However, according to dispatch recordings, the hiker subsequently told the dispatcher that she could not walk uphill or very far because she was very cold. In addition, the hiker stated that she could not see very well and did not know which way to hike. As a result, about 2015 (about 4 minutes before sunset), the dispatcher asked the pilot if he could land on top of the hill and send the spotter down to retrieve the hiker. The pilot said, “That’s about the only thing we’re going to be able to do.”

The spotter stated that the pilot made several passes over a large clearing on top of the ridge above the hiker before he landed the helicopter and shut off its engines. According to the spotter, the ride was very bumpy near the ground. After the helicopter landed on the ridge (at an elevation of about 11,600 feet msl), the spotter opened his door, felt very strong, cold westerly winds, and observed that it was starting to sleet. About 2030, the spotter contacted the dispatcher by cellular telephone to say that they had landed and to ask if the hiker was walking toward them. The dispatcher then advised the spotter that she thought that the hiker “did not want to move.” The spotter hung up to confer with the pilot, and, about 2 minutes later, the pilot called the dispatcher to clarify the hiker’s intentions. The dispatcher told the pilot that she believed the hiker expected them to help her to the helicopter.

About 2033, the pilot (who was wearing an unlined summer-weight flight suit) told the dispatcher that he knew the hiker’s general location, and he was going to walk down the hill to look for her while the spotter stayed with the helicopter. He added, “It’s going to start snowing up here and if it does that, I’ve got to get the [expletive] out of here.” The pilot told the dispatcher to tell the hiker to listen for him and blow her whistle to help him find her. He commented, “I’m not going to spend a lot of time or we’re going to have two search and rescues.” This call ended about 2035. According to the spotter, the pilot promptly left the

9 During the accident SAR mission, the dispatcher also relayed an inquiry from another NMSP pilot about a previously scheduled law enforcement mission for later that evening. The accident pilot responded, “I'll try to accommodate it, but I want to find this gal, at least have a good lock on her [location].”

10 According to the spotter, they saw the hiker just as it was getting dark. Astronomical data indicated that, on the day of the accident, sunset and the end of civil twilight (beginning of nighttime conditions) in the Santa Fe area occurred about 2019 and 2049, respectively. The moon had not yet risen when the accident occurred.

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helicopter (without stopping to retrieve a flashlight from his flight bag) and walked down the heavily forested slope to search for the hiker. Also according to the spotter, it got windier and began “sleeting like crazy” after the pilot left.

About 2045, the dispatcher reached the hiker on her cellular telephone and advised her that the pilot was walking down the hill toward her. The dispatcher remained on the telephone with the hiker and advised her to yell or whistle for the pilot. About 2053, the dispatcher heard the pilot and the hiker yelling to each other, and then the cellular telephone call ended. About 2103, the dispatcher called the spotter to inform him that the pilot had located the hiker, and she asked him to yell to help the pilot find his way back to the helicopter in the dark. The spotter told the dispatcher that the weather conditions were “windy,” and there was a “big cloud bank overhead.”

About 2113, the SAR area commander called the NMSP dispatcher and said he was worried because the weather conditions were deteriorating in the mountains and the SAR team had not heard anything from the pilot.11 The dispatcher connected the SAR area commander with the spotter’s cellular telephone. According to the SAR area commander, the spotter (who was still waiting for the pilot in the helicopter) reported that the winds were blowing and that the clouds were moving in. The area commander advised the spotter that, if the weather continued to deteriorate and they were unable to take off, they should “hang tight” in the helicopter and use its engines to generate heat until ground SAR personnel could reach them. According to SAR documents, about 2120, two SAR ground teams left the incident base, heading toward the helicopter’s last known position.12

The spotter told National Transportation Safety Board (NTSB) investigators that it was completely dark when he heard the pilot and the hiker approaching the helicopter,13 so the spotter exited the helicopter and used the pilot’s flashlight to help the pilot locate the helicopter in the dark. The spotter saw the pilot, carrying the hiker, about 35 to 40 yards away.14 About 2124, the spotter called the NMSP shift supervisor to report that the pilot had returned with the hiker. The shift supervisor asked about their intentions, and the spotter responded, “I don’t know, let me talk to [the pilot]. He’s getting some heat on right now. He’s a little out of breath. He was [carrying] her up [the hill].” The spotter told the shift supervisor that they would call back and ended the call. While the pilot prepared the helicopter for takeoff, the spotter helped the hiker get buckled into the right-side, forward-facing, aft passenger seat and then he buckled himself into the left-side, forward-facing, aft passenger seat. About 2127, the spotter called the NMSP dispatcher and advised her that they were going to fly back to Santa Fe. The helicopter’s engines could be heard starting during this recorded call.

11 According to SAR protocol, NMSP pilots involved in SAR efforts should be in communication with SAR

personnel; however, communication issues often arise in mountainous terrain. 12 The SAR IB was more than 4 nm over rugged terrain from the lost hiker’s approximate position (based on

the coordinates the pilot reported). The IB was established at a local ski area, which was the nearest site to the lost hiker that could be reached by motor vehicle.

13 The night of the accident was particularly dark, with no moonlight. In addition, the sky was overcast, minimizing starlight, and there were no ground lights in the remote area where the helicopter had landed.

14 The spotter stated that it was still snowing or sleeting lightly when the pilot and hiker arrived at the helicopter but that the snow was not sticking to the ground.

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The spotter stated that he estimated that the helicopter was pointing south and that he recalled that no city lights were visible to him as they prepared for takeoff. The spotter said that, before they lifted off, the pilot pointed out his right window; the spotter thought this gesture meant that they would be flying in that direction. During a postaccident interview conducted in the hospital 2 days after he was rescued, the spotter said that he thought the pilot was pointing toward a “break in the clouds” or a “little cloud free tunnel.” During a subsequent interview, the spotter clarified this remark, stating that there was “nothing but gray” outside, and, although there may have been some sort of “separation” in the clouds, he was not certain whether the pilot was pointing at something in particular.

The spotter stated that the pilot took off and began to maneuver the helicopter in the direction that he had pointed; however, the spotter stated that, almost immediately after takeoff, the helicopter was in the clouds with “zero visibility” and that the flight was very turbulent. The helicopter appeared on radar15 at 2132:48, and numerous radar targets for the helicopter were recorded before the last radar target was recorded at 2135:25.16 The radar data indicated that the helicopter initially headed northwest from the remote landing site. Subsequently (beginning a little more than 1 minute after the helicopter first appeared on radar), the data indicated that the helicopter began to fly erratically in a northeasterly direction and to climb, crossing terrain as high as 12,500 feet before descending rapidly near the crash site. See figure 1 for a map with the pertinent radar data shown.17

The spotter recalled hearing the pilot curse and then felt the helicopter pitch up abruptly, after which it began to make a grinding noise and the ride “got wild.” He said he assumed that the helicopter’s tail had hit something, and he stated that it seemed as if the pilot was struggling to control the helicopter. The spotter recalled that, after the abrupt pull-up, the helicopter moved in a “jerky” fashion, like there was “obviously something wrong”; however, he could not tell exactly how the helicopter maneuvered because he could not see anything outside.

Dispatch recordings show that, at 2134:10, the pilot radioed the dispatcher, asking if she could hear him. After the dispatcher responded in the affirmative, the pilot stated, “I struck a mountainside. [I’m] going down.” The dispatcher asked, “Are you [okay]?” and the pilot replied, “negative.” The pilot continued to key his microphone, and, on the dispatch recording, he could be heard breathing rapidly for about the next 39 seconds. The dispatcher inquired, “Santa Fe 606?” The pilot then said, “hang on [unintelligible],” and the radio transmission cut off immediately thereafter. The last radar return for the helicopter was recorded at 2135:25.18

15 The applicable radar data were provided by the U.S. Air Force from its radar sites at Mesa Rica and West

Mesa, New Mexico. 16 For additional information on the helicopter’s radar data, see section 1.16.2. 17 The radar data provided by the U.S. Air Force were not corrected for barometric pressures that differed from

the standard 29.92 inches of mercury, which resulted in altitude offset errors that made it appear as if the helicopter’s flightpath continued through terrain in some locations. The altitude of the data shown in this map have been adjusted to show the approximate ground track above terrain.

18 Time information from the dispatch recordings and radar data were not synchronized; therefore, it is unknown how long the helicopter continued flying after the end of the pilot’s last radio transmission.

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Figure 1. Google Earth map showing pertinent helicopter radar data and other points of interest near the accident site.

Note: Helicopter radar data are indicated by red dots connected by white lines. The map also shows the hiker’s approximate location (A); the helicopter’s likely landing zone, confirmed by the spotter (B); the main wreckage location (C); SAF (D); and the approximate location of the SAR IB (E). A compass showing north is located in the upper left corner.

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Examination of the accident site showed that the helicopter impacted terrain for the second time point at an elevation of 11,970 feet,19 about 1 nm north-northeast of the hiker’s location and about 21 nm northeast of SAF, near the top of a steep ridgeline. Investigators were unable to identify the exact location of the helicopter’s first impact with terrain, which the pilot referenced in his radio transmission. After the second impact, the helicopter rolled down a steep, rock-covered slope.20 During this descent, components of the helicopter separated from the fuselage, and the pilot and hiker were ejected. The separated portion of the tailboom was located at an elevation of about 11,780 feet, and the main fuselage was located at an elevation of about

Figure 2. View of the accid

11,490 feet (see figure 2).

ent location.

ghest piece of wreckage debris (A), highest impact marks (B), compass showing north.

wreckage. Although he was injured, the spotter crawled out of the helicopter to look for the pilot and hiker. The spotter stated that when he exited the helicopter, it was snowing, dark, and

Note: The map shows the locations of the hi tailboom (C), main fuselage wreckage (D), and a

According to the spotter, when the helicopter came to a stop, he was alone in the fuselage 21

19 The elevations described in this section are based on Google Earth elevations with onsite global positioning

system readings and topographical map elevations taken into consideration. 20 e NTSB estimated that the average slope gradient between the highest uphill ground strike and the main

wrec ed serious injuries during the accident,

incl

Th kage was about 35°, with portions of the hill near vertical. 21 The postaccident medical diagnosis indicated that the spotter sustain

uding a broken ankle, chipped vertebrae, separated ribs, and bumps and bruises to his head. He also suffered from hypothermia.

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hazy, w

ccident site as dangerously steep, rocky, and covered with snow and ice (see figures 3, 4, and 5).

Figure 3. Aerial photograph showing the main fuselage wreckage location, circled in red, on the west side of the lake.

Note: A compass showing north is located in the upper left corner.

ith poor visibility. He could still distinguish nearby objects and he could see that there was a lot of snow on the ground. He yelled to the pilot and he heard the pilot yell his name in return, albeit from a distance. The spotter saw the hiker’s body lying close to the wreckage. He checked her vital signs and determined that she was deceased. He removed her jacket and put it on to stay warm. He was unable to locate the pilot, who was no longer responding to his calls.22 The spotter took shelter for the night inside the wrecked fuselage of the helicopter. The next day, the spotter tried to hike down the mountain for help and was subsequently located (about 5.5 miles from the SAR IB) by ground search teams about 1155. About 1311, the spotter was airlifted to a hospital.

SAR ground teams did not locate the helicopter’s wreckage until 1816. The SAR ground teams described the a

22 During one postaccident interview, the spotter stated that he yelled to the pilot repeatedly after the pilot’s first response, and he believed that he heard him respond once again, more faintly. However, in a second interview, the spotter stated that the pilot did not respond after the first call. The location of the pilot’s body was not precisely documented by rescue teams; therefore, his precise location, relative to the wreckage, is unknown.

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Figure 4. Photograph showing the helicopter main fuselage wreckage.

Figure 5. Photograph at ground view looking from the helicopter main fuselage wreckage location in a southerly direction up the ridge that the accident helicopter rolled down.

Note: The location of the separated portion of the tailboom is indicated by the red circle at the base of the tree.

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1.2 Injuries to Persons

Table. Injury chart.

Injuries Flight Crew Cabin Crew Passengers Other Total

Fatal 1 0 1 0 2

Serious 0 0 0 1 1

Minor 0 0 0 0 0

None 0 0 0 0 0

Total 1 0 1 1 3 Note: Title 49 CFR 830.2, “Definitions,” states that a serious injury is any injury that (1) requires hospitalization for more than 48 hours, starting within 7 days from the date that the injury was received; (2) results in a fracture of any bone, except simple fractures of fingers, toes, or the nose; (3) causes severe hemorrhages or nerve, muscle, or tendon damage; (4) involves any internal organ; or (5) involves second- or third-degree burns or any burns affecting more than 5 percent of the body surface.

The helicopter was substantially damaged by impact forces as a result of damage to the fuselage, main and tail rotors, and tailboom.

1.4 Other Damage

No other damage occurred as a result of this accident.

1.5 Personnel Information

1.5.1 The Pilot

1.5.1.1 Professional Background

According to NMSP records, the pilot, age 36, completed high school at the New Mexico Military Institute23 and served in the U.S. Marine Corps and U.S. Marine Corps Reserve from 1991 to 1997. He was hired by NMSP as a patrol officer in 1995. After he completed recruit training, the pilot spent 2 years as a patrol officer and was then transferred to the NMSP academy where he worked as a police instructor. While at the academy, he became a lead instructor and served on the NMSP special weapons assault team.

1.3 Damage to Aircraft

23 The New Mexico Military Institute is a college-preparatory military boarding high school located in

Roswell, New Mexico.

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In November 2002, the p section, began his pilot training, and worked as

ilot was transferred to a pilot position in the NMSP aviation a pilot until the time of the accident. In

obtained a private pilot certificate and airplane single-engine land rating. In October 2003, he obtained an airplane multi-engine land rating, and, in April 2005, he obtained a comm pilot c ith air e- and ne lan irplane instrument ratings. In August 2005, the pilot completed Cessna 421 initial training at FlightSafety International, Incorporated’s facility in Long Beach, California.24 In early 2006, the pilot began helicopter flight training estern Helicopters and ea d a rotorcra r rating for his private pilot certificate on February 16, 2006.

the NMSP rank of patrol officer to that of sergeant and was assigned the additional duties of NMSP public information officer (PIO).25 In July and August 2007, the pilot received more advanced helicopter training, including a 3-hour mountain flying ground school course, and earned a rotorcraft/helicopter rating for his commercial pilot certificate on August 1, 2007. The pilot did not have a helicopter instrument

Records indicate that, on July 10, 2008, the pilot completed an Agusta A-109E ground with an independent instructor, which also included mountain

o, dated July 23, 2008, from the DPS cabinet secretary to the then-ch

missions, and for SAR missions below 9,000 feet.27 The memo indicated that the pilot was by a more experienced pilot when operating the helicopter above us terrain. No NMSP documentation indicated that the 9,000-foot

restrict interviews, several individuals in the acc eved that the restriction had been removed after the pilot completed a mountain flying course with an independent instructor.28

t he did provide the pilot with mountain flying training

May 2003, the pilot

ercial ertificate w plane singl multi-engi d and a

with W rne ft/helicopte

In February 2007, the pilot was promoted from

rating, nor was such a rating specifically required for NMSP aviation section helicopter operations, which were typically conducted in VFR conditions.26

and initial flight training course flying training. A subsequent mem

ief pilot of the NMSP aviation section stated that the pilot was authorized to operate the accident helicopter in VFR conditions with passengers in daylight, for all law enforcement

required to be accompanied 9,000 feet or in mountaino

ion had been removed. However, during postaccident ident pilot’s chain of command stated that they beli

The independent instructor stated tha

24 The pilot subsequently completed recurrent training at the same facility in December 2006 and

anagers, the pilot was promoted to sergeant because they saw lead

d- and rotary-wing pilot with the U.S. Air Force and NMSP and had held the NMSP aviation section chief pilot position until he retired from the NMSP in 1994. He was appointed as DPS cabinet secretary in 2003 and had since received annual training in the Agusta A-109E. According to the adjutant chief of police, the DPS cabinet secretary “kept a pretty close eye on what was going on” in the aviation section.

tween July 7 and 10, 2008.

February 2007. 25 According to the chief of police and other NMSP m

ership potential in him and because they wanted a smooth transition when the then-chief pilot retired. They stated that they assigned the pilot PIO duties because they needed someone to perform those functions, and the pilot was articulate and presented himself well in an NMSP uniform.

26 The NMSP aviation section’s “Policies and Procedures” document (which is reproduced in appendix B) required aviation section pilots to have an instrument rating. It did not explicitly require a helicopter instrument rating for helicopter operations. According to NMSP personnel, the aviation section helicopter was not intended to be operated in instrument flight rules (IFR) conditions.

27 The DPS cabinet secretary stated that he had been a fixe

28 The accident pilot’s logbook indicated that he received some mountain flying instruction from the independent instructor be

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during

ixed- and rotary-wing) in the 90, 60, and 30

dicated that he was not taking any prescription medication.

the training completed on July 10; however, the pilot’s training folder and logbook did not reflect any mountain flying training after the DPS cabinet secretary’s July 23, 2008, memo.29

In January 2009, the pilot completed an initial ground and flight training course for the night vision goggle system used by NMSP.30 Also in January 2009, in addition to his other duties, the pilot was appointed chief pilot of the aviation section.

According to NMSP records, the pilot had accumulated about 1,331 total flight hours, including about 482 hours in helicopters, of which about 411 hours were in the Agusta A-109E helicopter.31 He had flown about 70, 52, 29, and 2.2 hours (f

days, and 24 hours, respectively, before the accident flight. A review of the pilot’s helicopter logbook indicated that he met the night currency requirements for airplanes and helicopters, as specified in 14 CFR 61.57(b).32 A review of the pilot’s fixed-wing logbook indicated that he met Federal Aviation Administration (FAA) instrument currency requirements for airplanes, as specified in 14 CFR 61.57(c).33 The pilot’s most recent FAA first-class medical certificate, dated November 13, 2008, bore no limitations. During his aviation medical examination, the pilot reported no current health problems and in

A search of FAA records revealed no accident or incident history, enforcement action, pilot certificate or rating failure, or retest history. A search of the National Driver Register found no record of driver’s license suspension or revocation.

Pilots who had flown with the accident pilot described his helicopter flying skills favorably to NTSB investigators. In addition to the accident pilot, NMSP employed a full-time helicopter pilot, a part-time helicopter pilot, and a full-time fixed-wing pilot (all of whom had more flight experience than the accident pilot). The full-time helicopter pilot, who flew

29 The NTSB’s review of the insurance policy covering the operations of the aviation section and the accident

pilot revealed no restrictions regarding the pilot’s flight above 9,000 feet msl. 30 According to the former chief pilot, all of the NMSP aviation section pilots received night vision goggle

training so they could be Federal Aviation Administration-certificated to use the goggles even though NMSP (as a public operator) was not required to certify its pilots. The accident pilot’s training folder indicated that he had rece

s helicopter missions using night vision goggles before he completed a formal night vision goggle train

any of these flights, the pilot was flying with more expe

ccurred at night. During the 90 days preceding the accident, the p

owed only in the aircraft for which the privilege is earned. Records showed that, during the 6 m

uvers in fixed-wing aircraft.

ived training in system description and operation, terrain interpretation, pinnacle/ridgeline and confined area operations, and inadvertent IMC and emergency procedures. However, the pilot’s helicopter logbook indicated that he fl numerouew

ing course. 31 A comparison of the pilot’s helicopter logbook with the helicopter’s maintenance logbooks indicated that,

after the accident pilot received his private pilot helicopter rating, almost all of his helicopter flight time was logged as pilot-in-command. Logbook records indicated that, during m

rienced helicopter pilots, who also logged the flight time. 32 Title 14 CFR 61.57(b) states that, to maintain night currency, a pilot must perform at least three night

takeoffs and landings to a full stop in the same category aircraft within the preceding 90 days. The pilot’s records show that about 0.33 percent of his helicopter flying oed

ilot had documented 12 night takeoffs and 20 night landings in the helicopter. 33 Title 14 CFR 61.57(c) states, in part, that a pilot must perform and document at least 3 hours of instrument

time in an aircraft, including six instrument approaches, a holding procedure, and navigation exercises under actual or simulated instrument conditions, within the preceding 6 calendar months to maintain instrument currency. IFR privi ges are allle

onths preceding the accident, the pilot had logged 2.9 hours of actual and 3.7 hours of simulated instrument flight time and accomplished all of the required mane

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frequently with the accident pilot, described him as a “very skilled manipulator of the controls…for his experience level” and indicated that the accident pilot was proactive and “very aware.” The part-time helicopter pilot, who flew with the accident pilot once or twice per month, describ

was a “natural pilot.”

The accident pilot’s colleagues described him as a motivated, hard-working, disciplined officer

nd would “go 100 miles an hour all the time” if allowed.

down because of fatigue. The pilot’s wife said that she thought the accident pilot was willing to turn

not

the other aviation section pilots that he would take care of any unsafe situation that

pilo

ed him as a “competent pilot” who had “very good” stick and rudder skills. The DPS cabinet secretary, who flew infrequently with the accident pilot during training activities and transport flights, said that he had a “good feel for the aircraft” and

According to the NMSP aviation section’s full-time fixed-wing pilot, who was also the aviation section’s fixed-wing flight instructor, the pilot’s fixed-wing flying skills were comparable to those of other pilots with similar levels of experience. The fixed-wing pilot said that he had some concerns about the accident pilot’s instrument flying skills, in particular his “scan and situational awareness.” The fixed-wing pilot described an occasion when the accident pilot seemed confused about which way to turn to avoid rising terrain ahead during a standard instrument departure at night-time in marginal VMC. When the airplane did not turn as expected, air traffic control (ATC) issued turn instructions, and the accident pilot responded appropriately. The fixed-wing pilot stated that he was concerned about the occurrence and discussed it with the accident pilot the next day. He recalled that the accident pilot was receptive to his feedback.

who was outgoing and personable. The major in charge of the special operations division, which included the aviation section, described the pilot as a “very aggressive, high speed type” and stated that he was “high-spirited,” “enthusiastic,” a

Some of the accident pilot’s colleagues recalled that he had turned down missions in the past, either because of poor weather or because he was fatigued from performing other work-related duties; however, they did not provide examples of missions that the pilot had turned

down a mission if the weather was bad, but not if he was tired. When asked about whether he would turn down a mission for fatigue, she stated that he likely would not. She said, “He did

like to be too tired for the missions because that was his job. If he could do the mission and help, that was his focus.”

The accident pilot’s colleagues held varying opinions about his attitudes toward safety. The full-time helicopter pilot told NTSB investigators that the accident pilot, in his role as chief pilot, had told they reported. The special operations captain, who had known the accident pilot for about 10 years and was his supervisor at the time of the accident, stated that the accident pilot was capable of being assertive if he felt that a situation was unsafe. The aviation section’s fixed-wing

t also said that the accident pilot could be assertive. However, he stated that the accident pilot was a “very heroic type person” who disliked turning down missions. The fixed-wing pilot recalled hearing the accident pilot tell his supervisor that the aviation section would no longer be turning down missions without going up to “take a look”; however, he stated that the accident pilot had not pressured him when he subsequently turned down missions. Several of the accident pilot’s colleagues said that the accident pilot was the kind of person who was willing to put

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himself at risk to save others.34 The pilot’s wife told investigators that her husband probably accepted the accident SAR mission because the wind conditions on the mountain did not preclude it, he was concerned about the hiker’s safety, and because a supervisor had asked him to fly the mission.35

During postaccident interviews, the pilot’s colleagues expressed mixed opinions regarding the pilot’s aeronautical decision-making skills. For example, the full-time helicopter pilot sa

of his person

ficant changes in her husband’s health, financial situation, or personal life and there h

ilot medical conditions and use of medications, “If medication is require

id that the accident pilot usually examined all aspects of a mission and selected an intelligent strategy. However, the fixed-wing pilot said that the accident pilot tended to “act right away before thinking things out.” This opinion was shared by the part-time helicopter pilot, who said he thought the accident pilot lacked “temperance” because of his youth and inexperience. The former chief pilot said that he believed the accident pilot did not understand the limitations associated with his aeronautical inexperience.

1.5.1.2 Pilot Personal Background and Medical History

According to postaccident interviews with the pilot’s family and friends and a review al and FAA medical records, the pilot was in good health at the time of the accident

and engaged in some form of physical activity every day. The pilot’s wife stated that the pilot did not have a history of any medical conditions and that he did not exhibit any symptoms of illness in the days before the accident. The pilot’s wife stated that her husband did not snore and did not have any sleep disorders.36 The pilot’s wife reported that, in the year before the accident, there had been no signi

ad been no significant changes in his daily habits (that is, sleeping, eating, or leisure activities).

A review of the pilot’s personal medical records indicated that the pilot had been diagnosed with dysthymia (depression) in June 2002 and was prescribed fluoxetine37 to treat this condition. These records indicated that the pilot continued to take fluoxetine until the time of the accident and noted that the pilot had not experienced adverse effects from his use of this medication. According to the NMSP aviation section’s “Policies and Procedures” document (see appendix B) regarding p

d, it must be approved and the pilot certified fit for flight by an FAA-designated medical examiner or flight surgeon.” The pilot did not note the use of fluoxetine on any FAA airman

34 As an example, the colleagues stated that the accident pilot received the 2009 Officer of the Year Award and Medal of Valor (from the New Mexico Sheriffs and Police Association and the International Association of Chiefs of Police, respectively) for his rescue of a man trapped in a flooded arroyo. The supervisor who nominated the accident pilot for these awards wrote that the pilot searched for the man on foot, despite heavy rain and lightning at the time. When he located the man at the bottom of a steep concrete incline under a bridge, there was a high volume of fast-flowing water inside the arroyo. In addition, the trapped man weighed more than 200 pounds, was intoxicated, and had a broken wrist. The commendation letters stated that the conditions of the rescue were “life threatening” for the pilot and that he disregarded his own safety to save the man.

35 The former chief pilot, who supervised the accident pilot from 2002 to 2008, said that the pilot had difficulty saying “no” to managers. The pilot’s wife said that when a supervisor asked the aviation section pilots to fly a mission, they flew it if possible.

36 The accident pilot’s wife stated that he did not have any difficulty falling asleep at night or staying awake during the day, nor did he experience interrupted breathing at night.

37 Fluoxetine is a prescription antidepressant, also known as Prozac.

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medical certificate application in the 7 years during which he took the medication. (For additional information, see section 1.13.)

1.5.1.3 Pilot cS hedule and Duties

nd typically awoke between 0700 and 0730 and went to bed about 2100, after their children were in bed.

The pilot’s wife further stated that she could not remember the last day her husband had been co

hated” his duties as the NMSP PIO. She indicated that, although her husband was a private person who disliked being in front of the news media cameras, he was also concerned that fie

but NMSP management had not acted on his request.

The accident pilot’s wife told investigators that her husband’s typical work schedule was 0700 to 1500, Monday through Friday (although this schedule occasionally shifted to accommodate flight or other work commitments), with normal days off of Saturday and Sunday. She stated that, during his work week, her husband’s routine was to awaken about 0600, work from 0700 to 1500, take a 30-minute nap in the afternoon, spend time with their children until their children went to bed between 2000 and 2030, and go to bed between 2130 and 2200.38 The pilot’s wife stated that her husband normally slept about 8 to 8.5 hours on a night before a work day. She stated that on his days off, her husba

mpletely free of work-related duties because he was often expected to be available on call during his “days off” in his capacities as PIO and/or pilot. According to the pilot’s wife, her husband typically alternated weekends on call as PIO with his pilot on-call weekends; however, he often served as both PIO and pilot on call when the other full-time NMSP helicopter pilot was unavailable (due to New Mexico National Guard duty or family commitments).39

The pilot’s wife stated that her husband loved flying and appreciated that the NMSP had given him the opportunity to work as a pilot. However, the pilot’s wife stated that her husband “absolutely

lding calls from the media at all hours as PIO40 interfered with his ability to get adequate rest for his flying duties. The pilot’s wife told investigators that, when her husband advised his supervisors that the PIO assignment conflicted with his chief pilot responsibilities and his ability to get adequate rest, he was told to “get over it” and to do his job.41 The NMSP special operations captain (the accident pilot’s immediate supervisor) also told investigators that he was concerned about the pilot’s competing roles. He stated that the former chief pilot had asked NMSP management to relieve the accident pilot of the PIO assignment before the former chief pilot took an early retirement in 2008 (after which the accident pilot was appointed chief pilot),

38 The pilot’s wife typically worked a “swing shift” as a police dispatcher on weekday evenings, so that she and

the pilot could take turns watching their children during the day. The pilot was usually asleep when she returned home from work about 2315.

39 According to the other NMSP helicopter pilot, it was rare for the accident pilot to complete an entire wee

which the NMSP were involved 24 hours per day, which the pilot’s wife indicated ofte

d not understand the training and currency requ

kend without any work-related activity. 40 When he was assigned PIO duty, the accident pilot was required to serve as the point of contact for the news

med regarding any incidents inia n disturbed the pilot’s sleep. 41 The pilot’s wife stated that most of the NMSP managers di irements for pilots.

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Postaccident interviews with NMSP upper management indicated that, in general, these managers either did not recognize any potential conflict between the accident pilot’s PIO and pilot duties or did not believe that there was any reason for concern regarding this conflict.

ere aware that the chief pilot wanted to be relieved of s to his dislike of those duties and his preference

for his

ny responsibilities for the number of missions that our department flies.”

flying mission because of inadequate rest due to his other responsibilities, “another pilot would have to do it or the mis

aturday evening at home with his family. He made a brief call to a news organization about 2120 and went to bed about 2200, according to his wife.

Several interviewees indicated that they w his PIO duties, but they attributed this awarenes

flying duties. In general, NMSP upper management indicated that they relied on the chief pilot and other aviation section pilots to advise them if they were not rested enough to fly missions. The chief of police told investigators that the aviation section pilots were “not overworked. They don’t fly enough hours. They have a lot of idle time.” He stated that he had not relieved the accident pilot of his PIO duties after appointing him chief pilot because he “didn’t feel it was a conflict. …They’re not flying that often and the PIO position…if there’s nothing big happening in the state you’re not doing anything.” The chief of police further stated, “Look at the number of hours they fly and divide that by the number of pilots…he’s flying a couple hundred hours a year. …He didn’t have too ma

During postaccident interviews, the DPS cabinet secretary indicated that he had no concerns about the pilot’s PIO and pilot duties and that he was unaware that the pilot wanted to be relieved of his PIO responsibilities. The DPS cabinet secretary indicated that he had also performed numerous extra duties, including PIO and special investigation duties, when he served as NMSP aviation section chief pilot.42 He stated that, if he was unable to take a

sion wouldn’t be flown.”

1.5.1.4 Pilot Recent and 72-Hour History

The following description of the pilot’s activities during the days preceding the accident is based on postaccident interviews with the pilot’s wife and his coworkers and a review of other available records (for example, telephone and NMSP dispatch logs). During the weekend before the accident, the accident pilot served as both the NMSP PIO and the aviation section pilot on call. On Saturday, June 6, according to his wife, the pilot got up at a “normal time” for a weekend day (between 0700 and 0730), and he periodically worked with the news media in his PIO role throughout the day. During the day, the pilot also flew the accident helicopter to a public event at which he provided a static aircraft display. The pilot recorded two landings and 0.5 hours of flight time that day. The pilot spent that S

Telephone records indicate that the pilot received a work-related call about 0035 Sunday, June 7.43 The pilot’s wife stated that her husband then arose about 0730 and went out to breakfast with his family about 0900. Upon their return, the pilot periodically worked with the

42 In a postaccident interview, the DPS cabinet secretary indicated that he was the chief pilot when he left the

aviation section for a different position in the early 1990s. 43 The pilot’s wife did not specifically recall this late-night telephone call, but she said that the pilot’s sleep was

often interrupted when he was on call as PIO. She stated that she did not know how long it took him to get back to sleep after such calls.

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news m

e, the accident pilot returned home about 1100, ate a meal with his family, visited with his wife before she went to work, took a nap, interacted with the childre

pter pilot (who was the pilot flying on their return) stated that, during the second flight (to Las Vegas, New Mexico), the wind had been gusting to almost

south to avoid the mountainous terrain’s wind e saw her husband briefly at home at the end

of his

edia in his PIO role throughout the day. The pilot’s wife did not recall their activities that afternoon or evening, but she indicated that he might have taken a nap that afternoon and likely engaged in routine activities (for example, activities with the children or watching television) before going to bed about 2200. She said that it was his habit to watch television in bed until 2330 or 2345 on Sunday nights, but she could not recall if he did so that night. Telephone and the pilot’s records indicate that the pilot received work-related calls on his cellular telephone between about 2330 and midnight Sunday night and again between about 0245 and 0300 Monday morning, June 8.

On Monday, June 8, the pilot began his duty day about 0300. He flew missions between 0400 and 0500 and between 0630 and 0800, recording two landings and 1.4 hours of flight time. These flights involved an inspection of a canyon using forward-looking infrared (FLIR) technology44 before sunrise and a second inspection of the canyon during daylight hours. His logbook entry for these flights noted “mountain work up to 11,000 feet” and “slow search flight in mountains.” According to his wif

n, and likely went to bed between 2130 and 2200. The pilot was asleep when his wife returned home from work about 2315.

According to the pilot’s wife, on Tuesday, June 9, her husband awoke about 0600. He worked his routine shift, from 0700 to 1500. The other full-time helicopter pilot flew three flights with the accident pilot that day45 and said that the accident pilot seemed to be in good spirits. The other full-time helico

40 knots near the ground, and they deviated to the effects when they returned to SAF. The pilot’s wif

day before she left for work. She guessed that her husband napped that afternoon and indicated that he was lounging or resting when she called him about the accident flight.

1.5.2 The Spotter

The NMSP patrol officer who accompanied the pilot to act as a spotter during the accident SAR mission was not a pilot and had received no special training for aircraft missions. He had not ridden in the accident helicopter before, but he had previously been transported in helicopters while serving in the New Mexico National Guard.

44 FLIR technology uses detection of infrared radiation (heat) to create a “picture,” which can be used by pilots

flying at night or in fog, and to detect warm objects against a cold background when it is completely dark (such as a clou

owned aircraft and was called off about 15 minutes after take

dy, moonless night). 45 The first of the three flights involved a search for a d off. The second flight involved the transport of a criminal investigator to the scene of a homicide in Las Vegas,

New Mexico. The third flight occurred between 1200 and 1330 and involved a law enforcement search for a suspect’s vehicle.

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1.6 Aircraft Information

1.6.1 General Information

The accident helicopter, an Agusta A-109E, serial number 11209, was manufactured by Agusta S.p.A. Aerospace Company in March 2003 and was delivered new to the New Mexico DPS later that year. (Figure 6 is a preaccident photograph of the accident helicopter.) The Agusta A-109E is a twin engine, single main rotor helicopter with retractable tricycle landing gear. The helicop

of

days) under a manufacturer-developed progressive maintenance inspection

ter’s left and right Pratt & Whitney Canada PW206C turboshaft engines had

ter has a four-blade main rotor system for lift and thrust and a two-blade tail rotor system for directional control and antitorque. Four large doors, two on each side of the helicopter, provide ingress and egress for the pilot(s) and passengers.

Figure 6. Preaccident photograph of the accident helicopter.

The accident helicopter had a dual-engine service ceiling of 19,600 feet, a single-engine service ceiling of 13,100 feet, and a hovering ceiling of 11,800 feet. (According to the former chief pilot of the NMSP aviation section, the DPS chose the Agusta A-109E helicopter because

its high altitude performance.) The accident helicopter was properly certificated, and maintenance records indicated that it was being maintained and inspected at regular intervals (every 50 hours or 30 schedule. The helicopter’s most recent progressive maintenance inspection was conducted on May 28, 2009, at an aircraft total time of 1,710.7 hours. NMSP maintenance records indicated that the helicop

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accumulated 1,667.1 and 1,132 to NMSP maintenance records further indicated that

tal operating hours, respectively, at the time of the accident. annual inspections were performed on the left

2008, at 1,414.0 and 1,010.8 total engine hours, respectively. helicopter had accumulated about 1,729 total flight hours and

3,014 l

The helicopter was equipped with an autopilot that could fly a variety of instrument approaches, leaving the pilot to manage only the pedals and power setting. The autopilot had a go-around feature that would automatically set pitch and roll while the pilot adjusted the collective input to match the collective indicator. According to the NMSP aviation section’s other full-time helicopter pilot, the accident helicopter was “very easy” to fly compared to other helicopters he had flown. He thought it had a good autopilot and was stable.

The NMSP had purchased three night vision goggle units for the accident helicopter. According to pilots in the NMSP aviation section, night vision goggles were normally used to facilitate visual flight operations in low-light conditions. Although the presence of precipitation degrades the night vision goggles’ usefulness, they can help a pilot see the surrounding terrain if the helicopter remains clear of clouds.48

1.6.2 Helicopter Seating and Restraints

The accident helicopter was configured with two pilot seats in the front and six passenger seats (three aft-facing and three forward-facing bench seats) in the rear. The two pilot seats were a composite shell design, with integrated back and seat pans. These seats were equipped with four-point restraint systems with the lap belts anchored in the composite seat material. The passenger seats consisted of cushioned seat backs and seat pans, headrests, and three-point seatbelts anchored directly to the helicopter structure. The passenger seat restraint systems were three-point systems, with right and left side lap belts and a shoulder belt, which were to be attached to a common buckle.

and right engines on October 29, At the time of the accident, the

andings.

The accident helicopter was equipped with a radio that received and transmitted on police band frequencies and with a very high frequency transceiver radio; the two radios allowed the pilot to monitor two radio frequencies simultaneously while transmitting on one frequency.46 The NMSP helicopter did not have a multiband transceiver radio like those used by SAR personnel and therefore could not monitor the NMSP dispatch frequency and a SAR frequency at the same time.47

The police band radio frequencies used by NMSP dispatch and SAR personnel fell within the same frequency

range; however, the helicopter’s radio equipment only allowed the pilot to monitor and transmit on one frequency within that range at a time, whereas SAR personnel were also equipped with a multiband transceiver radio that allowed for communications on three frequencies simultaneously.

47 The helicopter that was purchased to replace the accident helicopter was equipped with a multiband transceiver radio that allowed for communications on three frequencies simultaneously. The new chief pilot stated that there had not been any formal change of procedures for communications with SAR personnel during SAR missions; however, communication changes are planned.

48 As previously mentioned, the accident pilot had received training in the NMSP night vision goggle system in January 2009.

46

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According to the manufacturer’s records, the pilot and passenger seats and restraints in the accident helicopter met the limit maneuvering load factor requirements of 14 CFR 27.337 and the emergency landing condition requirements of 14 CFR 27.561 that were in effect at the time of the helicopter’s original FAA type certification.49

1.7 M

nd 2100, respectively, showed VFR or marginal VFR conditions prevailing over much of New Mexico (including the accident site) and a trough of low pressure extending from a

and relatively dry environment with strong, gusty winds out of the west to southwest and high-based rain showers develop

nd mist after 2000, with a ceiling broken at 6,000 feet above ground level (agl) (about 12,000 feet msl) in cumulonimbus clouds and winds at 14 knots

the next day.

information were available in the NMSP SAF hangar and aviation section pilots indicated that they routinely used such services. (A review of the NMSP

eteorological Information

1.7.1 General

The National Weather Service (NWS) weather depiction chart and surface analysis chart in effect at 1900 a 50

low over Colorado through eastern New Mexico. The NWS radar summary chart for 2119 showed widely scattered rain showers over New Mexico with a few defined thunderstorms over the southern portion of the state.51 (Weather radar showed light-to-moderate precipitation over the search area at the time of the accident.)

During the day, all local weather observation sites reported a warm

ing during the afternoon and early evening; several stations in the area reported clouds obscuring the mountain tops near the time of the accident. The SAF terminal aerodrome forecast (TAF) in effect at the time of the accident expected VFR conditions to prevail throughout the forecast period with rain showers in the area throughout the evening and into the next day. The TAF for SAF indicated light rain showers a

gusting to 24 knots through the evening and into

The NWS area forecast in effect for the region when the helicopter departed SAF predicted the following for the mountainous western portion of New Mexico, which included the accident location: broken clouds at 14,000 feet layered to 22,000 feet; widely scattered light rain showers and isolated thunderstorms and light rain; winds from the southwest gusting to 25 knots until 2100; VFR conditions prevailing; and rain showers and thunderstorms after 0200.

There was no record of the pilot obtaining a formal weather briefing through the FAA flight service station or direct user access terminal service. However, computer internet services providing aeronautical weather

ter than 1,000 feet above ground level (agl) and visib

ns) was issued for a diminishing line of thunderstorms mov

the next hourly issuance).

49 The limit maneuvering load factor requirements were 1.0 G up and 3.5 G down, with ultimate load factors of 1.5 G up and 5.25 G down (one G is equivalent to the acceleration caused by the Earth’s gravity). The emergency landing load factor requirements were 4.0 G forward, 2.0 G side, 4.0 G up, and 1.5 G down.

50 VFR conditions are defined as no ceiling or a ceiling grea ility greater than 3 miles. Marginal VFR conditions are defined as a ceiling between 1,000 and 3,000 feet agl

inclusive and/or visibility between 3 and 5 miles inclusive. 51 About 1955 (after the helicopter departed on the accident mission), a convective SIGMET (weather advisory

rega ng significant convective meteorological conditiordi ing from east-southeast toward the accident region. The convective SIGMET was valid until 2155 (but it was

not updated on

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aviation

1.7.2 Local Airport Weather Information

six airports around the accident 52 ilar conditions on the day of the accident, with strong, southwesterly to

ting to 40 knots and warm, relatively dry, VFR conditions. However, a few hours b

ds gusting to 33 knots, cloud ceilings at 10,000 feet (less th

flying in the area before landing, and then saw the helicopter’s lights as it departed a short time later. They stated that it was dark at the ti

casional whiteout conditions on the night of the accident.

section computer Internet history showed the websites visited by users, but the history did not indicate the times and dates of those visits.) In addition, the pilot had a home computer where he could access Internet weather information.

NWS meteorological aerodrome reports (METARs) from location indicated sim westerly winds gus

efore the accident, the weather observations varied, showing broken or overcast layers of clouds and scattered rain showers and thunderstorms due to a weak weather disturbance moving across the area. All of the METARs reported rain showers or virga53 in the area around the time of the accident. For example, during the hour preceding the accident, SAF (the closest airport and weather reporting station to the accident site) reported a broken to overcast layer of clouds between 12,000 and 15,000 feet and rain showers moving across the region. In addition, Angel Fire Airport (AXX), Angel Fire, New Mexico (which was located in mountainous terrain similar to the accident site), reported westerly win

an 2,000 feet agl), and moderate precipitation near the time of the accident. Further, the Albuquerque International Sunport weather observations near the time of the accident reported virga and mountaintop obscuration to the northeast and east of the airport (in the direction of the accident site).

1.7.3 Local Witness Reports

Three hikers who were camping at a lake about 1.5 miles east-southeast of and at a lower elevation than the accident site reported seeing the helicopter

me of the accident and there was a “heavy overcast” with strong, gusty winds. The hikers also reported that heavy rain began at their location shortly after the helicopter crashed.

In addition, members of the New Mexico SAR ground teams described the weather conditions as “very bad,” with strong winds, cold temperatures, snow or sleet, and oc

1.8 Aids to Navigation

No problems with any navigational aids were reported.

52 Weather observations were obtained from the following airports: SAF (located about 21 nm southwest of the

acci

ional Airport, Taos, New Mexico (located about 39 nm nort

but is evaporating before it reaches the surface.

dent site at 6,348 feet); Los Alamos Airport, Los Alamos, New Mexico (located about 26 nm west of the accident site at 7,171 feet); Las Vegas Municipal Airport, Las Vegas, New Mexico (located about 31 nm east-southeast of the accident site at 6,877 feet); Taos Reg

h of the accident site at 7,095 feet); AXX (located in mountainous terrain about 43 nm north-northeast of the accident site at 8,380 feet); and Albuquerque International Sunport, Albuquerque, New Mexico (located about 63 nm southwest of the accident site at 5,355 feet).

53 Virga is precipitation that is falling

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1.9 Communications

No technical communications problems that were related to the accident were reported.

main wreckage. Numerous ground strikes (as evidenced by divots in the soil and scars up to 5 inches deep in the loose rock) and helicopter parts and components were observed

to the spotter and physical evidence, the helicopter tumbled parts and components as it descended. A kneeboard with a

local a

(see fig

consisted of most of the fuselage, both engines, the forward me associated debris, which came to rest in an area of large

boulders at an elevation of about exterior surfaces exhibited extensi pit portion of the fuselage was partially inverted and was attached to the cabin section only by some electrical wiring and various other components. The landing gear position selector and all three landing gear actuators wer

1.10 Airport Information

The accident helicopter was based at SAF, which is located about 21 miles southwest of the accident site. No airport problems were identified.

1.11 Flight Recorders

The helicopter was not equipped, and was not required to be equipped, with a cockpit voice recorder or a flight data recorder.

1.12 Wreckage and Impact Information

As previously stated, investigators were not able to identify the point of the helicopter’s first impact with terrain. However, evidence of the helicopter’s second impact with terrain (light debris from the helicopter and parts of an NMSP decal) was found just below 12,100 feet on the ridge above the

downhill from that point. According down a rocky, steep slope, shedding

rea guide, presumed to be from the accident helicopter, was located at an elevation of about 12,083 feet. Debris from the accident helicopter, including the FLIR, the battery, and portions of the main rotor blades, landing gear, tailcone, tailboom, a survival vest,54 and aircraft manuals and checklists, were scattered between 12,083 feet and 12,000 feet, where the tailcone was located. A large section of the tailboom, with the tail rotor skid tube and the inboard portions of the tail rotor blades55 attached, was found below the tailcone resting against rocks and a tree

ure 4). The tail rotor skid tube was bent upward (toward the tailboom) from its original position and exhibited scratches and abrasions in all directions. The outboard portions of the two tail rotor blades were not recovered.

The main wreckage area portion of the tailboom, and so

11,500 feet. Most of the fuselage ve crushing, deformation, and torn metal. The cock

e in the down position. The main landing gear struts were separated from the fuselage, and the nose landing gear assembly was in several pieces.

54 According to NMSP personnel, the survival vest likely contained a mirror, a whistle, a small first-aid kit,

flares, and a space blanket. 55 The outboard 9 to 10 inches of each tail rotor blade was missing.

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1.12.1 Seats and Restraints

1.12.1

were found unoccupied, outside the fuselage, and exhibited irection. The seat pan was partially separated from the seat

back, a s attached to a common buckle. The left

strap of the pilot’s lap belt was found still fastened to the buckle, but the right strap of the lap e. The left and right lap belt mounting flanges were both broken r harness was found still attached to the floorboard-mounted

inertial

er harness strap was not attached to the buckle, but the left-side shoulder harness strap was fastened to the buckle. There was no evidence of preimpact

g the accident sequence. Postaccident examination of the hiker’s lap belt and shoulder harness assembly revealed that the left and right lap belts were connec

ion

Exa of death as “environmental cold

.1 Pilot Seat (Right Front) and Restraint System

The pilot’s seat pan and back compression damage in an inboard d

nd its fabric covering was loose. The pilot’s restraint system was a four-point system, with right- and left-side lap belts and shoulder harnesse

belt was not attached to the buckl off the seat. The pilot’s shoulde

reel, which was in the locked position. The extended shoulder harness webbing measured about 12 inches from the reel to the beginning of the stitching where the right and left shoulder harness straps split. The right-side should

restraint system failure.

1.12.1.2 Aft, Forward-Facing Passenger Seats and Restraint Systems

During postaccident interviews, the spotter stated that he and the hiker were buckled securely into their seats when the helicopter lifted off to return to SAF. The spotter and the hiker occupied the left and right aft, forward-facing passenger seats, respectively, on the three-seat bench, which exhibited impact damage, but remained largely intact.

The spotter was still inside the aft fuselage when the helicopter came to rest; he recalled that he did not need to unbuckle his seatbelt when he crawled out of the fuselage. Postaccident examination of the spotter’s lap belt and shoulder harness assembly revealed that the lap belt buckle was not latched and was adjusted about 15.5 inches from the adjustment fitting. The bulkhead-mounted inertial reel operated and locked normally, although its extension and retraction felt “rough.” Both the right and left lap belt attachment hooks on the left-side seat were attached to their floorboard mounting brackets with the hook opening upward.

The hiker was ejected durin

ted at the belt buckle and the shoulder harness was disconnected. The right lap belt attachment hook was disconnected from its floorboard mounting bracket, whereas the left lap belt attachment hook remained attached to its floorboard mounting bracket with the hook opening downward. There was no evidence of restraint system failure or separation; however, the left and right floorboard mounting brackets were bent to the right (30, and 45°, respectively) of their normal positions.

1.13 Medical and Pathological Informat

The pilot and the hiker were ejected from the helicopter during the accident sequence and did not survive. The University of New Mexico, Health Sciences Center, Office of the Medical

miner autopsy report listed the pilot’s primary cause

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exposure,” adding, “[o]ther significant contributing conditions included multiple blunt force injuries” that “would have been incapacitating, but not necessarily rapidly fatal.” The autopsy

ries.

Several studies have shown minimal or no effect of the drug fluoxetine at normal doses rformance of

depressed patients on various task 58

nosis, to report the use and diagnosis within 6 m

report listed the hiker’s cause of death as multiple blunt force inju

The spotter was not ejected during the accident sequence and survived the accident with serious injuries. His injuries included a broken ankle, chipped vertebrae, separated ribs, and bumps and bruises to the head. He also suffered from hypothermia. The spotter was hospitalized for 10 days and then released. (For additional information on the survival aspects of the accident, see section 1.15.)

Toxicological analyses performed on fluid and tissue specimens from the pilot by the New Mexico Department of Health, Scientific Laboratory Division and the FAA’s Civil Aeromedical Institute produced largely similar results. The specimens tested negative for carbon monoxide, cyanide, ethanol, and a wide range of illegal drugs.56 However, toxicological tests did detect fluoxetine and norfluoxetine in the pilot’s fluid and tissue samples. (Norfluoxetine is a metabolite of fluoxetine.)

on a variety of performance measures,57 whereas other studies indicate that the pe s improves when taking fluoxetine. In April 2010, the FAA

revised its policy to permit pilots requiring fluoxetine for the treatment of depression to receive a medical certificate through the agency’s Special Issuance (waiver) process, provided that a number of diagnostic and evaluative criteria are met. The FAA also permitted pilots who had been using the drug for depression, but not reporting the use or diag

onths following the policy change without any civil enforcement action for previous falsification.

1.14 Fire

No in-flight or postcrash fire occurred.

56 Toxicological analyses screened for the following drugs: amphetamine, opiates, marijuana, cocaine,

phencyclidine, benzodiazepines, barbiturates, antidepressants, antihistamines, meprobamate, methaqualone, and nicotine.

57 See, for instance: (a) J.G. Ramaekers, N.D. Muntjewerff, and J.F. O’Hanlon, “A Comparative Study of Acute and Subchronic Effects of Dothiepin, Fluoxetine and Placebo on Psychomotor and Actual Driving Performance.” British Journal of Clinical Pharmacology, vol. 39, no. 4 (1995), pp. 397–404 and (b) H. Moskowitz and M. Burns,

ombination With Diazepam.” Progress in 8), pp. 783–792.

See, Tricyclic

“The Effects on Performance of Two Antidepressants, Alone and in C Neuro-Psychopharmacology & Biological Psychiatry, vol. 12, no. 5 (198

58 for instance: (a) Y. Levkovitz and others. “The SSRIs Drug Fluoxetine, but not the Noradrenergic Drug Desipramine, Improves Memory Performance During Acute Major Depression.” Brain Research

Bulletin, vol. 58, no. 4 (2002) pp. 345–350 and (b) G.B. Cassano and others, “Paroxetine and Fluoxetine Effects on Mood and Cognitive Functions in Depressed Nondemented Elderly Patients.” Journal of Clinical Psychiatry, vol. 63, no. 5 (2002), pp. 396–402.

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1.15 Survival Aspects

1.15.1 Postaccident Search and Rescue Efforts

The NMSP dispatcher contacted the initial SAR incident commander about the helicopter accident within minutes of the accident. The SAR incident commander instructed the SAR ground teams,59 who had departed the SAR IB area about 2120 to search for the lost hiker, to proceed toward the helicopter’s last known position (near the landing site where the accident pilot picked up the lost hiker) and provided them with the coordinates for that location. SAR logs also ind

ansmitter (ELT)-generated distress signal62 and relayed

The weather conditions eventually permitted the New Mexico National Guard helicopters to resume their search about 1045 that morning.

The spotter, after taking shelter in the fuselage wreckage overnight, began to hike down the mo t 1100, SAR commanders were advised that an analysis of pertinent radar data resulted in search coordinates that corresponded to a location on a ridge line 0.25 mile southwest of where the helicopter wreckage was ultimately located.

icated that about 2156, SAR personnel requested the assistance of New Mexico National Guard helicopters in their efforts to locate the accident helicopter.60 (National Guard helicopters did launch the night of the accident; however, these efforts to find the accident helicopter were hampered by the adverse weather conditions.)61

By 2240 (about 65 minutes after the accident occurred), satellites had detected the accident helicopter’s emergency locator tr

location information to the U.S. Air Force Rescue Coordination Center (AFRCC). AFRCC then provided SAR personnel with the ELT’s coordinates.63 During the SAR effort (about 2315 the night of the accident and then about 0725 on June 10), the AFRCC received two additional ELT satellite detection messages, both indicating slightly different locations than the first; however, all three ELT detections were located within 2 nm of the accident site.64

According to SAR logs, about 0900 on the morning of June 10, two New Mexico National Guard helicopters were dispatched again to search for the accident helicopter near the third ELT location; however, those helicopters returned to SAF 45 minutes later because of poor weather conditions.65

untain for help in the morning. Abou

59 Although all SAR incidents in New Mexico are coordinated by the NMSP, the primary resources (SAR

personnel) for these incidents are volunteers. SAR ground teams were also searching for the hiker’s companion. 60

ent site.

o delayed because of adverse weather conditions.

The New Mexico National Guard operated Sikorsky UH-60 “Blackhawk” helicopters with crews consisting of two helicopter instrument-rated pilots.

61 Adverse conditions (bad weather with fog, sleet, and “pouring rain,” and rugged, slippery terrain) were also reported by SAR teams who participated in the search for the accident helicopter through the night of the accident and into the next day.

62 The accident helicopter was equipped with an Artex C406-1HM ELT that transmitted on both 406- and 121.5-megahertz (MHz) frequencies.

63 This location was eventually determined to be about 0.3 mile northwest of the accid 64 The ELT locations generated by the type of ELT unit installed in the accident helicopter are generally

considered accurate to within 1 to 3 nm. 65 In addition, the SAR efforts of the Civil Air Patrol, which had planned to send airplanes to search at first light

on the morning of June 10, were als

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Although SAR ground teams di searching in the area, and, about 1155, one of

d not yet have the radar data coordinates, they were already the ground teams found the spotter. A New

e coordinates provided by after the accident occurred), the spotter

was be

with a blue line showing the likely route that the SAR ground tea

Mexico National Guard helicopter was immediately dispatched to th the ground search team, and, by 1230 (about 15 hours

ing airlifted to a hospital for treatment.

As previously mentioned, SAR ground teams did not locate the helicopter’s wreckage until 1816 on June 10. The accident site was described as dangerously steep and covered with snow and ice. Figure 7 shows the approximate route that the SAR ground team took to locate the spotter.

Figure 7. Google Earth image m took from the SAR IB (E) to the helicopter main wreckage location (C).

Note: Also shown are the hiker’s approximate location (A); the helicopter’s likely landing zone, confirmed by the spotter (B); and the three AFRCC ELT-provided coordinates (1, 2, and 3, in the order in which they were provided to SAR personnel) for the accident site. A compass showing north is located in the upper right corner.

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After an unsuccessful search of the wreckage and surrounding area for the pilot and hiker, about 2007 (about 12 minutes before sunset), the SAR ground team was airlifted from the site by a New Mexico National Guard helicopter. The bodies of the pilot and the hiker were not located until the next day.

1.16

t helicopter’s ELT activated as designed during the accident sequence. It was found intact and still mounted in a portion of the helicopter’s tailboom with its cable connected to the fractured external antenna.

The investigation revealed that the ELT’s transmissions were received by low-Earth polar orbiting satellites but were not received by the two geostationary operational environmental satellites. National Oceanic and Atmospheric Administration (NOAA) Search and Rescue Satellite-Aided Tracking (SARSAT)66 personnel examined the discrepancy between the signal’s transmission and reception and determined that this discrepancy could be explained by the topography of the crash site and the relative positions of the two geostationary satellites. According to NOAA’s report, the accident helicopter’s ELT was located on the north face of steeply sloped terrain, while the two geostationary satellites were positioned above the equator in the southern sky (one southwest and the other southeast of the accident site).

1.16.2 Radar Study

The U.S. Air Force provided the NTSB with radar data for the accident flight from its radar sites in Mesa Rica and West Mesa, New Mexico. The data showed that the helicopter flew for about 2 minutes 35 seconds after it lifted off after picking up the hiker. Radar data indicated that the helicopter initially headed northwest from the remote landing site toward the southern flank of the mountain and the much lower terrain of the valley beyond. The data indicated that the helicopter transitioned the southern flank of the mountain and then began to fly a somewhat erratic path, reversing direction, climbing, and heading northeast over the mountain’s peak. The radar data also showed that the helicopter crossed terrain as high as 12,500 feet before descending rapidly near the crash site. When plotted on Google Earth, the radar data show the helicopter apparently passing through terrain and continuing its flight on the other side. The NTSB’s review of the U.S. Air Force radar data indicated that the anomalous radar data may have been the result of the inconsistent radar coverage in the mountainous area and/or the different barometric pressures in the area, which would result in an altitude offset error. (The U.S. Air Force radar data were not corrected for barometric pressures that differ from the standard 29.92 inches of mercury, and the barometric pressure measured at airports in the

Tests and Research

1.16.1 Emergency Locator Transmitter’s Distress Signal Information

The acciden

mountainous region northeast of SAF varied between 30.11 and 30.19 inches of mercury at the time of the accident.)

66 The SARSAT system consists of a constellation of satellites and a network of ground receiving stations that

provide distress alert and location information to appropriate rescue authorities around the world. Instruments on board the satellites detect the ELT signals and transmit them to the ground receiving stations.

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The onset of the helicopter’s erratic flightpath and its turn to the northeast began a little more than 1 minute after the beginning of the radar-recorded portion of the flight and about 1.5 minutes before the flight disappeared from radar. The main helicopter wreckage was located about 0.25 mile east of the last radar target.

anagement Information

dix B), aviation section aircraft were used for searches; rescues; reconnaissance; surveillance; air traffic operations and highway patrol; miscellaneous law en

afety management system (SMS) program, and it did not have published safety goals and objectives; a designated

gnated safety committee; structured prelaunch and midlaunch risk al system for communicating safety-related information, other

than or

1.17 Organizational and M

1.17.1 NMSP Aviation Section—General Information

At the time of the accident, the NMSP aviation section operated three fixed-wing airplanes and the accident helicopter. According to the NMSP aviation section’s “Policies and Procedures” document (see appen 67

forcement operations; personnel, equipment, and materials transport; and assistance to other agencies. According to NMSP personnel, about 70 to 80 percent of the accident helicopter’s usage consisted of law enforcement and SAR missions.68 One of the fixed-wing airplanes was used exclusively for training, and the other two airplanes were used for transport, law enforcement, and occasional SAR missions. The NMSP operated its aircraft and conducted its flights as “public” operations for the state of New Mexico; those operations were exempt from many FAA regulations applicable to non-public (“civil”) aircraft operations.

At the time of the accident, the NMSP aviation section did not have a s 69

safety officer; a desi assessment protocols; or a form

al communication.

1.17.2 NMSP Aviation Section Personnel and Chain of Command

When the accident occurred, the NMSP aviation section employed four pilots to operate its aircraft: the chief pilot (the accident pilot, who flew the fixed-wing airplanes and the helicopter),70 a full-time helicopter pilot,71 a full-time fixed-wing pilot,72 and a part-time

67 The “State Police Aviation Section and Operations” is contained in the DPS Policy Manual, number

OPR: 49, issued 23 May 2007 (Santa Fe, New Mexico: State of New Mexico, 2007). 68 During calendar years 2007 and 2008, the accident helicopter flew 451 flights, about 17 percent of which

involved SAR operations. The accident helicopter flew 103 total flights during calendar year 2009 (including the accident mission) before the accident occurred, about 26 percent of which involved SAR operations. (Some of these search operations were conducted independent of a formal SAR operation.) The NTSB’s examination of NMSP pilot logbooks indicated that the duration of SAR missions varied widely and that the missions were sometimes interrupted because of darkness and resumed in daylight the next day.

69 According to the FA An SMS program also pro

A, an SMS is a quality management approach to controlling risk in aviation operations. vides the organizational framework to support a sound safety culture and to provide

assurance that risk controls are effective.

pilot certificate with

70 For information regarding the chief pilot’s experience and qualifications, see section 1.5.1. 71 The full-time helicopter pilot was an NMSP patrolman who was assigned to the aviation section in 2005,

after he learned to fly helicopters in the New Mexico National Guard. He had a commercial

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helicop

operations, maintenance coordination, purchasing, training, planning, and personnel matters involving aircraft and pilots.”

, who oversaw the aviation section’s budget. The special operations captain reported to the major in charge of special

he deputy chief of police reported to the chief of police and an adjutant chief of police, both of whom reported to the DPS cabinet

1.17.3.1 Flight Operations and Training

ull-time helicopter pilot said that he and the accident pilot aused the weather , the accident pilot

told the

According to NMSP personnel, aviation section helicopter pilots were not required to have a helicopter instrument rating because of cost constraints and mission requirements. NMSP

ter pilot.73 According to aviation section personnel, the chief pilot served as the aviation section’s day-to-day administrator and supervisor of its pilots and the aviation maintenance technician. NMSP aviation section documents indicated that the chief pilot’s specific responsibilities included “all daily flight

The chief pilot reported to an NMSP special operations captain

operations, who, in turn, reported to a deputy chief of police. T

secretary. Of the personnel in this chain of command (aside from the pilots in the aviation section), only the DPS cabinet secretary had any specialized aviation knowledge or experience.

1.17.3 Aviation Section Policies, Procedures, and Practices

The NMSP aviation section had a 9-page general standard operating procedure (SOP) document, titled “Policies and Procedures,” in effect at the time of the accident (see appendix B). The aviation section also frequently followed other unofficial practices. This section will describe some of the aviation section’s official and unofficial practices.

The SOP stated that the aviation section’s helicopters may operate “clear of clouds if operated at a speed that allows the pilot adequate opportunity to see any air traffic or obstruction in time to avoid collision.” The NMSP aviation section SOP did not contain official guidance regarding inadvertent IMC encounters or night takeoffs from remote landing sites. However, during a postaccident interview, the f had discussed inadvertent IMC procedures when clouds, rain, and fog c conditions to deteriorate during an approach to SAF. During that discussion

full-time helicopter pilot that, in the event of an inadvertent IMC encounter, he would climb, set up the horizontal situation indicator, turn, fly directly to the SAF very high frequency omnidirectional radio range navigational aid, and contact ATC.

personnel indicated that the helicopter was primarily used for SAR missions, which are not

rotorcraft-helicopter and instrument ratings, and he reported about 1,540 hours of total flight experience, about 1,440 hours of which were flown in helicopters.

72 The full-time fixed-wing pilot was an NMSP patrolman who was assigned to the aviation section in 2003. He was the section’s fixed-wing instructor pilot, held an airline transport pilot (ATP) certificate with numerous fixed ing certificates and ratings, and reported about 11,000 hours tot-w

73 Before joining the NMSP aviation section, the part-time helicopter pilot spent 7 years as a helicopter pilot in the U.S. Air Force and 16 years as a helicopter pilot for the U.S. Customs and Border Protection. He described hims f as an “auxiliary pilot” for the N

al flight experience, all in fixed-wing aircraft.

MSP aviation section, flying the helicopter on a part-time basis (with occa certificate with a fixe

el sional full-time service) between 2004 and the time of the accident. He held an ATP

d-wing rating, a commercial pilot certificate with helicopter and instrument ratings, and reported about 4,200 total flight hours, about 3,000 hours of which were in helicopters.

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typically conducted in IMC because, according to the former chief pilot, “…if you can’t see the ground you can’t see the person.” The former chief pilot further observed that, at higher elevations (where the accident helicopter typically operated), any visible moisture was associated with potential icing conditions, and the Agusta A-109E was not designed to be operated in icing conditions. As a result, a helicopter instrument rating was not a priority for NMSP helicopter pilots.

or extraordinary circumstances;75 however, it did not allow for increased flight time as PIC under

that “a minimum of eight hours rest is required following any duty day that exceeds twelve hours prior to subsequent duty time.”

ds that were less than 12 hours in duration. The former chief pilot noted that NMSP management thought rest meant

did not consider the accident pilot to be resting calls in his role as PIO. The former chief

pilot st

ilots to advise him if they were go

1.17.3.2 Pilot Flight and Duty Time

The NMSP aviation section’s SOP document limited its pilots’ pilot-in-command (PIC) flight time and duty time to 6 and 12 hours, respectively, during any 24-hour period.74 The document did permit increased duty times of up to 15 hours in a 24-hour period under emergency

any circumstances. The “Policies and Procedures” document specified

The NMSP aviation section “Policies and Procedures” document did not define the term “rest,” nor did it establish a minimum rest period between duty perio

being at home; however, he indicated that he when he was at home and received frequent telephone

ated that, when he was chief pilot, he tried to ensure that the accident pilot was not the pilot on call on a weekend when he was on call as PIO. The part-time helicopter pilot told investigators that the pilots’ rest periods76 were not protected and that they were not reset if they received a work-related telephone call or had to perform some other work-related duty after working their normal shift. He attributed this issue to the limited number of pilots and the often “life or death” nature of their mission.

According to the former chief pilot, the chief pilot was responsible for screening potential missions and ensuring that the aviation section pilots adhered to flight and duty time limitations. However, the aviation section had no formal system to track flight and duty time. As a result, when a potential mission arose, the chief pilot typically relied on the p

ing to exceed flight and duty time limitations. The former chief pilot stated that if he had to call a pilot to fly a mission after the pilot had already worked a full day, he relied on the pilot to tell him if he was too tired to fly the mission. The full- and part-time helicopter pilots stated

74 The document also limited NMSP pilots’ flight and duty time to 25 and 65 hours, respectively, during any

om limitations would only be permitted “in situations of extreme emer

heli

uld the occasion arise.”

7-day period. 75 The NMSP SOP stated that deviations fr gency or extraordinary circumstances.” The terms “emergency” or “extraordinary circumstances” were not

defined in the SOP document. According to the former chief pilot, circumstances justifying an extension of duty time beyond 15 hours in a 24-hour period had not occurred in his 18 years with the NMSP; however, the part-time

copter pilot said that he had exceeded 15 hours of duty on “at least a couple of occasions.” 76 14 CFR 91.1057 defines a rest period as follows: “…a period of time required pursuant to this subpart that is

free of all responsibility for work or duty prior to the commencement of, or following completion of, a duty period, and during which the flight crewmember…cannot be required to receive contact from the program manager. A rest period does not include any time during which the program manager imposes on a flight crewmember…any duty or restraint, including any actual work or present responsibility for work sho

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that they did not recall ever turning down a mission because of fatigue. The fixed-wing pilot reported that he turned down a mission once because of fatigue, when he was called for an evening flight after flying and working during the day.

The major in charge of special operations stated that the individual(s) who authorized aircraft missions considered the expected length of the mission to determine which pilots might be available to fly it, and then asked the available pilot(s) if he or they were “good to go.” NMSP

pected aviation section pilots to comply with NMSP e for tracking their own flight, duty, and rest times to

meet th

ccurred on weekends. About 33 percent of the pilot’s helicopter flying and less than 10 perc

aking The NMSP aviation section SOPs stated that the PIC was responsible for “determining

whethe

SAR mission was feasible, he would ask a pilot to check the weather and contact the incident

management personnel stated that they ex policies and that the pilots were responsibl

at goal.

The chief of police stated that it was the pilots’ responsibility to ensure that their supervisor was informed if they were not adequately rested for a flight. He further stated that the “vast majority” of the aviation section’s missions were flown during normal work hours. However, the NTSB’s review of the accident pilot’s logbook entries for the 12 months preceding the accident showed that 24 percent of his helicopter flying and 3 percent of his fixed-wing flying o

ent of his fixed-wing flying occurred at night. Most of the pilot’s helicopter night flying (about 85 percent) and all of his fixed-wing night flying occurred during the week. Information provided by the full-time pilot indicated that about 15 percent of the helicopter flights he flew in the 7 months before the accident77 occurred at night and about 11 percent occurred during a weekend. A review of the part-time pilot’s logbook indicated that about 35 percent of his helicopter flights in the 12 months before the accident occurred at night and about 1 percent occurred during a weekend.

1.17.3.3 SAR Helicopter Support Information

1.17.3.3.1 Prelaunch Decision-M

r a flight [was] safe, and for canceling or terminating flights determined to be hazardous.” However, the NMSP did not have an official risk assessment policy. The former chief pilot and current pilots in the aviation section said that the NMSP did not have written NMSP guidance to assist pilots in making launch decisions. The former chief pilot indicated that he used a mental risk management checklist when making safety of flight determinations.78 He indicated that, when he was chief pilot, he was typically notified first about potential missions and that he was responsible for making go/no-go decisions.79 The former chief pilot stated that if he thought a

commander for more information about the search area. The former chief pilot said that he would use the weather and search information to determine whether it was safe for aircraft operations. The former chief pilot said that he considered the “gravity” of the situation, the experience level

77 The full-time pilot did not fly with the NMSP until December 2008 because of his duties with the New

Mex

ts.

ico National Guard. 78 The former chief pilot stated that aviation section pilots determined whether they could comply with the

minimum weather requirements specified in 14 CFR Part 91 when deciding whether to depart on a mission. 79 He said that he made conservative decisions when dealing with the inexperienced, junior pilo

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of the pilot, how much flying the pilot had already done that day, and visibility and lighting conditions in his decision-making.

The former chief pilot stated that, during his tenure as aviation section chief pilot, he often r

prove aircraft missions, aviation section pilots were contacted directly by a mission initiator. After the initial contact, the pilot would decide whether to accept the mission and wa

anagement but added that SAR commanders should advise pilots about localized deteriorating weather conditions so that the pilots could make better-informed

pilot said that he thought that the PIC and ission; the special operations major

said tha t commander held that responsibility.

eceived complaints from the DPS cabinet secretary when the former chief pilot turned down missions that he considered too dangerous. He told investigators that, in March 2006, he was relieved of his chief pilot duties because he declined a SAR mission for safety-related reasons.80 (After being relieved of his chief pilot duties, the former chief pilot functioned as an NMSP aviation section pilot until he retired in 2008.) After the former chief pilot was no longer authorized to ap

s then responsible for obtaining authorization from upper management. The former chief pilot and the part-time helicopter pilot said that they were concerned about the new approval process because the managers who were authorized to approve aircraft missions (other than the DPS cabinet secretary,81 who was not typically involved in mission-related decisions) had no aviation expertise and were not qualified to evaluate the potential risks associated with accepting a particular mission.

1.17.3.3.2 Risk Management During SAR Missions Postaccident interviews with former and current aviation section pilots and management

revealed varying opinions about who was responsible for managing risk during a mission. The former chief pilot said that the PIC and the SAR incident commander were responsible for managing risk during a mission. The full-time helicopter pilot stated that the PIC bore most of the responsibility for risk m

decisions during a mission. The part-time helicopter the chief pilot were responsible for managing risk during a m

t the mission initiator and the SAR inciden

NMSP documents did not address procedures for preflight weather evaluation and/or in-flight weather-related decision-making. However, the full-time helicopter pilot said that NMSP aviation section pilots typically contacted the FAA flight service station for a weather briefing before cross-country flights, whereas they used the NOAA Aviation Weather Center website to obtain routine weather observations and TAFs for local flights. The pilots typically

80 The former chief pilot submitted a letter to NMSP management indicating that he had been relieved of his

position because he refused to send the aviation section’s two most junior pilots on a mission that he considered extremely high-risk. The mission would have involved high-altitude flying, strong wind conditions, intermittent snow, and zero illumination. The only available NMSP pilots were the accident pilot and the full-time helicopter pilot, who, at the time of that mission, had about 50 and 200 hours of helicopter time, respectively. The former chief pilot postponed the mission until the next morning; he received a call that morning from the NMSP deputy chief, duri

meant turb

ng which he was advised that he was being relieved of his chief pilot responsibilities (on orders from the DPS cabinet secretary) because of his decision to delay the SAR mission.

81 During postaccident interviews, the DPS cabinet secretary told investigators that aviation section helicopter pilots had to “stay VFR all the time” and avoid getting into a situation where they could encounter IMC. He further stated that aviation section helicopter pilots were to avoid strong wind conditions because they usually

ulence in the mountains.

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did not have access to official weather forecasts and official observations during SAR missions, unless they were in an area where th 82ey could reach Flight Watch.

P aircraft when highway speed-patrol operations were being performed. Observers u e “familiar with his/her equipm e policy did not address the need for aux

ission. Regarding cold-weather gear, the DPS cabinet secretary stated that the aviation section used to require

1.17.4 NMSP Aviation Section Staffing

Each full-time NMSP aviation section pilot was expected to work at least 2,080 hours per yea

1.17.3.4 Crew Staffing and Equipment Practices

The NMSP aviation section had no official guidance or policies specifying which aircraft missions should be flown with two pilots and which missions could be flown with one pilot. According to the former chief pilot, he tried to send two pilots on each mission, but it was not always possible because of staffing limitations. He stated that he also tried to require two pilots when the FLIR was used but that informal policy was not always enforced. The part-time helicopter pilot stated that the accident pilot had performed at least two aerial searches at night by himself during which he likely used the night vision goggles and maybe used the FLIR. The part-time helicopter pilot stated that he had urged the accident pilot to take another pilot with him on such missions.

Aviation section policy required the presence of an auxiliary crewmember, an observer or spotter, aboard NMS

sed in highway speed-patrol operations were required to b ent” and with the section of highway to be patrolled. Th iliary crewmembers on other types of missions and did not specify how such auxiliary

crewmembers should be trained.

The aviation section had no official policy regarding the minimum equipment (such as cold-weather gear, night vision goggles, or FLIR) that was required for missions. NMSP managers stated that it was the chief pilot’s responsibility to establish formal requirements regarding the minimum equipment needed for missions and to ensure that aviation section pilots understood what equipment was needed. The chief of police stated that he and the other NMSP managers who were not pilots did not know what equipment should be required for a m

at least a minimum supply of cold-weather gear and that he thought the current pilots had been told that they should dress for adverse weather conditions. He stated that, when he was a pilot in the aviation section, he routinely carried a survival kit and extra blankets because he had been stuck in the mountains before.

r (80 hours per 2-week pay period) for their salary, which was based on their NMSP rank plus a flight pay supplement. Work performed in the office and time spent performing mission-related activities (including the accident pilot’s PIO activities) were credited toward this total number of hours, but pilots were not paid for time spent on call outside of regular office hours, unless they were actually performing work-related tasks.

82 Flight Watch is an en route flight advisory service that provides en route weather updates and pilot report

information to pilots operating between 5,000 and 17,000 feet in the United States. Flight Watch services may be available below 5,000 feet, depending on terrain and the distance from the nearest station.

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When asked about the adequacy of NMSP aviation section staffing during postaccident interviews, the aviation section pilots and the managers in their chain of command provided differing opinions. According to the full-time helicopter pilot, when he joined the aviation

ith five full-time pilots. However, two the former chief pilot in 2008),

and no

issions and the amount of time the pilots spent on call made additio

at they shared the responsibility of being on call. He said most missions were flown during regular business hours. The DPS cabinet secretary also believed that the avi

ses between NMSP pilots, dispatch, and SAR personnel.

ntact with NMSP aviation section personnel and by the aviation section since the accident. The

aviation

xperience, currency, and quality of rest), and environmental conditions (for example, day, night, IMC, or icing conditions). The risk

section in 2005, it was adequately staffed for its mission w pilots had subsequently retired (a fixed-wing pilot in 2006 and

additional pilots had been hired to replace them. The full-time fixed-wing pilot stated that, at the existing staffing level, the aviation section pilots were almost always on call. The special operations captain who supervised the chief pilot at the time of the accident agreed that the aviation section needed more pilots. He noted that it was “challenging to provide coverage 24 hours a day, 7 days a week” with two and a half helicopter pilots and one fixed-wing pilot.

On the other hand, the special operations major, who supervised the special operations captain, told investigators that, before the accident, he believed that staffing in the NMSP aviation section was adequate. However, after the accident, he said he came to understand that the unpredictability of the m

nal staffing necessary. The former adjutant chief of police stated that he believed that the aviation section was adequately staffed. He noted that the aviation section had averaged only 569 flight hours per year during the last 4 years and that, as a result, he saw the pilots’ workload as very light and that he felt that additional staffing was not justified. When he was asked how many hours per week each pilot was expected to be on call, he said that each pilot was required to work 40 hours per week and th

ation section was adequately staffed at the time of the accident, explaining, “If we didn't have the resources to [fly a mission], we didn't do it.”

1.17.5 Postaccident NMSP Actions

The NMSP conducted a postaccident investigation into the conduct of the SAR mission for the accident helicopter and personnel and, in March 2010, presented the resultant report to the New Mexico Search and Rescue Review Board.83 The report recommended that the NMSP aviation section 1) follow proper protocol for SAR missions, specifically to include a mission initiator briefing, and NMSP aircraft use only at the request of the SAR incident commander, and 2) review the communications proces

NTSB investigators have been in co reviewed changes that were made or proposed

section had developed a strategic plan and improved its flight authorization procedures to ensure that the shift supervisor on duty receives all relevant information before dispatching section pilots and aircraft on a mission. The section also developed a mission risk assessment worksheet that addressed factors such as the type and complexity of the mission (for example, training, dignitary transport, SAR, mountain or overwater operations), planning time and guidance available, crew selection (pilot e

83 The New Mexico Search and Rescue Review Board is a governor-appointed board that evaluates the

operation of the New Mexico Search and Rescue Plan and problems on specific missions and makes recommendations to the appropriate authorities.

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assessm

n, the NMSP plans to further review and change as necessary its procedures regarding commu

actory” checkrides), ng officers for missions. The aviation section also rogram to provide dedicated and trained observers. In

additio

1.18.1

the search area. If an incident commander determined that aircraft SAR support was needed,84

ent worksheet also contained a mission briefer checklist, which included weather briefing, crew current and qualified, weight and balance, equipment, aircraft logbook, crew rest, and three approving signature blocks.

NMSP pilots indicated that the radio equipment on the accident helicopter limited the number of frequencies they could monitor at one time, which hampered their ability to monitor and communicate with NMSP dispatch and SAR personnel at the same time. According to NMSP personnel, the replacement helicopter is equipped with a radio that allows pilots to monitor and communicate on three separate frequencies. As a result, NMSP pilots can now monitor and communicate with NMSP dispatch and SAR personnel at the same time. In additio

nications with SAR personnel during SAR missions.

Additionally, since the accident, the NMSP has purchased a global positioning system (GPS)-based flight-following unit to improve flight-following capabilities for its aircraft. The NMSP purchased a service plan that provides position updates every 5 minutes and when the helicopter stops. In addition, the NMSP purchased personal emergency locator beacons (PLB) for its pilots to carry during missions. The PLBs transmit self-contained GPS coordinates to satellites when manually activated and, thus, provide SAR personnel with more precise location coordinates than an aircraft’s ELT signals.

After the accident, the aviation section also developed study guides for each of the section aircraft, instituted monthly aviation section safety meetings, increased flight training time, developed and incorporated programs to track and monitor quarterly training and proficiency checks for aviation section pilots (in addition to the annual “f and designated section safety and traini instituted a tactical flight officer training p

n, the aviation section created an aviation life support and equipment program to ensure that aircraft occupants have the equipment necessary to assist in their safe escape, survival, and recovery during an accident or other emergency.

1.18 Additional Information

New Mexico Search and Rescue Act and Plan

The New Mexico Search and Rescue Act (SAR Act), which was made law in 1978, governs SAR operations in the state of New Mexico. The New Mexico Search and Rescue Plan, dated January 1, 1996, is a working document that supports the SAR Act.

At the time of the accident, every NMSP district had police officers who were trained to function as mission initiators. When a call came in, the mission initiator investigated the need for SAR and, if needed, contacted a SAR incident commander, after which SAR volunteers would be contacted. SAR incident commanders would normally set up an incident command post near

84 Available SAR aircraft support options included the NMSP, the Civil Air Patrol, the New Mexico National

Guard, or a private helicopter emergency medical services operator.

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they had to request that support through the area commander, who would oversee the incident commander. According to the SAR plan, the incident commander would provide the area commander with a description of the situation, the related weather conditions, the urgency of the mission, and an assessment of the type of aircraft and related equipment he or she thought would be mos

the Independent Safety Board Act Amend

stem, the FAA has no statutory authority to regulate public

g:

craft would be considered ction. Also included would

t useful under the circumstances. If the area commander chose to request NMSP aircraft support, he or she should pass the relevant information described in the previous sentence (such as weather information, urgency, and equipment needed, for example) directly to the on-duty pilot so the pilot could make a decision about whether to proceed.

1.18.2 Public Aircraft Operations

Public aircraft, as defined by Public Law 103-411, ment of 1994, are exempt from many FAA regulations applicable to civil aircraft. The

statute, which became effective April 23, 1995, narrowed the definition of public aircraft with the intent that government-owned aircraft, which operate for commercial purposes or engage in the transport of passengers, be subject to the regulations applicable to civil aircraft.85 However, the law specifically does not apply to SAR, firefighting, or law enforcement operations. During the NTSB’s February 3 through 6, 2009, public hearing on the safety of helicopter emergency medical services (HEMS) operations,86 FAA representatives testified that, with the exception of operations within the National Airspace Sy

aircraft operations. FAA Advisory Circular (AC) 00.1-1, “Government Aircraft Operations,” dated April 19, 1995, provides “guidance on whether particular government aircraft operations are public aircraft operations or civil aircraft operations under the statutory definition of public aircraft.” On the subject of SAR, the AC states the following:

This term is commonly used to mean operations conducted to locate and rescue persons who are lost, injured, and/or exposed to some degree to danger or harm. Generally, the use of an aircraft is indispensable to the search effort or is the only feasible means of recovering the victim. Persons rescued would be considered “associated with” the activity.

The AC further states the followin

…persons engaging in [SAR] operations from an air necessary for the performance of the governmental fun be persons who are being carried to a remote search area from which they would conduct ground search and rescue operations, provided that the use of the aircraft is necessary for the performance of that mission.

The NTSB performed a safety study of public aircraft safety, adopted October 23, 2001. The study concluded

that public aircraft experienced fewer accidents per flight hour than general aviation aircraft but had accidents more frequently than aircraft operating under 14 CFR Part 135 or Part 121. The study also concluded that the use of different accident and activity data collection systems made it difficult, if not impossible, to compare accident rates for public aircraft operators. As a result of this study, the NTSB issued eight safety recommendations to the FAA and two safety recommendations to the General Services Administration. For more information, see Public Aircraft

01 (Washington, DC: National Transportation Safety Board, 2001) at

85

Safety, Safety Study NTSB/SS-01- <htt

ents/Hearing-HEMS/default.htm>. p://www.ntsb.gov/Publictn/A_Stu.htm>. 86 For details, see the NTSB’s website at <http://www.ntsb.gov/ev

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FAA Order 8900.1, volume 3, chapter 14, section 2, “Public Aircraft Operations and Surveillance, Government Aircraft Operations versus Civil Aircraft Operations,” part 3-565, “Surveillance,” dated September 13, 2007, states that “government-owned aircraft operators holding any type of FAA certification will be included in the normal surveillance activities such as spot inspections of the aircraft and aircraft records.” Further, the order provides the following example: “If an operation is considered public and the operator holds an airworthiness certificate, its maintenance records are eligible for review.” Additionally, it states that “government-owned aircraft operators that are conducting public aircraft operations should be included in the [flight standards district office] FSDO’s annual planned surveillance activities to ensure that the

of public safety missions through training, networking, advocacy and educational programs.” At the time of the accident, ALEA’ EA’s records at the time of ection pilots a

ALEA has established multiple programs to aid in the organization, safety, and efficiency of airb association makes available to its members a comprehensive start-up guide, which contains detailed standards for law enforcement units to use in deve vides membe opted for by ed to objectiv EA’s standar e aviation operations in support of law enforcement missions.” An audit process (to ensure that safety management efforts are effective) is in

operator’s status remains unchanged.”

The accident helicopter was maintained under a standard airworthiness certificate, issued March 20, 2003. The aviation section maintenance technician told investigators that FAA inspectors had not visited the NMSP aviation section facility to conduct an inspection of the helicopter since the maintenance technician was hired in September 2005. FAA personnel at the local FSDO told NTSB investigators that they had not conducted any oversight of NMSP operations because NMSP was a public operator.

1.18.3 Airborne Law Enforcement Association Standards

The Airborne Law Enforcement Association (ALEA) was founded in 1968 as a non- profit association comprised of local, state, and other public aircraft operators engaged in law enforcement activities. The association’s mission is to “support, promote and advance the safe and effective utilization of aircraft by governmental agencies in support

s records indicated about 3,500 member agencies in the association. Although AL showed that none of the NMSP aviation section pilots were members of ALEA the accident87 (nor was the NMSP a member organization), the current aviation s re all members.

orne law enforcement units.88 The

loping a set of SOPs, and numerous example manuals.89 In addition, ALEA pro rs with an extensive database of safety-related research and resource links and, if a public operator, an accreditation program. The accreditation program is design ely evaluate and certify a participating aviation unit’s overall compliance with AL

ds with a goal of “safe, efficient, and accident-fre

cluded as part of the ALEA accreditation program. ALEA also provides and encourages the use of an SMS toolkit for aviation sections to develop an SMS program.

87 During postaccident discussions, the then part-time pilot indicated that he had been a member of ALEA for more than 20 years except for 1 year when NMSP forgot to renew his membership.

88 See ALEA’s website at <http://www.alea.org>. 89 According to ALEA’s executive director, most small airborne law enforcement units use the association’s

sample manuals, standards, and guides to create their rules and procedures.

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Further, ALEA offers a library that contains explanations of public aircraft, the laws that affect police airborne units, and questions and answers concerning public aircraft. According to the ALEA website, the association continues to update its standards. The website contains a members-only section that allows members immediate access to sample manuals, updates, and other resources. In addition, ALEA conducts regional safety seminars and a weeklong national conference and exposition annually.90 (According to NMSP aviation section personnel, all NMSP pilots and tactical flight officers attended ALEA training in April 2011.)

1.18.4 Safety Management System Programs

In recent years, the International Civil Aviation Organization, FAA, International Helicopter Safety Team, ALEA, and the NTSB have encouraged aviation service providers to adopt SMS programs.91 A successful SMS program incorporates proactive safety methods to evaluate a company’s flight and maintenance operations to, at a minimum, identify safety hazards, ensure that remedial action necessary to maintain an acceptable level of safety is implemented, provide for continuous monitoring and regular assessment of the safety level achieved, and continuously improve the company’s overall level of safety. Further, a successful SMS approach relies on senior management to develop a formal safety policy, establish safety objectives,

ring an organizational safety culture. Research has shown that this kind of management involvement plays a key role in the success

develop standards of safety performance, and take the lead in foste

of organizational safety programs.92

At the NTSB’s February 3 through 6, 2009, public hearing on the safety of HEMS operations, representatives of the FAA and ALEA stated that an SMS program can be scaled to suit the size and characteristics of a specific operator.

90 For example, issues addressed during the 2010 national conference included tactical flight officer selection

and training, helicopter rescue and aerial firefighting, night operations, and aviation physiology and safety equipment.

91 For additional information, see International Civil Aviation Organization, Safety Management Manual, 2nd ed. ICAO Doc 9859 (Montreal, Quebec, Canada: International Civil Aviation Organization, 2009); Safety Management Systems for Aviation Service Providers, Advisory Circular 120-92A, (Washington, DC: U.S. Department of Transportation, Federal Aviation Administration, 2010); International Helicopter Safety Team, Safety Management System Toolkit (Alexandria, Virginia: U.S. Joint Helicopter Safety Implementation Team, 2009); Airborne Law Enforcement Association, Safety Management System Toolkit, (Frederick, Maryland: Airborne Law Enforcement Association, 2009). Also see (a) Crash of Pinnacle Airlines Flight 3701, Bombardier CL-600-2B19, N8396A, Jefferson City, Missouri, October 14, 2004, Aircraft Accident Report NTSB/AAR-07/01 (Washington, DC: National Transportation Safety Board, 2007); (b) In-flight Fire, Emergency Descent, and Crash in a Residential Area, Cessna 310R, N501N, Sanford, Florida, July 10, 2007, Aircraft Accident Summary Report NTSB/AAR-09/01/SUM (Washington, DC: National Transportation Safety Board, 2009); and (c) NTSB reco

of Successful Safety Programs, Journal of Safety Research, vol. n, J. Mayr, and T. Haines, “Overview of the Relationship Betw

mmendation letter to FAA Administrator J. Randolph Babbitt, dated September 24, 2009 <http://www.ntsb.gov/Recs/letters/2009/A09_87_96.pdf>.

92 See (a) M.J. Smith and others, “Characteristics , no. 1 (1978), pp. 5–15 and (b) H.S. Shanno 10

een Organizational and Workplace Factors and Injury Rates,” Safety Science, vol. 26, no. 3 (1997), pp. 201-217.

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1.18.5

rt of runway 36 at Kirksville Regional Airport, Kirksville, Missouri.93 Safety Recommendation A-06-10, which

ortation Safety Improvements since 2006, asked the FAA to do the following:

n a December 29, 2009, letter, the NTSB retained the classification “Open—Unacceptable Response” pending publication of the NPRM.

,” that proposed to amend Part 121 and establish Part 117 to create a single set of flight time limitations, duty period limits, and rest requirements for pilots in Part 121 operations. The NTSB’s November 15, 2010, response to the NPRM noted that the proposed rule takes into consideration length of duty day, starting time, workload, and time-zone changes and, if adopted, would likely meet the intent of Safety Recommendation A-06-10.

airport because both the captain and first officer fell asleep during the flight, the

Previously Issued Safety Recommendations

1.18.5.1 Pilot Flight and Duty Time and Rest Period Limitations

On February 7, 2006, the NTSB issued Safety Recommendation A-06-10 following its investigation of an October 19, 2004, accident in which Corporate Airlines (doing business as American Connection) flight 5966 struck trees on final approach and crashed sho

has been on the NTSB’s Most Wanted List of Transp

Modify and simplify the flight crew hours-of-service regulations to take into consideration factors such as length of duty day, starting time, workload, and other factors shown by recent research, scientific evidence, and current industry experience to affect crew alertness.

In a September 9, 2009, response, the FAA reported that it held a 3-day fatigue symposium that presented the most current scientific knowledge of fatigue in aviation. The FAA also reported that it had developed a plan that included developing a notice of proposed rulemaking (NPRM) on flight time limitations, duty period limits, and rest requirements for pilots in operations under Part 121 and 135. I

On September 14, 2010, the FAA published an NPRM, “14 CFR Parts 117 and 121: Flightcrew Member Duty and Rest Requirements

As a result of its investigation of a February 13, 2008, incident in which the flight crew of a Bombardier CL-600-2B19, operated by Mesa Airlines as go! flight 1002, flew past the destination NTSB issued Safety Recommendation A-09-64, which asked the FAA to do the following:.

Conduct research examining how pilot fatigue is affected by the unique characteristics of short-haul operations and identify methods for reducing those effects; include research into the interactive effects of shift timing, consecutive days of work, number of legs flown, and the availability of rest breaks.

The FAA’s October 23, 2009, response indicated that the aviation rulemaking committee that was established to assist in developing the flight crew duty and rest requirements NPRM

93 For more information, see Collision with Trees and Crash Short of Runway, Corporate Airlines Flight 5966, BAE Systems BAE-J3201, N875JX, Kirksville, Missouri, October 19, 2004, Aircraft Accident Report NTSB/AAR-06/01 (Washington, DC: National Transportation Safety Board, 2006) at <http://www.ntsb.gov/Publictn/A_Acc1.htm>.

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was also tasked with developing a single approach for addressing fatigue in all Part 121 and 135 operations, including short-haul operations. Therefore, the FAA did not believe that additional

d in its June 8, 2010,

address

basis for its recommendations on this issue. Accordingly, Safety Recommendation A-09-64 was classified “Open—Acceptable Response,” pending the FAA’s .

2010 NPRM that, although the proposed rule did shorten flight duty periods and maximum flight time based on the number of flight segments that exceed four in 1 day (which should help to mitigate fatigue

1.18.5

ndation A-09-89 asked the FAA to do the following:

s for HEMS operations in its Part 135 SMS rulemaking project. Pending the NTSB’s review of the propose nse” on Octo

research into short-haul operations was merited at that time. The NTSB state response that it looked forward to reviewing the proposed revisions, including those that will

the unique aspects of short-haul operations, but noted once again that there is little or no scientific research describing the interaction of the unique characteristics of short-haul operations (such as the interaction of time of day, cumulative time on duty, and number of legs flown) on flight crew fatigue. The NTSB asked the FAA to provide a list of the scientific literature on the unique characteristics of short-haul operations and flight crew fatigue that the aviation rulemaking committee used as the

performance of the recommended action or provision of the requested list of research

The NTSB observed in its November 15, 2010, response to the September 14,

in short-haul operations), it did not specifically address Safety Recommendation A-09- 64. The NTSB response stated that, as acknowledged in the NPRM, there is little data directly addressing short-haul operations, and, as recommended in Safety Recommendation A-09-64, research into factors affecting the development of fatigue in these operations (especially in the context of the proposed rule) would be beneficial.

.2 Safety Management Systems

On September 24, 2009, as a result of testimony given at the NTSB’s February 2009 public hearing on HEMS safety and the investigative findings of several 2008 HEMS accidents,94 the NTSB issued several safety recommendations to the FAA, public HEMS operators, and other federal agencies.95 Safety Recommendations A-09-89 (to the FAA) and A-09-98 (to 40 public HEMS operators) address the implementation of SMS for these operations. Safety Recomme

Require helicopter emergency medical services operators to implement a safety management system program that includes sound risk management practices.

In a December 23, 2009, response, the FAA stated that it is considering requirement

d rule, Safety Recommendation A-09-89 was classified “Open—Acceptable Respo ber 7, 2010.

94 The associated safety recommendation letter cited the following accidents: NTSB case numbers

DFW08FA062, CHI08FA128, DEN08FA101, DEN08MA116A and DEN08MA116B, MIA08MA203, and CEN09MA019. The briefs for these accidents can be accessed online at <http://www.ntsb.gov/ntsb/aviationquery/index.aspx>.

95 Because the NMSP aviation section does not perform HEMS operations, the section did not receive these safety recommendations.

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Safety Recommendation A-09-98 asked 40 public HEMS operators to do the following:

Implement a safety management system program that includes sound risk management practices.

To date, 2 of the 40 public HEMS recipients have replied, and the recommendation has an overall status of “Open—Acceptable Response.” Of particular note is the October 22, 2009, response from EMS STAR Flight in Austin-Travis County, Austin, Texas, which indicated that, in 2008, the organization implemented an SMS program that includes a risk assessment tool for HEMS operations and, in 2009, the program was revised. The response also stated that STAR Flight was developing a risk assessment tool for its other public use responders (including SAR). Noting that these actions exceeded the intent of the recommendation, the NTSB classified “Closed—Exceeds Recommended Action” for STAR Flight on June 2, 2010.

it

s reiterated in November 2009 following the NTSB’s investigation of the accident involving an Aerospatiale (Eurocopter) SA365N1 that was

tate Police (MSP) as a public medical evacuation ent landing system approach.97 Safety

Recom

s if the

ained classified “Open—Unacceptab rulema

M and to enact the final rule. The NTSB also noted that such a requirement should have minimal implementation costs and, given the 94 percent voluntary compliance the FAA reported in its August 17, 2009, response, should encounter little opposition. On October 12, 2010, the FAA published an NPRM titled “14 CFR Parts 1, 91, 120, and 135 Air

1.18.5.3 Risk Management and Assessment

On February 7, 2006, the NTSB issued Safety Recommendation A-06-13 (which was added to the NTSB’s Most Wanted List of Transportation Safety Improvements in October 2008) as a result of its special investigation of a number of accidents between January 2002 and January 2005 involving aircraft performing emergency medical services (EMS) operations.96 Safety Recommendation A-06-13 wa

registered to and operated by the Maryland S flight and impacted terrain during an instrum

mendation A-06-13 asked the FAA to do the following:

Require all emergency medical services (EMS) operators to develop and implement flight risk evaluation programs that include training all employees involved in the operation, procedures that support the systematic evaluation of flight risks, and consultation with others trained in EMS flight operation risks reach a predefined level.

In a March 12, 2010, letter, the NTSB noted that this recommendation rem le Response,” based on the FAA’s stated intent to pursue

king—rather than revise the operations specifications covering HEMS operators, as previously reported—to ensure all operators develop and implement flight risk evaluation programs. The NTSB stated its concern that often FAA regulatory projects require considerable time to issue the NPR

roach to Landing of Maryland State Police Aerospatiale SA3

rtation Safety Board, 2009) at <http://www.ntsb.gov/Publictn/A_Acc1.htm>.

96 For more information, see Special Investigation Report on Emergency Medical Services Operations, Special Investigation Report NTSB/SIR-06-01 (Washington, DC: National Transportation Safety Board, 2006) at <http://www.ntsb.gov/Publictn/A_Stu.htm>.

97 For more information, see Crash During App 65N1, N92MD, District Heights, Maryland, September 27, 2008, Aircraft Accident Report NTSB/AAR-09/07

(Washington, DC: National Transpo

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Ambul Aircraft Operations; Safety Initiatives and Miscellaneous Amendments; Proposed Rule.” The NPRM rams to inclu al risk assessments before each mission and consideration of the risks associated with each leg of a mission. Th the NP

ply even if flight risk evaluation programs were required for HEMS operators. Safety Recommendation A-09-131

As a result of the 2006 special investigation of EMS operations, the NTSB also issued Safety

ent decisions.

operations. Pending that action, Safety Recommendation A-06-14 was classified “Op

, NPRM contained proposed requirements to address this

ance and Commercial Helicopter Operations, Part 91 Helicopter Operations, and Part 135

proposed to require all HEMS operators to implement preflight risk assessment prog de the conduct of form

e NTSB noted in its January 10, 2011, response to RM that, if adopted, the proposed change would be responsive to Safety Recommendation

A-06-13.

Following its investigation of the September 27, 2008, MSP accident, the NTSB issued several recommendations to 40 public HEMS operators on November 13, 2009. The final report noted that the accident demonstrated the need for all EMS operators—both public and civil—to develop and implement flight risk evaluation programs and that, because the FAA does not have the authority to regulate public operators, they would not be required to com

asked 40 public HEMS operators to do the following:

Develop and implement flight risk evaluation programs that include training for all employees involved in the operation, procedures that support the systematic evaluation of flight risks, and consultation with others trained in helicopter emergency medical services flight operations if the risks reach a predefined level.

This recommendation is currently classified “Open—Await Response.”

1.18.5.4 Flight Following and Dispatch Procedures

Recommendation A-06-14, which asked the FAA to do the following:

Require emergency medical services operators to use formalized dispatch and flight-following procedures that include up-to-date weather information and assistance in flight risk assessm

In May 2008, the FAA published AC 120-96, “Integration of Operations Control Centers into Helicopter Emergency Medical Services Operations,” which provides detailed guidance about the creation and operation of operations control centers (OCC) for HEMS operations, as well as guidance for establishing the recommended formalized dispatch and flight-following procedures. The FAA also conducted a survey in January 2009 to determine how many operators had voluntarily adopted these recommended best practices and found that 89 percent had integrated an OCC into their operations. On January 23, 2009, the NTSB indicated that, although the AC was responsive to the recommendation, it was only guidance and that the FAA needed to require that all EMS operators incorporate the guidance contained in the AC into their

en—Acceptable Response.”

The FAA’s October 12, 2010 recommendation, proposing that commercial HEMS operators with 10 or more helicopters that are engaged in HEMS activities establish OCCs. In its January 10, 2011, response to the NPRM,

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the NTSB stated that it did not agree with this limitation and that the requirement for an OCC should be applied to all HEMS operators. The NTSB noted that AC 120-96 provides guidance on how to scale an OCC to fit the size of an organization. The NTSB also disagreed with the FAA’s contention that preflight risk assessments may suffice for smaller operators in lieu of an OCC, stating that preflight risk assessments cannot substitute for the services and support provided by an OCC. The NTSB stated that the proposed requirement was only partially responsive to Safety Recommendation A-06-14.

A-09-132 asked 40 public use HEMS operators to “Use formalized dispatch and flight-following procedures that include up-to-date weathe ion is current

1.18.5

the investigative findings of several 2008 HEMS accidents, the NTSB also issued Safety

ing them to do the following:

) pilots, to

they would never perform in a helicopter except in an emergency. The NTSB asked to be advised of whic

Safety Recommendation A-09-132 also resulted from the NTSB’s investigation of the September 27, 2008, fatal accident involving an Aerospatiale (Eurocopter) SA365N1, registered to and operated by MSP as a public medical evacuation flight. Although MSP does have formalized dispatch and flight-following procedures and access to up-to-date weather information, the final report expressed concern that other public HEMS operators may not have dispatch and flight-following procedures or include weather information and assistance in flight risk assessment decisions. Safety Recommendation

r information and assistance in flight risk assessment decisions.” This recommendat ly classified “Open—Await Response.”

.5 Helicopter Pilot Training for Inadvertent Encounters with IMC

As a result of its February 2009 public hearing on HEMS safety and

Recommendation A-09-97 to 40 public HEMS operators, ask

Conduct scenario-based training, including the use of simulators and flight training devices, for helicopter emergency medical services (HEMS include inadvertent flight into instrument meteorological conditions and hazards unique to HEMS operations, and conduct this training frequently enough to ensure proficiency.

Safety Recommendation A-09-97 is currently classified “Open—Await Response” for 39 of the 40 recipients. One recipient, EMS STAR Flight of Austin-Travis County, Austin, Texas, reported that its director of aviation and chief pilot conduct quarterly flight training that includes emergency IMC recovery. All crewmembers, flight paramedics, and flight nurses are included in this training and have roles and responsibilities in IMC encounters. The organization also reported that the director of aviation and chief pilot had evaluated a flight simulator at American Eurocopter Corporation for inclusion in advancing their instrument and emergency procedures training and planned to add this training to the annual pilot training program immediately.

In a June 2, 2010, letter, the NTSB commended STAR Flight for incorporating simulator training into its program and noted that the use of simulators permits pilots to practice procedures and maneuvers that

h topics are covered in simulators and flight training devices and which are covered in actual helicopter flight training after the training program has been revised. Safety Recommendation A-09-97 is currently classified “Open—Acceptable Response” for EMS STAR Flight.

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1.18.5.6 FAA Oversight of Public Operations

On December 27, 2010, the NTSB issued Safety Recommendation A-10-150 to the FAA following the investigation of an August 5, 2008, fatal accident in which a Sikorsky S-61N helicopter impacted trees and terrain during the initial climb after takeoff from a helispot in mountainous terrain near Weaverville, California.98 The helicopter was being operated by the U.S. Forest Service (USFS) as a public flight to transport firefighters from one helispot to another. The USFS had contracted with Carson Helicopters, Inc., of Grants Pass, Oregon, for the service

o the NTSB indicated that in partial response to ld a public forum to propose initial policy

to publish a licy changes.

Based o

s of the helicopter, which was registered to Carson Helicopters, Inc., and leased to Carson Helicopter Services, Inc., of Grants Pass. The NTSB determined that the accident occurred, in part, due to insufficient oversight by the USFS and the FAA.99 Safety Recommendation A-10-150 asked the FAA to do the following:

Take appropriate actions to clarify Federal Aviation Administration (FAA) authority over public aircraft, as well as identify and document where such oversight responsibilities reside in the absence of FAA authority.

The FAA’s March 28, 2011, response t this safety recommendation, on January 20, 2011, it he changes related to public aircraft operations. The FAA indicated that it also plans notice in the Federal Register to advise of proposed public aircraft operational po

n the comments received from this notice and the public forum, the FAA will revise policy documents as necessary to clarify FAA authority over public aircraft. While the NTSB is evaluating this response, Safety Recommendation A-10-150 is classified “Open—Initial Response Received.”

98 For more information, see Crash During Takeoff of Carson Helicopters, Inc., Firefighting Helicopter Under

Contract to the U.S. Forest Service, Sikorsky S-61N, N612AZ, Near Weaverville, California, August 5, 2008, Aircraft Accident Report NTSB/AAR-10/06 (Washington, DC: National Transportation Safety Board, 2010) at <http://www.ntsb.gov/Publictn/A_Acc1.htm>.

99 The full probable cause statement for this accident is as follows: “The National Transportation Safety Board determines that the probable causes of this accident were the following actions by Carson Helicopters: 1) the intentional understatement of the helicopter’s empty weight, 2) the alteration of the power available chart to exaggerate the helicopter’s lift capability, and 3) the practice of using unapproved above-minimum specification torque in performance calculations that, collectively, resulted in the pilots relying on performance calculations that significantly overestimated the helicopter’s load-carrying capacity and did not provide an adequate performance margin for a successful takeoff; and insufficient oversight by the USFS and the Federal Aviation Administration (FAA).”

“Contributing to the accident was the failure of the flight crewmembers to address the fact that the helicopter had approached its maximum performance capability on their two prior departures from the accident site because they were accustomed to operating at the limit of the helicopter’s performance. Contributing to the fatalities were the immediate, intense fire that resulted from the spillage of fuel upon impact from the fuel tanks that were not crash resistant, the separation from the floor of the cabin seats that were not crash resistant, and the use of an inappropriate release mechanism on the cabin seat restraints.”

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2. Analysis

dent; howeve verse effect o tients on vari ot had not experienced adverse

The NTSB concludes that postaccident examination of the helicopter’s seats and restraint systems revealed no evidence of preimpact inadequacies. The pilot and the hiker were ejected from the helicopter when their seats and restraint systems were subjected to forces beyond those for which they were certificated during the helicopter’s roll down the steep, rocky mountainside.

According to the spotter’s postaccident statements, the pilot survived the accident and responded to the spotter’s initial calls; however, at some time during the night, the pilot stopped resp

o find the accident site during the night were hampered

SAR response and also hindered the ground SAR teams’ progress; the darkness and the

takeoff, the helicopter reversed direction, climbed, and

2.1 General

The FAA has the authority to oversee the airworthiness of certificated aircraft used in public operations; however, it had not provided airworthiness surveillance for the accident helicopter. The investigation determined that the accident helicopter was properly certificated and maintained in accordance with NMSP policies and the manufacturer’s recommended maintenance program. There was no evidence of any preimpact structural, engine, or system failures.

The pilot had been taking fluoxetine to treat depression for 7 years before the acci r, studies have shown that normal doses of fluoxetine have had minimal or no ad n patient performance and might actually improve the performance of depressed pa ous tasks. The pilot’s personal medical records noted that the pil effects from his use of this medication. Therefore, it is unlikely that the pilot’s use of

fluoxetine to treat depression played any role in this accident. The investigation found no evidence that the pilot had any preexisting medical or toxicological condition that adversely affected his performance during the accident flight. Although the pilot had not reported his use of fluoxetine on his FAA medical certificate applications, the FAA has recently (since April 2010) permitted pilots taking fluoxetine for depression to receive a medical certificate through the agency’s waiver process and has offered amnesty to pilots who had not previously disclosed use of this medication.

onding to the spotter’s calls. Throughout the night, the SAR ground teams were traversing more than 5 miles of rugged terrain in darkness and adverse weather conditions, toward the accident location (based primarily on AFRCC-provided ELT coordinates). New Mexico National Guard helicopters that were launched t and eventually delayed until the next day by the adverse weather conditions. The SAR ground teams reached the general accident area the next morning and found the spotter about 1155; they did not locate the main helicopter wreckage until just before sunset that day. The NTSB concludes that neither the airborne nor ground SAR personnel could have reached the pilot before he died of exposure given the adverse weather conditions, which precluded a prompt airborne rugged terrain in which the ground SAR teams were responding; the distance they had to travel; and the seriousness of the pilot’s injuries.

The radar data indicated that, beginning a little more than 1 minute after the helicopter first appeared on radar after the accident

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flew erratically, crossing site. Dispatch records sh dispatcher and asked if she could hear him

terrain as high as 12,500 feet before descending rapidly near the crash owed that, shortly after the erratic flying began, the pilot radioed the

. After the dispatcher responded in the affirmative, the truck a mountainside.” Postaccident wreckage examination indicated that the ’s tail rotor skid tube was bent upward (toward the tailboom) from its original

position

cause there was no evidence of any preimpact structural, engine, or system failures with th

equire clear identification of the timing and location of the initial collision with te

pilot stated, “…I s accident helicopter

and exhibited scratches and abrasions in all directions. In addition, the outboard 9 to 10 inches of the two tail rotor blades were missing and were not recovered along the main wreckage path, indicating that the helicopter did strike something prior to the identified wreckage field. The pilot continued to key his microphone, and on the dispatch recording he could be heard breathing rapidly for about the next 39 seconds.

Be e helicopter, it is likely that the helicopter’s initial collision with terrain resulted from

either 1) pilot geographic disorientation (lack of awareness of position) and a controlled collision with terrain, because the pilot likely could not see the surrounding terrain in the dark night100 IMC conditions or 2) pilot spatial disorientation and an uncontrolled collision with terrain, because multiple risk factors for spatial disorientation (the pilot’s lack of a helicopter instrument rating and lack of helicopter instrument flying proficiency, maneuvering in dark night conditions, and turbulence) were present during the accident flight.101

The first of these scenarios, geographic disorientation, would likely result in a relatively stable flightpath leading up to the initial collision with terrain followed by an erratic flightpath. Spatial disorientation and loss of control, on the other hand, would likely result in a more erratic flightpath before the initial collision. Using the radar data to distinguish between these two possibilities would r

rrain. While it appears that the pilot reported to the dispatcher that he hit the mountainside shortly after the erratic flying began, without knowing the exact point of impact, it is unclear whether the erratic flying led to the impact or if the erratic flying occurred because of the impact. As a result, it was not possible to evaluate the relative likelihood of these two possible causal explanations.

The remainder of this analysis discusses safety issues related to the following: the pilot’s decision-making, flight and duty times and rest periods, NMSP staffing, SMS programs and risk assessments, communications between the NMSP pilots and volunteer SAR organization personnel, instrument flying, and flight-following equipment.

2.2 Pilot Decision-Making

2.2.1 Decision to Launch on the Mission

An NMSP dispatcher contacted the accident pilot about 1756 (almost 3 hours after he had completed his normal 8-hour work shift) regarding use of the NMSP helicopter to aid in SAR efforts to find a lost hiker in the mountains northeast of Santa Fe. According to NMSP dispatch

100 As previously noted, there was no moonlight at the time of the accident. 101 Spatial disorientation is the mistaken perception of an aircraft’s attitude relative to the earth.

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recordings, the pilot was initially reluctant to launch on the accident mission because he believed it was too windy; the pilot stated that he would prefer to go up to look for the hiker in the morning. The pilot’s concern about the windy conditions likely stemmed from a flight he operated with the full-time helicopter pilot a few hours earlier when the two pilots encountered winds gusting to near 40 knots on the ground in Las Vegas, New Mexico,102 and adjusted their return flight to SAF. However, minutes after the request to fly the accident mission, the pilot called the dispatcher back and told her that he had “checked the wind”103 and could “probably go up and take a look” for the missing hiker.

The full-time helicopter pilot said that the aviation section pilots normally obtained the TAF and METARs for SAF using the NOAA Aviation Weather Center website rather than checkin

er elevations in which the SAR efforts took place predicted broken clouds at 14,000 feet, layered clouds to 22,000 feet, with widely scattere

he pilot likely believed that he could fly to the search area (which was only 20 nm from SAF) and return to SAF quickly and safely before dark. (Several preflight comments indicate

ith the English language and the remote, wooded, and unfamiliar area in which she was lost. The SAR mission extended into

inet secretary, when he was a pilot in the NMSP aviation r was carried on board, and he routinely carried a survival

g the area forecast for a local flight. TAFs and METARs are only valid within a 5-mile radius of the airport, but they provide detailed local weather information. It is possible, therefore, that the accident pilot reviewed the TAF and/or METAR for SAF before the accident mission. The TAF in effect for SAF at that time indicated that, between 1800 and 2200, temporary conditions would exist for the next 4 hours that included a cumulonimbus cloud ceiling at 6,000 feet agl (about 12,000 feet msl). (If such conditions extended an additional 15 miles to the northeast, there was a potential for thunderstorms and mountain obscuration in the search area during the mission.) The area forecast in effect for the high

d light rain showers and isolated thunderstorms and gusting wind until 2100.

A little more than 2 hours of daylight remained when the accident pilot was notified about the mission, and he might have thought it would be a short mission. The pilot knew that the hiker was in communication with the NMSP dispatcher via cellular telephone, and he might have believed that the hiker could quickly guide him to her location. This belief and the fact that the weather at SAF was warm and clear and the wind was calmer than earlier in the day likely contributed to the pilot’s decision to accept the flight. Further, the mountains in the search area were visible from SAF, and the pilot would have seen that they were clear of clouds at the time of departure. T

d that the pilot predicted that the mission would be a quick “in and out” flight.) However, the hiker was unable to provide the pilot with much of the useful guidance that lost hikers can typically provide (such as describing her position relative to the sun, nearby landmarks, or terrain features), likely in part because of her limited proficiency w

nighttime. According to the DPS cab section, a supply of cold-weather gea kit and extra blankets on such missions.

Additionally, based on the elevation of the targeted search area (estimated to be 11,700 feet), the pilot should have anticipated that the helicopter would be operating near the

102 Las Vegas, New Mexico, is located about 40 miles east of SAF and 34 miles southeast of the accident

loca . viewed before accepting the

acci

tion 103 The NTSB was unable to determine which specific weather reports the pilot re dent mission.

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upper limit of its hovering and/or landing performance capabilities. (The helicopter’s dual-engine hover ceiling was 11,800 feet.)104

The NTSB concludes that, when the pilot made the decision to launch, the weather and lighting conditions, even at higher elevations, did not preclude the mission; however, after accepting a SAR mission involving flight at high altitudes over mountainous terrain, with darkness approaching and with a deteriorating weather forecast, the pilot should have taken steps to mitigate the potential risks involved, for example, by bringing cold-weather survival gear and ensuring that night vision goggles were on board and readily available for the mission.

the landing site. It is possible that the pilot initially expected the hiker to walk up to the helicopter landing site, an

ey arrived at the landing site and that, when they exited the helicopter after landing to pick up the hiker, they encountered strong wind and sleet.

landed, the dispatcher again reported that the hiker “did not want to move.” The pilot sub

Although the pilot may have considered some personal restrictions regarding maximum altitudes, terrain characteristics, and winds that would permit a safe landing in the search area, no official NMSP risk assessment policy existed and, therefore, there was no evidence that the pilot considered such restrictions. For additional information regarding risk assessments, see section 2.4.1.

2.2.2 Decision-Making During the Mission

About 2010, when the pilot finally located the lost hiker, she was in a small clearing in a wooded area, with no suitable landing site nearby. The pilot maneuvered above the hiker and told the dispatcher to instruct the hiker to walk in the direction he was flying to reach

d, as a result, the pilot likely believed that they would be able to depart the remote landing site relatively quickly after landing. However, although the hiker was ambulatory, she indicated to the dispatcher that she was cold and could not see well enough to move toward the helicopter’s landing site. NMSP dispatch records show that, about 2015 (about 4 minutes before sunset), the dispatcher asked if the pilot could land on top of the hill and send the spotter down to retrieve the hiker. The pilot, sounding exasperated, said, “That’s about the only thing we’re going to be able to do.”

According to the spotter, during the pilot’s efforts to evaluate the nearest suitable landing site, the helicopter encountered strong winds and turbulence below 200 feet agl, it was getting dark, and low clouds were approaching from the west, all of which would have made the landing more hazardous. Although the incoming weather and the increasing darkness meant that the operation was growing increasingly risky, the pilot made several passes over the landing site and, after determining that a safe landing could be accomplished, proceeded with the landing. About 2030 (11 minutes after sunset), the pilot landed the helicopter on a ridge about 0.5 mile uphill from the hiker and at an elevation of about 11,600 feet. The spotter reported that they encountered moderate turbulence when th

When the spotter contacted the dispatcher by cellular telephone after the helicopter had

sequently called the dispatcher to clarify the hiker’s intentions, and the dispatcher told him that she believed that the hiker expected them to help her to the helicopter. As a result, about

104 The accident helicopter’s dual- and single-engine service ceilings were 19,600 and 13,100 feet, respectively.

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2033, the pilot (who was wearing an unlined summer-weight flight suit) told the dispatcher he was going to “walk down the hil 105l a little bit.” He indicated that he expected the weather conditions to deteriorate and stated, “…if it does that, I’ve got to get the [expletive] out of here.” The pil

.

y reported “a heavy overcast” with heavy rain within 30 minutes of the accident. These conditions indicated a strong likelihood of reduced visibility and the potential for

was surrounded by high, rugged terrain that or departure and, about

9 minu

d shelter, and the pilot could have periodically used its engines to generate heat as needed throughout the night. However, because the remote landing site was less than 15

ot added, “I’m not going to spend a lot of time or we’re going to have two search and rescues.” There is no evidence that the pilot took the time to consider his options; rather, he promptly left the helicopter and walked down the heavily forested slope to find the hiker without stopping to get his flashlight out of his flight bag. These communications and actions suggest that the pilot was feeling increasing stress as a result of the deteriorating conditions and that he was fixated on the goal of retrieving the hiker and taking off again as quickly as possible

The spotter stated that the strong wind continued to blow while the pilot was recovering the hiker. By the time the pilot and hiker returned to the helicopter (about 50 minutes after the pilot left the helicopter to retrieve the hiker and more than 1 hour after sunset), the sleet had turned to snow, and the clouds had lowered. Other witnesses who were camping at a lower elevation nearb

structural icing. In addition, the remote landing site was no longer visible. Yet the pilot quickly prepared the helicopter f

tes after the pilot returned to the helicopter with the hiker, the helicopter was airborne again. According to the spotter, the pilot seemed to indicate that he intended to depart through a narrow path, a “tunnel in the clouds.”

An interim risk assessment performed at this point may have indicated to the pilot that a different course of action would be more prudent. Even rudimentary consideration of the adverse weather conditions should have indicated to the pilot that it was no longer safe to take off and attempt to return to SAF at that time. At that point, the only safe option was to wait inside the helicopter at the remote landing site, contact SAR personnel for information and assistance, and wait for the weather conditions to improve. Although the temperature was near freezing, the helicopter provided goo

minutes flying time from SAF, the pilot was likely very tempted to attempt to fly back to SAF rather than wait inside the helicopter for an indefinite period of time. The fact that the helicopter was airborne within about 9 minutes of the pilot’s return indicates that the pilot was still fixated on departing as soon as possible, and he did not spend much time considering alternative courses of action.106

Taking off in a helicopter in dark (moonless) lighting conditions, with marginal visibility, strong wind, turbulence, low clouds, the potential for structural and/or engine icing conditions, and surrounded by high terrain poses an unacceptably high risk of spatial and/or geographic

105

appropri

G.A. Klein, eds., Linking Expertise and Naturalistic Decision Making (Mahwah, New Jersey: Lawrence Erlbaum Asso

Although the dispatcher suggested that the spotter retrieve the lost hiker, the pilot, who was slightly more ately clothed for the conditions, hiked to retrieve her.

106 In this regard, the pilot’s decision-making performance during the accident mission is reminiscent of a category of decision-making error that researchers have labeled “plan continuation error.” Plan continuation error has been defined as “failure to revise a flight plan despite emerging evidence that suggests it is no longer safe.” [J. Orasanu, L. Martin, and J. Davison, “Cognitive and Contextual Factors in Aviation Accidents,” in E. Salas and

ciates, 2001), pp. 209-225.]

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disorientation, which could lead to loss of control and/or a controlled flight into terrain accident. Had the pilot performed an interim risk assessment and considered the external circumstances or discussed them with the spotter,107 the NMSP dispatcher, or SAR ground personnel, he would have been more likely to recognize the potential hazards associated with an immediate takeoff and might have delayed his departure from the remote landing site until more favorable conditions prevailed. The NTSB concludes that the pilot exhibited poor decision-making when he chose to take off from a relatively secure landing site at night and attempt VFR flight in adverse weather conditions.

2.3 F

re complex or perceptually demanding,108 experts on cold exposu

actors Affecting the Pilot’s Decision-Making

This section addresses factors that could have influenced the pilot’s decision-making both before accepting the mission and when he took off from the mountain to return to SAF, including fatigue, self-induced pressure, and situational stress.

The NTSB considered whether environmental and/or physiological factors related to the cold temperature or the high altitude might have degraded the pilot’s decision-making in this case. The pilot spent about 50 minutes searching for the hiker and carrying her up a steep slope in very cold, windy conditions, in freezing precipitation, while dressed only in an unlined summer-weight flight suit and undergarments. Although cold stress can degrade cognitive performance, especially for tasks that a

re at the U.S. Army Research Institute for Environmental Medicine indicated that, based on the pilot’s level of exertion and the terrain, the pilot’s metabolic rate would likely have been fairly high, offsetting the cold weather’s effects and minimizing the risk of hypothermia. After reviewing the circumstances of this accident for evidence of any physiological effects from the high altitude (the pilot was operating in the unpressurized helicopter for more than 2 hours before the accident), U.S. Army Research Institute for Environmental Medicine personnel indicated that the altitude would have affected the pilot very little as well. Because the pilot lived at an altitude of about 6,000 feet, he would likely have been sufficiently acclimatized to operate at higher altitudes.109 Since the time at altitude was relatively short (about 3 hours), there was likely little hypoxic effect on the pilot’s cognitive function.

107 The SAR commander spoke with the spotter while the pilot was retrieving the hiker and urged the spotter to

remain in place and wait for ground teams to arrive if it was not safe to take off. However, it is not clear that the spotter shared this information with the pilot when he returned to the helicopter; the spotter did not recall the pilot raisi

formance in Cold Environments,” in D.E. Lounsbury, R.F.

ng the possibility of remaining on the mountain overnight. 108 R.G. Hoffman, “Chapter 12: Human Psychological Per Bellamy, and R. Zajtchuck, eds., Medical Aspects of Harsh Environments, Volume 1 (Fort Detrick, Maryland:

Department of the U.S. Army, Office of The Surgeon General, Walter Reed Army Medical Center Borden Institute, 2002), pp. 399–400.

109 For additional information, see S.R. Muza and others, “Residence at Moderate Altitude Improves Ventilator Response to High Altitude,” Aviation, Space, and Environmental Medicine, vol. 75, no. 10 (2004), pp. 1042–1048.

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2.3.1 Fatigue

Scientific research and accident investigations have demonstrated the negative effects of fatigue on human performance,110 including a breakdown in vigilance, degraded response times, and poor decision-making and risk assessment. As discussed in the NTSB’s report on a 1993 accident involving American International Airways flight 808 at Guantanamo Bay, Cuba, fixation on a course of action (for example, the NMSP accident pilot’s decision to take off again and fly to SAF) while disregarding critical evidence that the course of action is no longer safe is also consistent with the effects of fatigue.111 Thus, the pilot’s most critical decision during the

ions rather than wait on the fatigue.

led 4 hours 6 minutes112 and was split into two sep

e day of the accident), the pilot was in bed for 8 to 8.5 hours. Additionally, according to his wife, the pilot likely took a 30-minute

accident mission—his decision to take off in adverse weather condit ground for conditions to improve—was consistent with the effects of

Cellular telephone records, notes in the accident pilot’s planner, and information provided by the pilot’s wife indicate that the pilot’s available sleep time between Sunday evening, June 7, and Monday morning, June 8, tota

arate possible sleep periods (2200 to 2326 on June 7 and 0003 to 0243 on June 8) due to work-related phone calls that occurred between 2326 Sunday night and 0003 Monday morning and between 0243 and 0256 Monday morning. Further, the pilot had to get up earlier than usual because of two missions that he flew between 0300 and 1100 Monday morning.

According to the pilot’s wife, her husband normally slept about 8 hours (beginning between 2130 and 2200) in a single consolidated sleep period on a night before a work day. However, the pilot’s wife said that he frequently watched television later than usual on Sunday nights; although she did not specifically recall her husband’s actions on the Sunday before the accident, he might have still been awake when he began to receive work-related telephone calls about 2326 Sunday night.113 If the pilot watched television rather than slept during this earlier available sleep period, his maximum available sleep time would have been only 2 hours 35 minutes (again, assuming he used every minute of available sleep). Because of his work-related sleep disruptions and the fragmented nature of the pilot’s sleep during the preceding 24 hours, it is highly likely the pilot experienced acute fatigue on Monday, June 8.

Between Monday evening and Tuesday morning (th

110 For the scientific research, see (a) J.A. Caldwell, “Fatigue in the Aviation Environment: An Overview of the

Causes and Effects as Well as Recommended Countermeasures,” Aviation, Space, and Environmental Medicine, vol. 68, no. 10 (1997), pp. 932–938; (b) D.R. Haslam, “The Military Performance of Soldiers in Sustained Operations,” Aviation, Space, and Environmental Medicine, vol. 55, no. 2 (1984), pp. 216–221; and (c) G.P. Kruger, “Su

t’s wife was working at the time, so she could not be certain about the pilot’s actions at home.

stained Work, Fatigue, Sleep Loss, and Performance: A Review of the Issues,” Work and Stress, vol. 3, no. 1 (1989), pp. 129–141. For accident investigation research, see A Review of Flightcrew-Involved, Major Accidents of U.S. Air Carriers, 1978 through 1990, Safety Study NTSB/SS-94/01 (Washington, DC: National Transportation Safety Board, 1994) at <http://www.ntsb.gov/Publictn/A_Stu.htm>.

111 See Uncontrolled Collision with Terrain, American International Airways Flight 808, Douglas DC-8-61, N814CK, U.S. Naval Air Station, Guantanamo Bay, Cuba, August 18, 1993, Aircraft Accident Report NTSB/AAR-94/04 (Washington, DC: National Transportation Safety Board, 1994) at <http://www.ntsb.gov/Publictn/A_Acc2.htm>.

112 Because people do not normally fall asleep instantaneously, it is likely that the pilot actually slept less than the 4 hours 6 minutes of available sleep time.

113 The pilo

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nap on Tuesday afternoon. Therefore, the pilot could have received as much as 8.5 to 9 hours of sleep in the 24 hours before the accident. Research shows that fatigue-related effects linger after one nig

ormal 8-hour work day (from 0700 to 1500), he spent 2.8 hours flying in the helicopter. Three hours after his normal work d

2 hours of time since waking.115

ht of near-normal recovery sleep (8 hours) that is preceded by a night of acute sleep restriction.114 Therefore, the sleep the pilot got Monday night and Tuesday morning probably alleviated some, but not all, of the fatigue resulting from his sleep restriction the day before. It is likely, therefore, that the pilot was still experiencing some residual fatigue on the day of the accident as a result of work-related activities, both PIO duty and flying, that he performed on the preceding day.

At the time of the accident, the pilot had accumulated 11 hours 41 minutes of duty time and 4 hours 30 minutes of flight time in the previous 24 hours. During his n

ay ended, the pilot went back on duty for the accident mission, during which he accumulated an additional 3 hours 41 minutes of duty time and 1 hour 41 minutes of flight time. The accident mission, in addition to the pilot’s normal work day, resulted in a long day that approached (and may have eventually exceeded) the aviation section’s 12-hour duty time limits. An NTSB study of flight crew-involved major accidents found that pilots with more than 12 hours (averaging 13.8 hours) of time since waking made significantly more procedural and tactical decision errors (mostly errors of omission) than pilots with less than 1

A 2000 FAA-sponsored study found accidents to be more prevalent among pilots who had been on duty for more than 10 hours.116 Additionally, a study performed by the U.S. Naval Safety Center found that helicopter pilots who were on duty for more than 10 of the last 24 hours were more likely to be involved in pilot-at-fault accidents than pilots who had not accumulated as much duty time.117 The U.S. Naval Safety Center study also found that helicopter flights that began between 2100 and 2400 (as the accident flight did) experienced a higher rate of pilot-at-fault accidents than flights originating at other times of day. Therefore, the pilot’s time since waking and his substantial cumulative duty time on the day of the accident also increased the likelihood that he was experiencing some fatigue. NMSP flight and duty time policies will be discussed in section 2.4.2.

114 r more information, see (a) M. Sallinen and others, “Recovery of Cognitive Performance From Sleep

Debt

, pp. 535–538; (b) M.S. Borowsky and R. Wall, “Flight Experience and

Flight Experience and Likelihood of U.S. Navy Aircraft Mishaps,” Avia

Fo : Do a Short Rest Pause and a Single Recovery Night Help?”, Chronobiology International, vol. 25, nos. 2 and

3 (2008), pp. 279–296; (b) G. Belenky and others, “Patterns of Performance Degradation and Restoration During Sleep Restriction and Subsequent Recovery: A Sleep Dose-Response Study,” Journal of Sleep Research, vol. 12, no. 1 (2003), pp. 1–12; and (c) H.P.A. Van Dongen and others, “The Cumulative Cost of Additional Wakefulness: Dose-Response Effects on Neurobehavioral Functions and Sleep Physiology from Chronic Sleep Restriction and Total Sleep Deprivation,” Sleep, vol. 26, no. 2 (2003), pp. 117–126.

115 See NTSB/SS-94/01. 116 See GRA, Inc., Flight and Rest Time Safety and Cost Analysis, Report prepared for FAA Office of Aviation

Policy and Plans under Contract No. DTFA01-98-C-00096 (Washington, DC: GRA, Inc. 2000). 117 See (a) M.S. Borowsky and R. Wall, “Naval Aviation Mishaps and Fatigue,” Aviation, Space, and

Environmental Medicine, vol. 54, no. 6 (1983) Naval Aircraft Mishaps,” Aviation, Space, and Environmental Medicine, vol. 54, no. 5 (1983), pp. 440–446;

(c) M.S. Borowsky, Pilot Flight Experience and Aircraft Mishaps (Norfolk, Virginia: U.S. Naval Safety Center, 1986 and (d) D.W. Yacavone and others, “);

tion, Space, and Environmental Medicine, vol. 63, no. 1 (1992), pp. 72–74.

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2.3.2 Self-Induced Pressure

Self-induced pressure might also have contributed to the pilot’s decision to accept the mission and then take off from the remote landing site. The pilot was described by his colleagues as having an exceptionally high degree of motivation for work-related tasks. According to some statements, the pilot may also have had a tendency to act before thinking things through. Specifically, the NMSP fixed-wing pilot told investigators that the accident pilot tended to “act right away before thinking things out.” Further, the part-time helicopter pilot told NTSB investigators that he thought the accident pilot lacked “temperance.”

Further, the accident pilot was likely aware that the former chief pilot was relieved of his chief pilot duties by the DPS cabinet secretary after he decided not to accept a high-risk mission that would have involved less experienced pilots. The pilot’s decision to accept the accident mission, while not inappropriate, was consistent with his understanding of NMSP management’s priorities. (Management

ave also played a role in the pilot’s dete from the mountain. The pilot’s communications with the dispatcher ind

not

The pilot’s wife and other aviation section pilots described the accident pilot as being “heroic” and indicated that it was in his nature to take personal risks to try to save others. Although the pilot did not know that the hiker lacked warm clothing and other survival equipment when he accepted the mission,118 he likely recognized that it would take ground SAR teams a long time to reach her remote location. Because of this concern and his awareness of the cold nighttime conditions on the mountain, the accident pilot was likely concerned that if he did not accept the mission, the hiker would not survive on the mountain overnight. Furthermore, successful past rescue outcomes for the pilot (for example, his recent commendations for the successful rescue of a man trapped in a flooded arroyo) may have reinforced his tendency toward risk-taking in the line of duty. It is likely that the pilot’s nature in this regard, combined with his concern for the well-being of the hiker, created significant self-induced pressure for him to ensure that the mission was successfully completed, despite increasingly difficult conditions.

In addition, the accident pilot’s relatively brief tenure (about 6 months) in the chief pilot position may have left him vulnerable to management pressure to accept missions. Postaccident interviews with NMSP aviation section pilots and management personnel indicated that the DPS cabinet secretary’s questioning of pilots regarding launch decisions and his evident displeasure when the NMSP pilots did not accept a mission when others did (such as the New Mexico National Guard) sent the message that he wanted NMSP aviation section pilots to accept SAR missions, without adequate regard for the potential risks involved.

priorities and influence are further discussed in section 2.4.1.)

2.3.3 Situational Stress

The stress associated with the mission may h rmination to depart

icated elevated concern after landing on the mountain, as evidenced by his statements, “It’s gonna start snowing up here and if it does that I’ve gotta get the [expletive] out of here,” “I’m

gonna spend a lot of time or we’re going to have two search and rescues,” and, “Just tell her to start blowing her [expletive] whistle and I’ll try to find her, okay?” These statements and the pilot’s use of profanity (which was absent during earlier communications with the dispatcher)

118 The pilot became aware of the hiker’s situation during the mission.

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suggest that the pilot was experiencing increased situational stress as a result of the perceived challenge posed by the deteriorating conditions. Cognitive effects of stress can include narrow

king

pressures that contributed to a reduction in the safety of flight operations conducted by the NMSP

ating the weather conditions, the approaching darkness, and the potential for pilot fatigue, he may have elected to bring a second

ait until morning to search for the hiker. At the very least, a ent process would likely have prompted the pilot to mitigate

potenti

ing of attention, response rigidity, longer reaction time to peripheral stimuli, and increased errors.119 It is possible, therefore, that the “tunnel vision” created by acute situational stress caused the pilot to fixate on the goal of taking off from the remote landing site as soon as possible and to disregard mounting evidence that it was not safe to take off after he returned with the hiker.

2.3.4 Summary of Factors Affecting the Pilot’s Decision-Ma

The NTSB concludes that the pilot decided to take off from the remote landing site, despite mounting evidence indicating that the deteriorating weather made an immediate return to SAF inadvisable, because his fatigue, self-induced pressure to complete the mission, and situational stress distracted him from identifying and evaluating alternative courses of action.

2.4 Organizational Issues

A number of organizational and management issues, including NMSP aviation section staffing, pilot flight and duty time and rest period limitations, and SMS programs and policies, were identified in this accident investigation. Although they may not have directly caused the accident, these latent deficiencies represented a culture and foundation of organizational

on a daily basis.

2.4.1 Risk Assessments and Safety Management Systems

Investigators noted that, at the time of the accident, the NMSP aviation section did not have an SMS program. Additionally, the aviation section did not require its pilots to perform a structured, systemic risk assessment before accepting a mission or to reassess risks during a mission. Such risk assessments would have helped the pilot identify and mitigate some of the factors that affected his decision-making. For example, although it was warm and sunny when the pilot left SAF, the forecast for the accident flight included strong wind conditions, lowered ceilings, and precipitation (freezing at higher elevations). If the pilot had completed a structured risk assessment checklist that included obtaining and evalu

pilot along on the flight or w structured preflight risk assessm

al risks by bringing night vision goggles120 and cold-weather survival gear on the accident

119 E. Salas, J.E. Driskell, and S. Hughes, “Introduction: The Study of Stress and Human Performance,” in

J.E. Driskell and E. Salas, eds., Stress and Human Performance (Mahwah, New Jersey: Lawrence Erlbaum, 1996), pp. 1–46.

120 Night vision goggles would provide the wearer with visual images with increased levels of illumination in low ambient light conditions (such as moonless nights), which might have allowed the pilot to better maintain outsi visual references during the accident flight. However, the benefits of the night vision goggles would have been

de reduced by the precipitation at the time.

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flight.121 Further, if the NMSP aviation section had implemented a thorough risk assessment program that included interim risk assessments, the accident pilot would have evaluated the associated risks before landing at the remote site and (if he determined that such a landing was prudent) again before departing the remote landing site. The lack of such a risk assessment allowed the decision-making errors that manifested themselves in this accident situation to occur. (Since the accident, the NMSP aviation section has implemented a risk assessment checklist.)

Upper management plays a key role in any safety program because, ultimately, osure to risk. The

o develop a formal safety p

2,

123

The New Mexico DPS policies placed responsibility for safety exclusively on pilots and aviation

ental to safety. As previously noted, in 2006, when the former chief pilot declined to send two inexperienced helicopter pilots on a SAR mission in mountainous

net secretary relieved the former chief pilot of his chief pilot duties (and associated launch decision-making authority). Accord

management has control over the personnel and resources that generate exp safety management approach places a responsibility on senior management t

olicy, establish safety objectives, develop standards of safety performance, and take the lead in fostering an organizational safety culture. It specifies that management should take responsibility for an organization’s safety performance by designating a senior manager as the executive who is accountable for safety performance. Research has shown that this kind of management involvement plays a key role in the success of organizational safety programs.12

maintenance technicians. No organizational policy established a formal management commitment to safety. The DPS cabinet secretary was the senior manager who devoted the most attention to the aviation section and seemed to have the greatest influence over it. He did not, however, take responsibility for the safety performance of the aviation section, nor did he take the initiative to ensure that it had an effective safety program. In fact, he engaged in behaviors that were actually detrim

terrain in poor weather and dark lighting conditions, the DPS cabi

ing to interviews with NMSP aviation section pilots, the DPS cabinet secretary demanded an explanation whenever a pilot declined a SAR mission and complained vigorously when New Mexico National Guard pilots launched on a mission that NMSP pilots had declined. Aviation section pilots stated that the DPS cabinet secretary sometimes asked NMSP pilots to continue checking the weather when they had already decided that the weather was not good enough for an executive transport flight. The NTSB believes that this pattern of behavior sent a message to NMSP pilots that the highest-ranking official in the DPS prioritized mission completion over flight safety and that he was closely monitoring their decisions.

There is no evidence that the DPS cabinet secretary or any NMSP manager advised the pilot to accept the accident mission or that they urged him to take off from the remote landing site. The accident pilot had previously engaged in behaviors that demonstrated a high degree of

cience, vol. 26, no. 3 (1997), pp. 201–217.

121 As previously stated, the DPS cabinet secretary stated that when he was a pilot in the NMSP aviation section, cold-weather gear was carried on board, and he routinely carried a survival kit and extra blankets on missions.

122 M.J. Smith and others, “Characteristics of Successful Safety Programs,” Journal of Safety Research, vol. 10, no. 1 (1978), pp. 5–15.

123 H.S. Shannon, J. Mayr, and T. Haines, “Overview of the Relationship Between Organizational and Workplace Factors and Injury Rates,” Safety S

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risk tolerance, and, as discussed, his judgment was likely degraded by a combination of fatigue, stress, and self-induced pressure. These factors are sufficient to explain his decision-making. The DPS cabinet secretary’s history of inappropriately involving himself in pilot launch decisions, however, encouraged NMSP pilots to accept higher levels of risk without ensuring that appropriate controls were in place to mitigate those risks. NMSP management’s lack of attention to safety management resulted in the absence of an effective safety program. Therefore, the NTSB concludes that, although there was no evidence of any direct NMSP or DPS management pressur

ion, in 2009, as a result of the NTSB’s public hearing on HEMS safety and the investigative findings of several 2008 HEMS accidents,125 the NTSB issued safety recommendations related to the i

mmends that the governor of the state of New Mexico require the New Mexico DPS to bring its aviation section policies and operati

the National Association of State Aviation Officials (NASAO) and the International

e on the pilot during the accident mission, there was evidence of management actions that emphasized accepting all missions, without adequate regard for conditions, which was not consistent with a safety-focused organizational safety culture, as emphasized in current SMS guidance.

The NTSB has previously discussed the benefits of risk assessment and management programs and issued related safety recommendations. For example, in 2006, the NTSB issued related safety recommendations in its special investigation report on EMS operations.124 In addit

ncorporation of SMS programs, including risk assessment and management practices.

Although the NTSB has noted the need for all operators—both public and civil—to develop and implement flight risk assessment and evaluation programs, public operators would not be required to comply with such programs because the FAA does not have the authority to regulate public operators. The NTSB concludes that if operators of public aircraft implemented structured, task-specific risk assessment and management programs, their pilots would be more likely to thoroughly identify, and make efforts to mitigate, the potential risks associated with a mission.

The incorporation of the policies, procedures, and guidelines published by ALEA in its “Standards for Law Enforcement Aviation Units” and related material would provide an organization like the NMSP aviation section with a comprehensive foundation upon which to build a thorough, explicit set of policies and procedures. However, the NTSB’s evaluation of the NMSP aviation section’s policies indicated that they did not conform to ALEA’s standards. The NMSP aviation section’s “Policies and Procedures” document lacked adequate SOPs126 in several areas, including those of risk management and pilot rest periods, thereby reducing the safety of NMSP aviation operations. Therefore, the NTSB reco

ons into conformance with industry standards, such as those established by ALEA. Because other state and/or public organizations would also benefit from incorporation of industry standards and policies, such as those developed by ALEA, the NTSB further recommends that

127

124 For more information, see NTSB/SIR-06-01at <http://www.ntsb.gov/publictn/A_Stu.htm>. 125 The associated safety recommendation letter cited several accidents. The briefs for these accidents can be

acce r a reproduction of the complete document.

state, and regional needs.

ssed at <http://www.ntsb.gov/ntsb/aviationquery.index.aspx>. 126 See appendix B fo 127 NASAO was established by the states in 1931 to ensure uniformity of safety measures, standardize airport

regulations, and develop a truly national air transportation system responsive to local,

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Association of Chiefs of Police (IACP)128 encourage members to conduct an independent review and evaluation of their policies and procedures and make changes as needed to align those policies and procedures with safety standards, procedures, and guidelines, such as those outlined in ALEA guidance. In addition, because other state and/or public organizations would also benefit from the incorporation of risk assessment and management procedures and policies, the NTSB recommends that NASAO and the IACP encourage members to develop and implement risk assessment and management procedures specific to their operations.

2.4.2 NMSP Flight and Duty Time, Rest Period Limitations, and Staffing

NMSP aviation section policies limited the pilots to 12 hours of duty time and 6 hours of flight tim

est times.130

he commencement of, or following completion of, a duty period, and during

e per day. When the accident pilot accepted the accident mission, he had been on duty 8 hours, with 4.5 hours of flight time in the 24 hours preceding the SAR mission. Because the pilot’s total flight and duty times did not approach the aviation section’s limits,129 NMSP policies did not prevent him from accepting the accident mission; however, as stated previously, the accident pilot was likely fatigued as a result of his sleep restriction the preceding day.

The NTSB has issued many safety recommendations related to pilot flight, duty, and r To ensure optimal performance, regulations should not only limit daily flight and duty

times but also ensure that pilots are provided with a rest period that provides sufficient time for meals, personal hygiene, and obtaining at least 8 hours of uninterrupted sleep in every 24-hour period. Although NMSP SAR operations are not subject to FAA regulations, the FAA defines a rest period in 14 CFR 91.1057 as follows:

…a period of time required…that is free of all responsibility for work or duty prior to t which the flight crewmember…cannot be required to receive contact from the program manager. A rest period does not include any time during which the program manager imposes on a flight crewmember…any duty or restraint, including any actual work or present responsibility for work should the occasion arise.

A review of NMSP aviation section policies revealed that, although the NMSP had established maximum pilot flight and duty times for a 24-hour period, it had not defined what constituted a pilot “rest period” or established a minimum continuous pilot rest period before being assigned to another flight. NMSP management had assigned the accident pilot multiple duties (full-time pilot, chief pilot of the NMSP aviation section, and part-time PIO), which, in

NASAO represents the men and women in state government aviation agencies who serve the public interest in all 50 states, Guam, and Puerto Rico.

ing to the use of poli

nd complexities of aviation management.” ds.

128 The IACP Aviation Committee’s goals are to “provide guidance to IACP in all matters relat ce aircraft; to enhance cooperation and the sharing of information between agencies who use aircraft and those

exploring the possibility of starting an aviation operation; to sponsor police aviation management training; and publish articles to assist in the understanding of the benefits, costs, a

129 The NMSP policies did not specifically address pilot rest perio 130 For example, see NTSB/AAR-06/01 at <http://www.ntsb.gov/publictn/A_Acc1.htm>.

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combination, often interfered with the pilot’s ability to get adequate rest for flying.131 For example, the accident pilot had performed work-related duties at various times of the day and night during the preceding 72 hours, without adequate opportunity for a contiguous, ensured restful sleep period. As a result, when the pilot reported for duty about 0300 the day before the accident, he was functioning on, at most, 4 hours 9 minutes of interrupted sleep.132 Thus, the pilot’s work duties did not afford him an opportunity for sufficient restful sleep in the days before the accident, even though they were not in violation of the NMSP aviation section’s pilot flight and duty policies.

ty time or pilot re

allowed

ly affected the pilot’s decisions and actions on the night o ogram would ts for minimu tion’s flight a

d one part-tim helicop ility 24 hours per day, 7 days per week, while also ensuring that each pilot could r

ability to obtain adequate rest.) The NTSB found that it was not possible to devise such a schedule with this level of staffing. The NTSB further noted that NMSP aviation section staffing

Because the NMSP aviation section is a public operator, it has no flight and du st limitations imposed on it by the FAA, and the NMSP is responsible for monitoring its

own compliance with flight and duty time policies. However, FAA regulations for similar civil operations (commuter or on-demand charter operations under 14 CFR Part 135) state that each flying assignment must provide for “at least 10 consecutive hours of rest during the 24-hour period that precedes the planned completion time” of the flight and “no certificate holder may assign any flight crewmember to any duty with the certificate holder during any required rest period.” (A slightly shorter minimum rest period of 8 consecutive hours per 24-hour period is

for HEMS pilots, but 10 consecutive hours of rest are required before a HEMS pilot transitions to “on-call” status.)

Although the accident pilot’s schedule during the 2 days leading up to the accident flight was permitted by NMSP flight and duty time policies, the pilot’s PIO duties prevented him from obtaining sufficient rest, and NMSP policies did not ensure protected rest periods for its pilots. Fatigue was one of several factors that like

f the accident. The NTSB concludes that an effective pilot flight and duty time pr address not only maximum flight and duty times but would also contain requiremen m contiguous ensured rest periods to reduce pilot fatigue; the NMSP aviation sec nd duty time policies did not ensure minimum contiguous rest periods for its pilots.

The NTSB reviewed the NMSP aviation section’s staffing level of two full- an e helicopter pilots133 to determine whether this level of staffing was sufficient to support

ter availab eceive a protected rest period of at least 10 consecutive hours per 24 contiguous hours (a

rest period sufficient to allow for adequate sleep, meals, and personal hygiene) and could be afforded 2 full days off per week. (In its evaluation, the NTSB also took into account the fact that the accident pilot had additional duties and responsibilities associated with his chief pilot and PIO assignments, which imposed unpredictable demands on his time and interfered with his

131 The pilot had asked to be relieved of the PIO duties for safety-related reasons; however, his requests were

deni largely because NMSP upped, t and chief pilot responsibilities. 132 The part-time helicopter pilot also reported being called out to fly missions late in the evening after he had

worked all day.

er management did not understand how the pilot’s PIO duties conflicted with his pilo

held chief pilot and PIO responsibilities. The ening, after he had already worked a day shif

133 One of the two full-time helicopter pilots (the accident pilot) also t-time helicopter pilot was typically called to fly missions in the evpar

t performing duties unrelated to aviation.

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levels also limited its ability to assign two pilots to potentially high-risk missions (such as the accident flight) in an effort to mitigate the potential risks during such missions.134

A recent study sponsored by the U.S. Air Force assessed the minimum number of flight crews required to provide 24-hour availability for an aircraft; the study found that four flight crews provided the optimal balance between “the work, health, social, and safety demands placed upon the shiftworker (in terms of hours worked per unit time…) and personnel cost to the employer for safe and pr 135oductive system operation.” Thus, based on this study, the NMSP aviation section would be unable to support an appropriate 24 hours per day, 7 days per week schedu

ed ALEA’s requirements for organizations operating public aircraft under its accreditation program. ALEA’s program (which conducts routine audits to ensure

LEA policies regarding pilot flight and duty time should define rest and establish minimum, protected rest per

two radios, the pilot could m

le under existing staffing levels. The NTSB concludes that at the time of the accident, the NMSP aviation section staffing level was insufficient to allow helicopter operations 24 hours a day, 7 days a week without creating an unacceptable risk of pilot fatigue. Therefore, the NTSB recommends that the governor of the state of New Mexico require the New Mexico DPS to develop and implement a comprehensive fatigue management program for the NMSP aviation section pilots that, at a minimum, requires NMSP to provide its pilots with protected rest periods and defines pilot rest (in a manner consistent with 14 CFR 91.1057) and ensures adequate pilot staffing levels and aircraft hours of availability consistent with the pilot rest requirements.

The NTSB also review

compliance) specifies that participating operators must establish a maximum number of flight and duty hours that a pilot may work in a 24-hour period with a specified rest period, specifically taking into consideration the type of operation and the environmental conditions (for example, challenging weather or night operations). However, ALEA standards do not require an operator’s flight and duty time policy to define rest, establish minimum rest periods, or prevent the assignment of additional, conflicting duties. Because public aircraft operators who are members of ALEA base their operating policies and procedures on the standards set forth by ALEA and because protected rest periods are critically important to minimize fatigue, A

iods. Therefore, the NTSB further recommends that ALEA revise its standards to define pilot rest and ensure that pilots receive protected rest periods that are sufficient to minimize the likelihood of pilot fatigue during aviation operations.

2.5 Relationship with the Volunteer Search and Rescue Organization

The overall communication and coordination of efforts between the NMSP and the volunteer New Mexico SAR personnel did not ensure that the accident mission was performed as safely as possible. The accident helicopter was equipped with a radio that received and transmitted on police band frequencies and a very high frequency transceiver radio. Using the

onitor two frequencies simultaneously but could transmit on only one frequency. As a result, the pilot could not monitor and communicate on both the NMSP dispatch frequency and a SAR frequency at the same time. SAR personnel, with the use of their

134 A two-pilot operation would allow for additional monitoring and reduces an individual pilot’s workload.

tection Division, Biobehavioral Performance Branch, 2006), p. 26.

135 See  J.C.  Miller, Fundamentals of Shift-Work Scheduling, Technical Report No. AFRL-HE-BR-TR-2006-0011. (Brooks City Base, Texas: U.S. Air Force Research Laboratory, Human Effectiveness Directorate, Biosciences and Pro

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multiband transceiver radio, were able to communicate on three frequencies simultaneously. (The helicopter that was purchased to replace the accident helicopter was equipped with a multiband transceiver radio that allowed for communications on three frequencies simulta

SAR resources (including NMSP aviation section personnel); however, postaccident interviews indicate

t the right-side window and then flew in that direction. The spotter stated that he thought the pilot intende

the section helicopters were not expected to operate in IFR conditions because the nature of thos ts wer to c clo

neously.)

Although SAR command personnel communicated with the dispatcher and with the spotter (through cellular telephone calls with the NMSP dispatcher and SAR personnel) during the mission, they could not communicate directly with the pilot. After the helicopter had landed to pick up the hiker, SAR command personnel suggested to the spotter (via cellular telephone) that the helicopter remain on the mountain if the weather deteriorated to the point that it was not safe to take off. There is no indication that the pilot was apprised of this suggestion; if this suggestion had been passed on to the accident pilot, he might have been prompted to reassess his decision to take off.

During postaccident interviews, it was apparent that NMSP personnel were confused about how the chain of command was supposed to work during airborne SAR missions. The SAR plan indicated that the SAR field coordinator was responsible for directing all

d that NMSP personnel often conducted SAR missions based on 911 notifications before receiving SAR initialization. Additionally, the NMSP aviation section SOP did not address procedures for SAR missions. These issues likely resulted in the accident pilot believing that he did not need to communicate with SAR field commanders during the accident mission, and, as a result, he did not. If the pilot had communicated with SAR field commanders, he would have been aware of the SAR ground teams’ efforts, which might have influenced his decision to takeoff from the remote landing site. The NTSB concludes that NMSP personnel did not regularly follow the SAR plan, and NMSP pilots, including the accident pilot, did not routinely communicate directly with SAR commanders during SAR efforts, which reduced the safety and effectiveness of SAR missions. Therefore, the NTSB recommends that the governor of the state of New Mexico revise or reinforce NMSP SAR policies to ensure direct communication between NMSP aviation units and SAR ground teams and field personnel during a SAR mission.

2.6 Instrument Flying

According to the spotter, when the pilot departed the mountain for SAF, he pointed ou

d to maneuver toward lower and more open terrain in VFR conditions. However, the low clouds and snow likely obscured the mountains and led to an inadvertent IMC encounter shortly after takeoff. Although the pilot had a fixed-wing instrument rating and met instrument currency and proficiency requirements for that rating, he did not have a helicopter instrument rating. The pilot’s lack of a helicopter instrument rating was not technically an issue when he accepted the accident mission because VMC prevailed and NMSP aviation section pilots were not required to have instrument ratings for helicopter operations. NMSP management personnel explained that

e operations (for example, SAR missions) required VMC. Further, NMSP helicopter pilo e expected stay lear of uds.

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As a result of its 2009 public hearing on HEMS safety and the investigative results of several 2008 HEMS accidents, the NTSB issued Safety Recommendation A-09-97, which recommended that public HEMS operators conduct scenario-based training, to include inadvertent flight into IMC, frequently enough to ensure proficiency. Although the accident flight was not a HEMS flight, if the accident pilot been trained in how to exit inadvertent IMC in a helico

c operators and can affect the most pilots and operators, the NTSB recomm

hat the m the accident helicopter’s 406-MHz ELT were primarily

rs on areas near the accident site and for eventually locating both the survivor and th recomm

pter, he might have followed different procedures (for example, he might have climbed to a safe altitude and contacted ATC for assistance) or a different route (with potentially better results) when the helicopter departed the landing site and thus avoided the subsequent collision with terrain. The NTSB concludes that, because the accident pilot did not have a helicopter instrument rating, experience in helicopter instrument operations, or training specific to inadvertent helicopter IMC encounters, he was not prepared to react appropriately to the loss of visual references that he encountered shortly after takeoff. Because ALEA has the broadest membership of publi

ends that ALEA revise its accreditation standards to require that all pilots receive training in methods for safely exiting inadvertently encountered IMC for all aircraft categories in which they operate.

2.7 Emergency Locating Equipment

The accident helicopter was equipped with an ELT that transmitted on both the 406- and 121.5-MHz frequencies. The ELT’s signal was not received by the two geostationary operational environmental satellites most likely because of the topography of the crash site and the relative positions of the two satellites. However, ELT signals were received by low-Earth polar orbiting satellites. Within about 1 hour of the accident, SAR personnel had an ELT location that allowed them to focus their search efforts in the region where the accident occurred instead of the helicopter’s last known location (near the hiker’s location). The SAR ground teams’ use of the information provided by the accident helicopter’s 406-MHz ELT allowed them to identify and reach the accident location as soon as practical, especially given the challenging conditions (for example, the remote location, rugged and snowy/icy terrain, adverse weather, and nighttime conditions) under which the SAR efforts were conducted.136 The NTSB concludes t 406-MHz ELT signals received fro responsible for focusing searche

e helicopter wreckage. Because of the benefits of 406-MHz ELTs, the NTSB ends that ALEA, NASAO, and IACP encourage members to install 406-MHz ELTs on

all of their aircraft.

At the time of the accident, the NMSP did not use a flight-following system to ensure consistent tracking of its aircraft. The NTSB has advocated the installation and use of such systems. For example, as a result of its 2006 special investigation of EMS operations,137 the NTSB recommended that the FAA require EMS operators to use formalized dispatch and flight-following procedures. Additionally, in its report on the September 27, 2008, accident

136 Although SAR command personnel had received a last known position from radar data shortly before the

SAR ground teams located the spotter, it is unlikely that SAR ground teams were provided that information before they found the spotter.

137 For additional information, see NTSB/SIR-06/01 at <http://www.ntsb.gov/Publictn/A_Stu.htm>.

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involvi

an agency’s assets, could shorten search times for downed public aircraft and their occupants. Therefore, the NTSB recommends that ALEA, NASAO, and IACP

ment on all public aircraft that would allow

ng an MSP helicopter,138 the NTSB expressed concern that HEMS operators may not have dispatch and flight-following procedures and issued a related recommendation.

Low-cost units that use satellite-based technology to follow flights are commercially available. The satellite tracking data obtained by these units can be downloaded as frequently as desired by the operator (depending on the supporting program’s subscription) and can be viewed on a communications or dispatch center computer.139 Given the remote locations of many of the NMSP SAR missions and the possibility that the location of the accident helicopter and its occupants could have been identified more rapidly if it had been equipped with a flight-following technology, such a system would be invaluable to the NMSP. Since the accident, the NMSP purchased a portable flight-following unit, which it primarily intends for use in its helicopter. The flight-following unit service plan purchased by NMSP automatically provides updated helicopter position information at 5-minute intervals and every time the helicopter stops. The NTSB concludes that, although it is unlikely that the use of flight-tracking systems would have resulted in a different outcome in this case, the use of such systems, which provide real-time information regarding

encourage members to install flight-tracking equip for near-continuous flight tracking during missions.

138 For additional information, see NTSB/AAR-09/07 at <http://www.ntsb.gov/Publictn/A_Acc1.htm>. 139 Flight-following devices transmit self-contained GPS coordinates to satellites instead of relying on signal

triangulation as occurs with an ELT.

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3. Conclusions

3.1 Findings

1. The investigation determined that the accident helicopter was properly certificated and maintained in accordance with New Mexico State Police policies and the manufacturer’s recommended maintenance program. There was no evidence of any preimpact structural, engine, or system failures.

2. The investigation found no evidence that the pilot had any preexisting medical or toxicological condition that adversely affected his performance during the accident flight.

3. Postaccident examination of the helicopter’s seats and restraint systems revealed no evidence of preimpact inadequacies. The pilot and the hiker were ejected from the helicopter when their seats and restraint systems were subjected to forces beyond those for which they were certificated during the helicopter’s roll down the steep, rocky mountainside.

4. Neither the airborne nor the ground search and r descue (SAR) personnel coul have reached the pilot before he died of exposure given the adverse weather conditions, which precluded a prompt airborne SAR response and hindered the ground SAR teams’ progress; the darkness and the rugged terrain in which the ground SAR teams were responding; the distance they had to travel; and the seriousness of the pilot’s injuries.

5. When the pilot made the decision to launch, the weather and lighting conditions, even at higher elevations, did not preclude the mission; however, after accepting a search and rescue mission involving flight at high altitudes over mountainous terrain, with darkness approaching and with a deteriorating weather forecast, the pilot should have taken steps to mitigate the potential risks involved, for example, by bringing cold-weather survival gear and ensuring that night vision goggles were on board and readily available for the mission.

6. The pilot exhibited poor decision-making when he chose to take off from a relatively secure landing site at night and attempt visual flight rules flight in adverse weather conditions.

7. The pilot decided to take off from the remote landing site, despite mounting evidence indicating that the deteriorating weather made an immediate return to Santa Fe inadvisable, because his fatigue, self-induced pressure to complete the mission, and situational stress distracted him from identifying and evaluating alternative courses of action.

8. Although there was no evidence of any direct New Mexico State Police or Department of Public Safety management pressure on the pilot during the accident mission, there was evidence of management actions that emphasized accepting all missions, without adequate regard for conditions, which was not consistent with a safety-focused organizational safety culture, as emphasized in current safety management system guidance.

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9. If operators of public aircra management programs, their efforts to mitigate, the potentia

ft implemented structured, task-specific risk assessment and pilots would be more likely to thoroughly identify, and make l risks associated with a mission.

ot flight and duty time program would address not only maximum flight and

the New Mexico State Police aviation section staffing level was

ter (ELT) signals received from the

their

10. An effective pil duty times but would also contain requirements for minimum contiguous ensured rest periods to reduce pilot fatigue; the New Mexico State Police aviation section’s flight and duty time policies did not ensure minimum contiguous rest periods for its pilots.

11. At the time of the accident, insufficient to allow helicopter operations 24 hours a day, 7 days a week without creating an unacceptable risk of pilot fatigue.

12. New Mexico State Police (NMSP) personnel did not regularly follow the search and rescue (SAR) plan, and NMSP pilots, including the accident pilot, did not routinely communicate directly with the SAR commanders during SAR efforts, which reduced the safety and effectiveness of SAR missions.

13. Because the accident pilot did not have a helicopter instrument rating, experience in helicopter instrument operations, or training specific to inadvertent helicopter instrument meteorological condition encounters, he was not prepared to react appropriately to the loss of visual references that he encountered shortly after takeoff.

14. The 406-megahertz (MHz) emergency locator transmit accident helicopter’s 406-MHz ELT were primarily responsible for focusing searchers on areas near the accident site and for eventually locating both the survivor and the helicopter wreckage.

15. Although it is unlikely that the use of flight-tracking systems would have resulted in a different outcome in this case, the use of such systems, which provide real-time information regarding an agency’s assets, could shorten search times for downed public aircraft and occupants.

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3.2 Probable Cause

The National Transportation Safety Board determines that the probable cause of this

lice aviation section’s

airborne and ground personnel during search and rescue missions.

accident was the pilot’s decision to take off from a remote, mountainous landing site in dark (moonless) night, windy, instrument meteorological conditions. Contributing to the accident were an organizational culture that prioritized mission execution over aviation safety and the pilot’s fatigue, self-induced pressure to conduct the flight, and situational stress. Also contributing to the accident were deficiencies in the New Mexico State Po safety-related policies, including lack of a requirement for a risk assessment at any point during the mission; inadequate pilot staffing; lack of an effective fatigue management program for pilots; and inadequate procedures and equipment to ensure effective communication between

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4. Recommendations

NMSP to provide its pilots with protected rest periods and defines pilot rest (in a manner consistent with 14 Code of Federal Regulations 91.1057) and ensures adequate pilot staffing levels and aircraft hours of availability consistent with the pilot rest requirements. (A-11-54)

Revise or reinforce New Mexico State Police (NMSP) search and rescue (SAR) policies to ensure direct communication between NMSP aviation units and SAR ground teams and field personnel during a SAR mission. (A-11-55)

As a result of this investigation, the National Transportation Safety Board makes the following recommendations to the Airborne Law Enforcement Association:

Revise your standards to define pilot rest and ensure that pilots receive protected rest periods that are sufficient to minimize the likelihood of pilot fatigue during aviation operations. (A-11-56)

Revise your accreditation standards to require that all pilots receive training in methods for safely exiting inadvertently encountered instrument meteorological conditions for all aircraft categories in which they operate. (A-11-57)

Encourage your members to install 406-megahertz emergency locator transmitters on all of their aircraft. (A-11-58)

Encourage your members to install flight-tracking equipment on all public aircraft that would allow for near-continuous flight tracking during missions. (A-11-59)

As a result of this investigation, the National Transportation Safety Board makes the following recommendations to the National Association of State Aviation Officials:

Encourage your members to conduct an independent review and evaluation of their policies and procedures and make changes as needed to align those policies and procedures with safety standards, procedures, and guidelines, such as those outlined in Airborne Law Enforcement Association guidance. (A-11-60)

As a result of this investigation, the National Transportation Safety Board makes the following recommendations to the governor of the state of New Mexico:

Require the New Mexico Department of Public Safety to bring its aviation section policies and operations into conformance with industry standards, such as those established by the Airborne Law Enforcement Association. (A-11-53)

Require the New Mexico Department of Public Safety to develop and implement a comprehensive fatigue management program for the New Mexico State Police (NMSP) aviation section pilots that, at a minimum, requires

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Encourage your members to deve management procedures specific to the

lop and implement risk assessment and ir operations. (A-11-61)

Board makes the followi

your members to develop and implement risk assessment and

(A-11-67)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

DEBOR Chairm

CHRIS MARK R. ROSEKIND Vice Chairman

Adopte

Encourage your members to install 406-megahertz emergency locator transmitters on all of their aircraft. (A-11-62)

Encourage your members to install flight-tracking equipment on all public aircraft that would allow for near-continuous flight tracking during missions. (A-11-63)

As a result of this investigation, the National Transportation Safety ng recommendations to the International Association of Chiefs of Police:

Encourage your members to conduct an independent review and evaluation of their policies and procedures and make changes as needed to align those policies and procedures with safety standards, procedures, and guidelines, such as those outlined in Airborne Law Enforcement Association guidance. (A-11-64)

Encourage management procedures specific to their operations. (A-11-65)

Encourage your members to install 406-megahertz emergency locator transmitters on all of their aircraft. (A-11-66)

Encourage your members to install flight-tracking equipment on all public aircraft that would allow for near-continuous flight tracking during missions.

d: May 24, 2011

AH A.P. HERSMAN ROBERT L. SUMWALT an Member

TOPHER A. HART Member

EARL F. WEENER Member

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5. A

App Inves

ident on Jun uman Perform

Parties to the investigation were the Federal Aviation Administration and New Mexico State P ional Civil A ) and the Transportation Safety Board of Canada (TSB Canada) participated in the investigation as the representatives of the Sta ., and Pratt an n the investigation as technical advisors to ANSV and TSB Canada, respectively.

Public

No public hearing was held for this accident.

ppendixes

endix A tigation and Public Hearing

Investigation

The National Transportation Safety Board (NTSB) was initially notified of this acc e 9, 2009. The following investigative groups were formed: Operations and H ance, Meteorology, Airworthiness, Medical Factors, and Survival Factors.

olice. In accordance with the provisions of Annex 13 to the Convention on Internat viation, the Agenzia Nazionale per la Sicurezza del Volo (ANSV

te of Design and Manufacture (Airframe and Engines, respectively). Agusta S.p.A d Whitney Canada participated i

Hearing

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Appendix B NMSP Aviation Section “Policies and Procedures” Document

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NTSB Aircraft Accident Report NTSB Aircraft Accident Report

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77

Crash Following Encounter with Instrument Meteorological

Conditions After Departure from Remote Landing Site

Alaska Department of Public Safety

Eurocopter AS350 B3, N911AA

Talkeetna, Alaska

March 30, 2013

Accident Report

NTSB/AAR-14/03 PB2014-108877

National

Transportation

Safety Board

NTSB/AAR-14/03 PB2014-108877

Notation 8602 Adopted November 5, 2014

Aircraft Accident Report

Crash Following Encounter with Instrument Meteorological

Conditions After Departure from Remote Landing Site

Alaska Department of Public Safety

Eurocopter AS350 B3, N911AA

Talkeetna, Alaska

March 30, 2013

National

Transportation

Safety Board

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

National Transportation Safety Board. 2014. Crash Following Encounter with Instrument

Meteorological Conditions After Departure from Remote Landing Site, Alaska Department of Public

Safety, Eurocopter AS350 B3, N911AA, Talkeetna, Alaska, March 30, 2013. Aircraft Accident Report

NTSB/AAR-14/03. Washington, DC.

Abstract: This report discusses the March 30, 2013, accident involving a Eurocopter AS350 B3

helicopter, N911AA, operated by the Alaska Department of Public Safety, which impacted terrain while

maneuvering during a search and rescue flight near Talkeetna, Alaska. The airline transport pilot, an

Alaska state trooper serving as a flight observer for the pilot, and a stranded snowmobiler who had

requested rescue were killed, and the helicopter was destroyed by impact and postcrash fire. Safety issues

include inadequate pilot decision-making and risk management; lack of organizational policies and

procedures to ensure proper risk management; inadequate pilot training, particularly for night vision

goggle use and inadvertent instrument meteorological condition encounters; inadequate dispatch and

flight following; lack of a tactical flight officer program; punitive safety culture; lack of management

support for safety programs; and attitude indicator limitations. Safety recommendations are addressed to

the Federal Aviation Administration, the state of Alaska, 44 additional states, the Commonwealth of

Puerto Rico, and the District of Columbia.

The National Transportation Safety Board (NTSB) is an independent federal agency dedicated to promoting

aviation, railroad, highway, marine, and pipeline safety. Established in 1967, the agency is mandated by Congress

through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable

causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety

effectiveness of government agencies involved in transportation. The NTSB makes public its actions and decisions

through accident reports, safety studies, special investigation reports, safety recommendations, and statistical

reviews.

The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation,

“accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties … and

are not conducted for the purpose of determining the rights or liabilities of any person.” 49 C.F.R. § 831.4.

Assignment of fault or legal liability is not relevant to the NTSB’s statutory mission to improve transportation safety

by investigating accidents and incidents and issuing safety recommendations. In addition, statutory language

prohibits the admission into evidence or use of any part of an NTSB report related to an accident in a civil action for

damages resulting from a matter mentioned in the report. 49 U.S.C. § 1154(b).

For more detailed background information on this report, visit http://www.ntsb.gov/investigations/dms.html and

search for NTSB accident ID ANC13GA036. Recent publications are available in their entirety on the Internet at

http://www.ntsb.gov. Other information about available publications also may be obtained from the website or by

contacting:

National Transportation Safety Board

Records Management Division, CIO-40

490 L’Enfant Plaza, SW

Washington, DC 20594

(800) 877-6799 or (202) 314-6551

NTSB publications may be purchased from the National Technical Information Service. To purchase this

publication, order product number PB2014-108877 from:

National Technical Information Service

5301 Shawnee Rd.

Alexandria, VA 22312

(800) 553-6847 or (703) 605-6000

http://www.ntis.gov/

NTSB Aircraft Accident Report

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Contents

Figures …………………………………………………………………………………………………………………………. iii

Tables ………………………………………………………………………………………………………………………….. iv

Abbreviations …………………………………………………………………………………………………………………v

Executive Summary …………………………………………………………………………………………………….. vii

1. Factual Information …………………………………………………………………………………………………….1 1.1 History of the Flight …………………………………………………………………………………………………..1

1.1.1 Mission Coordination …………………………………………………………………………………………1 1.1.2 Outbound Flight to Remote Rescue Location ………………………………………………………..2

1.1.3 Accident Flight ………………………………………………………………………………………………….4 1.2 Personnel Information ………………………………………………………………………………………………….7

1.2.1 Pilot ………………………………………………………………………………………………………………….7 1.2.1.1 Training and Performance at Alaska DPS …………………………………………………7 1.2.1.2 Work/Sleep/Wake History ………………………………………………………………………9

1.2.1.3 Previous Accident ………………………………………………………………………………..10 1.2.1.4 Schedule and Compensation ………………………………………………………………….10

1.2.1.5 Colleagues’ and Others’ Perceptions ………………………………………………………11 1.2.2 Flight Observer ………………………………………………………………………………………………..13

1.3 Helicopter Information……………………………………………………………………………………………….13

1.3.1 Maintenance …………………………………………………………………………………………………….15 1.3.2 Pilot’s Concerns about Maintenance …………………………………………………………………..16

1.4 Meteorological Information ………………………………………………………………………………………..16 1.4.1 Weather Information Available Before Departure ………………………………………………..17

1.4.2 Weather and Lighting Conditions at Accident Site and Time …………………………………18 1.5 Cockpit Image, Audio, and Data Recorder ……………………………………………………………………19 1.6 Wreckage and Impact Information ………………………………………………………………………………23

1.7 Medical and Pathological Information………………………………………………………………………….24 1.8 Organizational and Management Information ……………………………………………………………….24

1.8.1 General ……………………………………………………………………………………………………………24 1.8.2 Aircraft Section Policies and Procedures …………………………………………………………….26

1.8.2.1 Operational Control and Go/No-Go Decisions …………………………………………26 1.8.2.2 Flight and Duty Time Policies ……………………………………………………………….27

1.8.2.3 Preflight Risk Assessment and Weather Minimums …………………………………28 1.8.2.4 Safety Program…………………………………………………………………………………….28

1.8.3 Response to Pilot’s Previous Accident and Events ……………………………………………….30

1.8.3.1 Accident in 2006 ………………………………………………………………………………….30 1.8.3.2 Engine and Rotor Overspeed Event in 2009 …………………………………………….32 1.8.3.3 Overtorque Event in 2011 ……………………………………………………………………..33

1.8.4 Use of Flight Observers …………………………………………………………………………………….34 1.8.5 Use of MatCom Dispatch Services ……………………………………………………………………..35

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1.8.6 Alaska DPS Changes Since This Accident …………………………………………………………..36

1.9 Previously Issued Safety Recommendations …………………………………………………………………38 1.9.1 Airborne Law Enforcement Association Safety Policies Guidance …………………………38 1.9.2 HEMS Operations …………………………………………………………………………………………….39

1.9.2.1 Pilot Training on Inadvertent IMC Encounters ………………………………………..39 1.9.2.2 Preflight Risk Assessment …………………………………………………………………….40

1.9.3 Inconsistencies Among Weather Information Products …………………………………………42

2. Analysis …………………………………………………………………………………………………………………….45 2.1 General …………………………………………………………………………………………………………………….45

2.1.1 Pilot Qualifications and Fitness for Duty …………………………………………………………….45 2.1.2 Helicopter Maintenance and Wreckage Examinations …………………………………………..45 2.1.3 Weather Conditions ………………………………………………………………………………………….46

2.2 Accident Flight………………………………………………………………………………………………………….47 2.3 Pilot’s Risk Management Considerations ……………………………………………………………………..50

2.3.1 Decision to Accept Mission ……………………………………………………………………………….50

2.3.2 Preparations for Departure …………………………………………………………………………………51 2.3.3 Decision to Continue Mission ……………………………………………………………………………53

2.4 Organizational Issues …………………………………………………………………………………………………54 2.4.1 Risk Assessment ………………………………………………………………………………………………54 2.4.2 Pilot Training …………………………………………………………………………………………………..56

2.4.3 Use of Trained Observers ………………………………………………………………………………….58 2.4.4 Safety Management and Safety Culture ………………………………………………………………59

2.5 Similarities with Other Public Aircraft Operations Accidents …………………………………………63 2.6 Attitude Indicator Limitations……………………………………………………………………………………..64 2.7 Investigative Benefits of Onboard Recorder………………………………………………………………….66

3. Conclusions ……………………………………………………………………………………………………………….69 3.1 Findings……………………………………………………………………………………………………………………69 3.2 Probable Cause………………………………………………………………………………………………………….71

4. Recommendations ……………………………………………………………………………………………………..72

References …………………………………………………………………………………………………………………….74

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Figures

Figure 1. End of GPS flight track from Sunshine to landing site with flight track shown in

orange. …………………………………………………………………………………………………………………………… 3

Figure 2. Aerial photograph of helicopter landing site. . ……………………………………………………… 4

Figure 3. GPS-derived flight track of the accident flight (shown in orange). ………………………….. 5

Figure 4. Aerial view of the accident site with helicopter wreckage circled in red. …………………. 6

Figure 5. Preaccident photograph of the helicopter. ………………………………………………………….. 14

Figure 6. Appareo Vision 1000 unit from the accident helicopter. ………………………………………. 20

Figure 7. Accident site showing main wreckage. ……………………………………………………………… 23

Figure 8. Chain of command structure in place at the time of the accident. ………………………….. 25

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Tables

Table 1. Pilot’s estimated potential sleep. ………………………………………………………………………… 10

Table 2. Summary of select information from Appareo images ………………………………………….. 21

Table 3. Summary of Alaska DPS safety improvements since the accident………………………….. 37

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Abbreviations

AAWU

Ag

Alaska Aviation Weather Unit

agl above ground level

ALEA Airborne Law Enforcement Association

AMPA Air Medical Physicians Association

AMRG Alaska Mountain Rescue Group

ANC Ted Stevens Anchorage International Airport

ASOS automated surface observing system

AST Alaska State Troopers

AWT Alaska Wildlife Troopers

CDI course deviation indicator

CFR Code of Federal Regulations

DPS Department of Public Safety

ELT emergency locator transmitter

EMS emergency medical services

FA area forecast

FAA Federal Aviation Administration

FLI flight limit indicator

FLIR forward-looking infrared

fpm feet per minute

FSS flight service station

HEMS helicopter emergency medical services

HSI horizontal situation indicator

IFR instrument flight rules

IMC instrument meteorological conditions

in Hg inches of mercury

METAR meteorological aerodrome report

min Minutes

NTSB Aircraft Accident Report

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msl mean sea level

NMSP New Mexico State Police

NTSB National Transportation Safety Board

NVG night vision goggles

NWS National Weather Service

OCC operations control centers

PAQ Palmer Municipal Airport

PED portable electronic device

PIC pilot-in-command

RCC Alaska Air National Guard Rescue Coordination Center

SAR search and rescue

SFAR special federal aviation regulation

SMS safety management system

TAF terminal aerodrome forecast

TFO tactical flight officer

TKA Talkeetna Airport

TSO technical standard order

VFR visual flight rules

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Executive Summary

On March 30, 2013, at 2320 Alaska daylight time, a Eurocopter AS350 B3 helicopter,

N911AA, impacted terrain while maneuvering during a search and rescue (SAR) flight near

Talkeetna, Alaska. The airline transport pilot, an Alaska state trooper serving as a flight observer

for the pilot, and a stranded snowmobiler who had requested rescue were killed, and the

helicopter was destroyed by impact and postcrash fire. The helicopter was registered to and

operated by the Alaska Department of Public Safety (DPS) as a public aircraft operations flight

under 14 Code of Federal Regulations Part 91. Instrument meteorological conditions (IMC)

prevailed in the area at the time of the accident. The flight originated at 2313 from a frozen pond

near the snowmobiler’s rescue location and was destined for an off-airport location about 16 mi

south.

After picking up the stranded, hypothermic snowmobiler at a remote rescue location in

dark night conditions, the pilot, who was wearing night vision goggles (NVG) during the flight,

encountered IMC in snow showers within a few minutes of departure. Although the pilot was

highly experienced with SAR missions, he was flying a helicopter that was not equipped or

certified for flight under instrument flight rules (IFR). The pilot was not IFR current, had very

little helicopter IFR experience, and had no recent inadvertent IMC training. Therefore,

conducting the flight under IFR was not an option, and conducting the night flight under visual

flight rules in the vicinity of forecast IFR conditions presented high risks. After the helicopter

encountered IMC, the pilot became spatially disoriented and lost control of the helicopter.

At the time the pilot was notified of the mission and decided to accept it, sufficient

weather information was available for him to have determined that the weather and low lighting

conditions presented a high risk. The pilot was known to be highly motivated to accomplish SAR

missions and had successfully completed SAR missions in high-risk weather situations in the

past.

The investigation also identified that the Alaska DPS lacked organizational policies and

procedures to ensure that operational risk was appropriately managed both before and during the

mission. Such policies and procedures include formal pilot weather minimums, preflight risk

assessment forms, and secondary assessment by another qualified person trained in helicopter

flight operations. These risk management strategies could have encouraged the pilot to take steps

to mitigate weather-related risks, decline the mission, or stay on the ground in the helicopter after

rescuing the snowmobiler. The investigation also found that the Alaska DPS lacked support for a

tactical flight officer program, which led to the unavailability of a trained observer on the day of

the accident who could have helped mitigate risk.

Any organization that wishes to actively manage safety as part of an effective safety

management system must continuously strive to discover, understand, and mitigate the risks

involved in its operations. Doing so requires the active engagement of front-line personnel in the

reporting of operational risks and their participation in the development of effective risk

mitigation strategies. This cannot occur if a focus of the organization’s approach to dealing with

safety-related events is to punish those whose actions or inactions contributed to the event.

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Although front-line personnel may, on rare occasions, be involved in intentional misdeeds, the

majority of accidents and incidents involve unintentional errors made by well-intentioned

personnel who are doing their best to manage competing performance and safety goals. An

organizational safety culture that encourages the adoption of an overly punitive approach to

investigating safety-related events tends to discourage the open sharing of safety-related

information and to degrade the organization’s ability to adapt to operational risks.

The Alaska DPS safety culture, which seemed to overemphasize the culpability of the

pilot in his past accident and events, appears to have had this effect. The pilot had adopted a

defensive posture with respect to the organization, and he was largely setting his own operational

limitations and making safety-related operational decisions in a vacuum, masking potential risks,

such as the risk posed by his operation of helicopter NVG flights at night in low IFR conditions.

This had a deleterious effect on the organization’s efforts to manage the overall safety of its SAR

operations. The investigation found that Alaska DPS had a punitive safety culture that impeded

the free flow of safety-related information and impaired the organization’s ability to address

underlying safety deficiencies relevant to this accident.

The National Transportation Safety Board (NTSB) determines that the probable cause of

this accident was the pilot’s decision to continue flight under visual flight rules into deteriorating

weather conditions, which resulted in the pilot’s spatial disorientation and loss of control. Also

causal was the Alaska Department of Public Safety’s punitive culture and inadequate safety

management, which prevented the organization from identifying and correcting latent

deficiencies in risk management and pilot training. Contributing to the accident was the pilot’s

exceptionally high motivation to complete search and rescue missions, which increased his risk

tolerance and adversely affected his decision-making.

It is important to note that the investigation was significantly aided by information

recovered from the helicopter’s onboard image and data recorder, which provided valuable

insight about the accident flight that helped investigators identify safety issues that would not

have been otherwise detectable. Images captured by the recorder provided information about

where the pilot’s attention was directed, his interaction with the helicopter controls and systems,

and the status of cockpit instruments and system indicator lights, including those that provided

information about the helicopter’s position, engine operation, and systems. Information provided

by the onboard recorder provided critical information early in the investigation that enabled

investigators to make conclusive determinations about what happened during the accident flight

and to more precisely focus the safety investigation on the issues that need to be addressed to

prevent future accidents. For example, the available images allowed the investigation to

determine that the pilot caged the attitude indicator in flight. This discovery resulted in the

development of important safety recommendations related to attitude indicator limitations.

Although the recording device on board the accident helicopter was not required and was

not a crash-protected system, the NTSB has a long history of recommending that the Federal

Aviation Administration (FAA) require image recording devices on board certain aircraft. Some

of these safety recommendations, which were either closed or superseded after the FAA

indicated that it would not act upon them, date as far back as 1999. The NTSB notes that, had the

FAA required all turbine-powered, nonexperimental, nonrestricted-category aircraft operated

under Parts 91, 135, and 121 to be equipped with crash-protected image recording system by

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ix

January 1, 2007 (as the NTSB had recommended in 2003), 466 aircraft involved in accidents

would have had image recording systems; in 55 of these accidents, the probable cause statements

contained some element of uncertainty, such as an undetermined cause or factor.

As a result of this investigation, the NTSB makes 3 safety recommendations to the FAA

and 7 safety recommendations to the state of Alaska, 44 additional states, the Commonwealth of

Puerto Rico, and the District of Columbia that conduct law enforcement public aircraft

operations.

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1

1. Factual Information

1.1 History of the Flight

On March 30, 2013, at 2320 Alaska daylight time, a Eurocopter AS350 B3 helicopter, 1

N911AA, impacted terrain while maneuvering during a search and rescue (SAR) flight near

Talkeetna, Alaska. The airline transport pilot, an Alaska state trooper serving as a flight observer

for the pilot, and a stranded snowmobiler who had requested rescue were killed, and the

helicopter was destroyed by impact and postcrash fire. The helicopter was registered to and

operated by the Alaska Department of Public Safety (DPS) as a public aircraft operations 2 flight

under 14 Code of Federal Regulations (CFR) Part 91. Instrument meteorological conditions

(IMC) prevailed in the area at the time of the accident. The flight originated at 2313 from a

frozen pond near the snowmobiler’s rescue location and was destined for an off-airport location

about 16 mi south.

1.1.1 Mission Coordination

At 1935, the snowmobiler used his cell phone to call 911 to request rescue after his

snowmobile became stuck in a ditch under the Intertie (a major power transmission line) between

Larson Lake and Talkeetna. According to the MatCom 3 dispatcher who handled the call, the

snowmobiler reported that he bruised his ribs but was more concerned about developing

hypothermia if not rescued soon. After receiving notification from MatCom, the trooper on duty

at the Alaska State Troopers (AST) Talkeetna post tried to coordinate a ground rescue mission. 4

The trooper found that no local Alaska Wildlife Troopers (AWT) units were on duty and that

other local resources (residents with snowmobiles and SAR experience) did not want to

participate because of the distance involved and the deteriorating weather, which included rain

and poor snow conditions on the ground. After the trooper’s attempts to coordinate a ground

rescue were unsuccessful, at 2009, he telephoned the AST on-duty SAR coordinator, 5 and they

agreed that it would be appropriate to use the Alaska DPS’s primary SAR helicopter to retrieve

the snowmobiler.

1 Eurocopter is now known as Airbus Helicopters, a wholly owned subsidiary of the Airbus Group, which is

headquartered in France. 2 The term “public aircraft” refers to a subset of government aircraft operations that, as such, are not subject to

some of the regulatory requirements that apply to civil aircraft. Because public aircraft operators (like the Alaska

DPS) are exempted from certain aviation safety regulations, government organizations conducting public aircraft

operations supervise their own flight operations without oversight from the Federal Aviation Administration. 3 MatCom, a public safety dispatch center located in Wasilla, Alaska, is a division of the Wasilla Police

Department. 4 The Alaska DPS has two major divisions, the AST and the Alaska Wildlife Troopers (AWT). The AST is

charged with statewide law enforcement, prevention of crime, pursuit and apprehension of offenders, service of civil

and criminal process, prisoner transport, central communications, and SAR. The AWT is charged with enforcing

fish and game regulations; AWT troopers also enforce criminal laws and participate in SAR operations. 5 According to the Alaska DPS SAR protocol, the SAR coordinator handled all requests for the use of the

accident helicopter. If the SAR coordinator approved, then the coordinator would notify the pilot, who would

evaluate the weather and determine if the mission was acceptable.

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According to records from the pilot’s portable electronic device (PED), 6 at 2019, he

received an incoming call from the SAR coordinator. The SAR coordinator stated that he relayed

details of the situation to the pilot, and the pilot said he would check the weather. The pilot’s

spouse recalled that, immediately after the pilot received the call, he went upstairs to check the

weather. The pilot called the SAR coordinator soon after and said he would accept the mission. 7

The pilot’s spouse recalled that she asked her husband about the weather, and he said that it was

“good.” The pilot then drove to Ted Stevens Anchorage International Airport (ANC),

Anchorage, Alaska, where the helicopter was based.

At 2051, the pilot called a fixed-base operator and asked for help towing the helicopter

out of its hangar. Two line service technicians drove a tug across the airport to the hangar,

arriving about 2100. They towed the helicopter out of the hangar and watched as the pilot

performed a walk-around inspection, went through cockpit checks, and started the engine. They

estimated that the helicopter’s rotors were turning about 10 or 15 minutes (min) after they

disconnected the tug, and they watched the helicopter depart shortly thereafter.

1.1.2 Outbound Flight to Remote Rescue Location

At 2117, the pilot radioed the MatCom dispatcher that he had departed ANC, and, at

2142, he reported to the dispatcher that he was landing at “Sunshine,” a landing zone near the

AST Talkeetna post, to pick up the trooper/flight observer. At 2154, the pilot radioed the

dispatcher that he had spotted the snowmobiler and would land nearby and walk to his location.

GPS data 8 showed that the helicopter departed Sunshine and proceeded north until it

reached the Intertie. As shown in figure 1, the helicopter continued north along the Intertie for

about 0.6 mi at an altitude of about 1,100 to 1,200 ft mean sea level (msl), made a right 360° turn

over the Intertie, and landed immediately west of it on a frozen, snow-covered pond at 2156. The

flight duration was about 11 min, and the landing site pond was about 16 mi north of Sunshine.

The landing site elevation was about 460 ft above msl. Hand-written coordinates on the pilot’s

kneeboard that was recovered from the wreckage indicate that the snowmobiler’s location was

about 0.2 mi from the landing site.

6 Records recovered from the pilot’s PED, which was an Apple iPhone 4, included call and text message log

information for the 3 days leading up to the accident and six photographs of the helicopter’s cockpit, which were

dated July 18, 2012. 7 The pilot’s PED records did not show a second call with the SAR coordinator; however, it is possible that the

pilot used his home phone. 8 The helicopter was equipped with a Garmin GPSMAP 296 portable GPS unit capable of storing flight route

information. References in this report to the helicopter’s position (at specific times), altitude, and groundspeed are

based on information retrieved from the unit’s nonvolatile memory.

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Figure 1. End of GPS flight track from Sunshine to landing site with flight track shown in orange.

At 2159, the trooper radioed the dispatcher that they were walking to the snowmobiler’s

location. At 2209, he asked the dispatcher, who had cell phone contact with the snowmobiler, to

have the snowmobiler stand up so that he would be easier to spot in the deep snow, but the

dispatcher advised that the snowmobiler was too weak to stand. At 2220, the pilot and the

trooper reached the snowmobiler.

The pilot and trooper did not report to the dispatcher how they assisted the snowmobiler

or transported him to the helicopter. However, the snowmobile was later found parked on the

frozen pond (not under the Intertie) near two parallel linear marks in the snow with dimensions

that corresponded to the helicopter’s landing skids (see figure 2).

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Figure 2. Aerial photograph of helicopter landing site. (Red arrows point to marks consistent with helicopter’s landing skids. Green arrow points to the snowmobile.)

1.1.3 Accident Flight

As shown in figure 3, GPS data for the accident flight (which lasted about 7 min) showed

that the helicopter departed the frozen pond about 2313. It climbed to about 700 ft msl (about

250 ft above ground level [agl]) and accelerated to about 60 knots. The helicopter flew southwest

and then southeast, circumnavigating a 1,000-ft msl hill at altitudes of 700-800 ft msl (about

150-200 ft agl, depending on terrain elevation), and then it slowed to about 20 knots as it

approached the Intertie. About 2315, the helicopter turned right and headed south along the

Intertie for about 30 seconds at altitudes of about 900-1,100 ft msl (about 200-300 ft agl) and a

speed of 60 knots. Before the helicopter reached an area where the Intertie crossed over another

1,000-foot msl hill (which was one of several in a cluster of low-lying hills directly ahead of the

helicopter’s flightpath), the helicopter turned right and deviated toward a slight gap in the hills at

a speed of 70 knots.

At 2316, the flight observer radioed the dispatcher that the helicopter was en route back

to Sunshine, and he requested that an ambulance meet the flight to receive the hypothermic

snowmobiler. No further radio communications were received from the flight.

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At 2317:14, the helicopter was flying about 1,000 ft msl over 900-ft terrain in the middle

of the cluster of low-lying hills and had slowed to 23 knots. 9 At 2317:31, the helicopter was

about 1,100 ft msl and 44 knots. At 2317:49, the helicopter was at 1,060 msl (about 200 ft agl)

and 16 knots.

At 2317:59, the helicopter began to climb and turn left rapidly with little forward

airspeed. According to images recovered from the helicopter’s onboard Appareo Systems Vision

1000 recorder (see section 1.5), at 2318:40, as the helicopter completed about a 360º turn, the

pilot caged the attitude indicator. 10

Caging an attitude indicator sets it to display a level flight

attitude (0° pitch and 0° roll). This action is meant to be performed only when an aircraft is in a

level flight attitude, such as on the ground or in straight-and-level, unaccelerated flight. After

this, the helicopter entered a series of erratic turns, climbs, and descents. The GPS data for the

accident flight ended at 2320:17, and the last position recorded placed the helicopter about 3 mi

south of the takeoff point and 13 mi north of Sunshine.

Figure 3. GPS-derived flight track of the accident flight (shown in orange).

9 The presence of many tall trees in the area meant that obstacle clearance was much less than 100 ft.

10 The attitude indicator, also known as an artificial horizon, displays a visual representation of the helicopter’s

pitch and roll relative to the Earth’s horizon.

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At 0039 on March 31, 2013 (about 1.5 hours after being notified to meet the helicopter),

emergency medical services (EMS) personnel awaiting the helicopter’s arrival at Sunshine

contacted a MatCom dispatcher to request the helicopter’s estimated time of arrival. The

dispatcher’s attempts to locate the helicopter via radio and phone and by contacting personnel at

Sunshine and the Talkeetna flight service station (FSS) were unsuccessful. The dispatcher had

only limited information from Alaska DPS about the helicopter, and DPS personnel did not

perform any flight tracking. (For more information about dispatch and DPS activities to locate

the helicopter, see section 1.8.5.) No signals were received from the helicopter’s 406-MHz

emergency locator transmitter (ELT). At 0217, the Alaska Air National Guard Rescue

Coordination Center (RCC) advised that the National Guard helicopters could not fly for 3 hours

(due to crew rest requirements, however, the weather was also adverse), and, at 0230, the

decision was made to search for the helicopter using snowmobiles. About 0700, after the weather

improved, a 210 th

Air National Guard Rescue Squadron Sikorsky HH-60 Pave Hawk helicopter

departed from Anchorage to join the search. The wreckage was located by the National Guard

helicopter crew about 0930 on March 31, 2013 (see figure 4). The accident site was about 200 ft

north of the last recorded GPS position at an elevation of about 940 ft.

Figure 4. Aerial view of the accident site with helicopter wreckage circled in red.

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1.2 Personnel Information

1.2.1 Pilot

The pilot, age 55, held a commercial pilot certificate with ratings for helicopters,

single-engine and multiengine land airplanes, and single-engine sea airplanes, and he was

instrument-rated for helicopters and airplanes. He also held a flight instructor certificate for

helicopters and single-engine land airplanes and an airline transport pilot certificate with a rating

for multiengine land airplanes. The pilot’s most recent Federal Aviation Administration (FAA)

second-class medical certificate was dated August 23, 2012, with the limitation, “Must wear

corrective lenses [and] possess glasses for near/intermediate vision.” The pilot also held an

airframe and powerplant mechanic’s certificate.

Based on available records, 11

the pilot had accumulated about 10,693 total flight hours, of

which about 8,452 hours were in helicopters. His logbooks showed a total of 247.1 hours

simulated instrument time and 141.3 hours of actual instrument time, primarily in airplanes and

all logged before 2001. The logbooks documented 38.3 hours of instrument flight in helicopters,

of which 0.5 hour was actual instrument time. The most recent instrument helicopter flight was

logged in 1986.

1.2.1.1 Training and Performance at Alaska DPS

Alaska DPS hired the pilot in December 2000 to be the primary pilot for the accident

helicopter. He had flown a total of 3,415 flight hours for Alaska DPS, which included

1,738 hours flown during SAR missions. He flew 242 hours in the year before the accident, of

which 239 hours were in the accident helicopter. The pilot flew 23 hours in the 90 days before

the accident, with 8 hours flown in the last 30 days. His most recent flight in the accident

helicopter before the day of the accident took place on March 17, 2013. That flight was a SAR

mission to retrieve an injured hiker.

The pilot’s most recent Alaska DPS check flight took place on March 18, 2013. The

check flight was conducted in a Robinson R-44 by an independent instructor and included a

flight review in accordance with 14 CFR 61.56 and the special awareness training required by

Special Federal Aviation Regulation (SFAR) 73 12

to act as pilot-in-command (PIC) of a

Robinson R-44. On November 20, 2012, the pilot completed an AS350 B3 pilot recurrent

training course at the American Eurocopter training center in Grand Prairie, Texas. According to

11

Total flight times were derived from the pilot’s logbooks (which contained no recent entries) and DPS

records. For more information about the pilot’s flight experience, see the Operations/Human Performance Factual

Report contained in the public docket for this accident. 12

SFAR 73 imposes training requirements (in addition to those contained in Part 61) that are specific to the

Robinson R-22 and R-44 model helicopters. The rule requires special awareness training covering energy

management, mast bumping, low rotor rpm (blade stall), low G hazards, and rotor rpm decay.

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the training record, the pilot received a total of 1.5 hours of flight training, which included

normal and emergency procedures. The training did not include any instrument flight. 13

The pilot’s logbooks did not reference night vision goggle (NVG) 14

flight time, and

Alaska DPS did not maintain pilot NVG flight time records. 15

Log sheets for the helicopter

showed that the pilot flew 16.2, 13.2, and 2.2 hours using NVGs within the 6 months, 90 days,

and 30 days before the accident, respectively. His most recent flight using NVGs was on March

15, 2013.

The pilot’s performance evaluation report for 2009 listed as a goal for 2010, “attend a

commercial initial NVG course to update his training in the NVG environment.” A quotation

dated October 13, 2009, for an NVG course including 8 hours of ground school and 5 hours of

flight training to be given by Aviation Specialties Unlimited of Boise, Idaho, was found in the

pilot’s office. However, the pilot’s performance evaluation report for 2010 stated that “it was

decided not to send [the pilot] to a commercial initial NVG course due to the cost of the course.”

The pilot had previous military helicopter flying experience, and one of the Alaska DPS

pilots who provided the pilot with his NVG training at DPS reported that the pilot had previous

NVG experience in the military. Investigators could find no record that the pilot received formal

NVG training in the military. According to the pilot’s Alaska DPS training records, he completed

NVG training on December 18, 2003, and was authorized to use NVGs in accordance with “the

department NVG and policy manual.” According to the records, the NVG training included

6 hours of ground school and 4.4 hours of flight training, which was provided by other Alaska

DPS pilots. The records specify that during one of the NVG training flights, inadvertent IMC

operations were performed and that, during another flight, blowing snow takeoffs were

performed. There were no records found indicating that any subsequent recurrent NVG or

instrument training in helicopters was provided. Alaska DPS provided the pilot with instrument

flight training in a Cessna 208 airplane at a FlightSafety training center in 2001.

In the “Weather Restrictions” section of the pilot’s Alaska DPS Flight

Authorizations/Limitations form dated December 18, 2003, the box for “VFR [visual flight rules]

Flight” was checked with no restrictions noted, and the box for “Night Flight” was checked with

the restriction “[NVG] use w/ 500’ ceiling and 2 miles visibility.” This was the most recently

completed copy of this form found in the pilot’s records.

13

None of the pilot’s previous training at American Eurocopter included instrument flight. He received training

there in 2002, 2005, 2006, 2008, 2009, 2010, and 2011. 14

NVGs are used during night operations to provide a brighter visual scene, allowing the user to more easily

see external references. NVG limitations include a reduced field of view, reduced image resolution, and the presence

of digital noise. Also, low lighting conditions can result in lower contrast images that are more difficult to interpret

and may cause a tendency to fly lower in an effort to maintain an acceptable image. The use of NVGs in low light

conditions also requires high levels of gain, which worsens digital noise and can lead to “scintillation.” Further, the

presence of meteorological obscurants, like rain and snow, has the potential to further degrade NVG image quality. 15

DPS required that the pilot maintain a record showing that he met the NVG operating experience required by

14 CFR 61.57. This requirement was satisfied by the pilot completing a form titled “State of Alaska Department of

Public Safety NVG Operating Experience…on an AS350B3 (Astar).” Copies of completed forms dating back to

December 7, 2010, were located in the pilot’s personnel file. The most recent form was dated March 15, 2013.

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Review of the pilot’s Alaska DPS personnel file revealed that he had received ratings of

“outstanding” or “high acceptable” on his yearly performance evaluations since joining the

agency. 16

The pilot had been commended numerous times by state officials, including the governor.

Most recently, in 2011, the pilot received an honorable mention for the Governor’s Denali Peak

Performance Award in the category of Crisis Responder. Also, in 2008, the pilot and the on-duty

SAR coordinator (who was a sergeant stationed in Girdwood, Alaska, at the time) received the

Governor’s Denali Peak Performance Award in the category of Exceptional Performance Team

and a Commendation for Meritorious Service for saving the life of a kayaker on July 29, 2007.

According to the commendation, the kayaker became caught in a bore tide, 17

and the pilot flew

the helicopter steady close to the turbulent water’s surface while the sergeant leaned out of the

helicopter and pulled the kayaker from the water. The pilot’s personnel file also contained

numerous letters and e-mails of appreciation from people the pilot had rescued and their families.

For example, one of three people who had become stranded on a gravel bar with two airplanes

due to rising water sent an e-mail dated September 27, 2012, to the pilot’s supervisor that stated,

in part, the following:

I wanted to tell you thank you for rescuing us during the flooding.…Our situation

was pretty grim. We were surrounded by rising waters with no way to get out… .

Your pilot who was only asked to do a weather check pushed on through to get us

out of that situation…. The weather wasn’t all that great when he flew in and got

us back.

1.2.1.2 Work/Sleep/Wake History

The pilot’s spouse said that the pilot was a morning person who woke every day at 0530

but sometimes went back to sleep until about 0800 on weekend mornings. He normally left for

work between 0600 and 0615 Monday through Friday. He typically went to bed early in the

evening (about 2100 on weeknights and 2130 on Friday and Saturday nights) so that he would be

rested if called to fly a mission. He had no difficulty falling asleep at night.

The pilot’s spouse said that the pilot had not recently experienced any significant

negative life events, and she reported no recent changes in his daily habits. He normally ate

breakfast at a fast food restaurant on the way to work, ate lunch at home about 1100, ate dinner

at home between 1700 and 1800, and sometimes ate a late evening snack. He visited a gym for

cardiovascular exercise and strength training 3 or 4 days a week, normally in the afternoon.

Based on the pilot’s spouse’s recollections of his schedule and a review of his PED

activity, the pilot’s estimated potential sleep time for the 3 nights before the accident is

summarized in table 1.

16

The rating levels were unacceptable, low acceptable, mid acceptable, high acceptable, and outstanding. There

was no performance evaluation report for the rating period January 16, 2008, to January 15, 2009, in the pilot’s

personnel file. 17

A bore tide is a wave or series of waves formed by a rush of seawater as the incoming tide from a wide bay is

funneled into a shallow and narrowing inlet.

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Table 1. Pilot’s estimated potential sleep.

Date Went to Bed Awoke Potential Sleep

March 27-28 2100 0530 8.5 hours

March 28-29 2100 0530 8.5 hours

March 29-30 2200 0800 to 0900 10 to 11 hours

1.2.1.3 Previous Accident

The pilot was involved in a previous accident in the helicopter on April 21, 2006.

According to the National Transportation Safety Board (NTSB) report for the accident, the pilot

stated that, just after takeoff, as the helicopter transitioned from a hover to forward flight,

blowing snow from the helicopter’s main rotor momentarily reduced his visibility, and he lost all

visual reference with the surface. He elected to abort the takeoff while he was attempting to

regain a visual reference, and the helicopter’s tail rotor guard and vertical stabilizer struck the

surface of the lake. The NTSB determined that the probable cause of the accident was “the

pilot’s failure to maintain adequate altitude/clearance from terrain during an aborted takeoff in

whiteout conditions, which resulted in an in-flight collision with terrain. A factor associated with

the accident was whiteout conditions.” 18

As a result of the accident, the FAA requested that the pilot undergo a commercial pilot

reexamination given by an FAA inspector in accordance with 49 United States Code 44709(a).

The pilot successfully completed the reexamination on May 15, 2006, in a Robinson R-44

helicopter. There were no records of any other certificate actions in the pilot’s FAA records.

Also as a result of the accident, DPS required the pilot to undergo training on takeoffs in blowing

snow conditions with one of the department’s senior pilots. Alaska DPS conducted an internal

investigation of the accident and other events 19

involving the pilot. (For more information, see

section 1.8.3.1.)

1.2.1.4 Schedule and Compensation

The pilot’s work schedule was Monday through Friday, 0700 to 1530, with an hour lunch

break from 1200 to 1300. According to his wife and colleagues, he was always on call except

when he took leave for a special family occasion or to use a few days of leave that he would

otherwise have to forfeit. 20

An examination of the pilot’s time sheet for the period of

March 16-31, 2013, indicated that he was on “standby” every day during that period. According

to the pilot’s wife and colleagues, the pilot sometimes went off call temporarily when he

exceeded flight or duty time limits and needed to rest.

18

The NTSB report for this accident, ANC06TA047, can be accessed from the NTSB web site at

www.ntsb.gov. 19

The events, each of which did not meet the criteria to be classified as an accident, were not investigated by

the NTSB or the FAA. 20

The pilot was required to use a minimum of 5 days of vacation time or forfeit it at the end of the year.

NTSB Aircraft Accident Report

11

The pilot’s last day off was Saturday, March 9, 2013, and his last extended time off was a

week-long family vacation in January 2013. Alaska DPS records indicated that, before the

accident, the pilot had not done any flying since he completed a flight review on March 18, 2013,

and had not worked outside of his normal office hours since Sunday, March 17, 2013.

The pilot was paid for his work on an hourly basis and was expected to work at least

40 hours per week. He received additional compensation (premium pay) for additional hours

worked (overtime), for working in the evenings or at night (swing shift or graveyard shift pay

differentials), for working on a holiday, and for being on call outside of normal work hours

(standby pay). DPS records indicated that, for calendar year 2012, about 37% of the pilot’s total

earnings consisted of premium pay.

1.2.1.5 Colleagues’ and Others’ Perceptions

1.2.1.5.1 Proficiency

The aircraft section commander, who was a nonhelicopter-rated pilot and had flown with

the pilot, said that the pilot had a “high level of proficiency” and was “always very professional.”

He characterized him as a “by the book” pilot.

The relief pilot for the accident helicopter, who had flown with the pilot numerous times

(most recently in November 2012), said that the pilot was the “best helicopter pilot” he had ever

flown with. He described the pilot as “a sound professional.”

An Alaska Mountain Rescue Group (AMRG) observer who often flew with the pilot

described him as an excellent pilot who he “completely trusted.” (The Alaska DPS’s use of flight

observers is further described in section 1.8.4).

The former relief pilot, who had provided the pilot with his NVG training in 2003 and

had most recently flown with the pilot in December 2010, rated the pilot’s skill level as

“average.”

1.2.1.5.2 Attitude Regarding Weather Risks

The aircraft section commander said that he knew the pilot was aware of weather-related

safety issues because when he talked with the pilot about his SAR missions, the pilot always

discussed the conditions he encountered and how he compensated for them. He said that the pilot

did not display hazardous attitudes and that he did not consider him to be a “risk-taker.” He

recalled a discussion he had with the pilot about the risks involved in some of the SAR missions

the pilot conducted, including flying in bad weather and at night, and he said that the pilot told

him, “I told them when I took this job that I would do this, and that’s what I am going to do.”

The aircraft section commander expressed the opinion that the pilot knew what the risks were

and felt a self-imposed obligation to conduct SAR missions in difficult conditions.

The relief pilot had received helicopter flight instruction from the pilot and had flown

missions with him. The relief pilot said that the pilot was “extremely safe” and that for

“everything [the pilot] did, he had a backup plan.” The relief pilot recalled that, on one occasion,

he expressed concern to the pilot about the weather conditions for a particular mission, and the

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12

pilot had encouraged him to decline it. He recalled that the pilot had repeatedly told him not to

“fight” or “push” the weather.

The AMRG observer said that the pilot did not take risks flying in bad weather and that

he had been on missions with the pilot numerous times where they had to turn around because

the weather was too bad to continue. He said that, after the pilot’s 2006 accident, the pilot was

“extra careful” because he wanted to avoid another accident or incident. The pilot had previously

briefed him that, if they ever encountered zero-visibility conditions, he would climb and

transition to instrument flight rules (IFR) flight while the observer monitored the cockpit display

for terrain conflicts. The pilot told the observer he would then continue the flight under IFR until

they reached the nearest airport or exited the bad weather. The observer told investigators the

pilot had never been forced to execute this plan during the 300-plus missions they had conducted

together because, aside from momentary whiteouts during takeoff or landing, they had never

encountered zero-visibility conditions in flight.

The recently retired aircraft section supervisor, who was a nonhelicopter-rated pilot and

left the Alaska DPS about 3 weeks before the accident, characterized the pilot as a “very careful

pilot.” She said that although she had never flown with the pilot, she knew this because she had

seen him in the office checking the weather before accepting a mission, and she had also

received notifications that the helicopter had been assigned to a SAR mission but was on hold

because of poor weather conditions such as low ceilings or freezing rain.

1.2.1.5.3 Pilot’s Motivational Factors

The pilot’s spouse stated that the pilot enjoyed flying the helicopter and was highly

motivated about flying-related tasks. She said that he was very close to his family and found it

rewarding to rescue people and bring them back safely to their families.

Describing the September 2012 mission that the pilot performed to rescue three people

from two airplanes that had become stranded on a gravel bar by rising water, 21

the aircraft

section commander stated that a 210th Air National Guard Rescue Squadron crew attempted to

reach the location in a Sikorsky HH-60 Pave Hawk helicopter but had to turn back when they

were unable to cross a mountain pass due to poor weather conditions. The pilot stayed up all

night and continued to check the weather until he saw a “weather window on the radar” that he

thought would allow him to reach the location. About 0300, the pilot launched, and, by using a

different route that avoided the mountain pass where the Air National Guard crew was forced to

turn back, he reached the location and rescued the three people. The aircraft section commander

said that this mission demonstrated how “motivated and driven” the pilot was to perform rescues.

1.2.1.5.4 Attitude Regarding Overtime

The recently retired aircraft section supervisor said that the pilot considered overtime “an

expected part of his job.” Also, the aircraft section commander said that it was difficult to get the

pilot to take time off. He said that any time he talked to the pilot about adjusting his schedule or

bringing in another pilot to share the standby duty, the pilot would complain that this was going

to take away from his overtime pay.

21

One of the individuals who was rescued wrote an e-mail commending the pilot.

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The major who was the AWT deputy director said that he had recently become aware of

the number of days the pilot was on standby and that his concern about this prompted him to

discuss it with the aircraft section commander. He said that if a pilot were paid a salary rather

than hourly pay, this might be beneficial because it would remove the incentive to work more

hours to make more money.

The relief pilot said that the pilot wanted to be on standby because he wanted the

overtime. The relief pilot said that he had offered to cover for the pilot if he needed a break and

that he had done so when the pilot wanted time off, such as when he went on vacation or got

sick. He said that the pilot had expressed to him that he was afraid that he would be replaced if

other pilots were allowed to fly more of the helicopter’s missions.

The relief pilot recalled that, on Thursday, March 28, the pilot had visited him at Alaska

DPS headquarters between 0700 and 1200. During the conversation, he discussed a proposed

change with the pilot regarding the pilot scheduling for the helicopter. The AWT deputy director

had proposed that the relief pilot serve as the primary pilot for the helicopter 2 days a week. The

AWT deputy director said that he made this decision when he realized that the pilot was

continuously on call. The purpose of the change was to allow the pilot to have some time off

duty each week. The relief pilot said that the pilot was upset about this scheduling change.

1.2.2 Flight Observer

The trooper who served as a flight observer held a commercial pilot certificate with

ratings for single-engine land, multiengine land, single-engine sea, and instrument airplanes. He

was issued an FAA second-class medical certificate on August 20, 2012, with no limitations. He

owned a Piper PA-18 Super Cub airplane, which he flew on his days off.

According to the flight observer’s spouse, the flight observer had previously

accompanied the pilot on several missions and enjoyed flying with him. According to the pilot’s

mission records, the flight observer most recently accompanied him on a March 15, 2013, SAR

mission. The flight observer received no Alaska DPS training for using NVGs or assisting with

helicopter flight tasks, such as operating some of the helicopter’s navigational equipment.

1.3 Helicopter Information

The accident helicopter, pictured in figure 5, was a Eurocopter AS350 B3 model powered

by a single Turbomeca Arriel 2B turboshaft engine with a single three-bladed main rotor system

using a conventional two-bladed tail rotor for antitorque and heading control. The helicopter had

four large doors, two located on either side of the helicopter, for access to the cockpit and

passenger seating area. For the SAR mission, the left seat controls had been removed, and the

NTSB Aircraft Accident Report

14

seating capacity was for a pilot and six passengers. The helicopter was not certified for IFR flight

operations. 22

Figure 5. Preaccident photograph of the helicopter.

The helicopter was equipped with a Garmin GNS 430 GPS mounted in the center of the

instrument panel; a Garmin GPSMAP 296, which was mounted on the lower right side of the

instrument panel; an Avalex Technologies™ mapping flight display system that had various map

display capabilities; and a forward-looking infrared (FLIR) system. 23

The Garmin 430 unit could

be connected to the horizontal situation indicator (HSI) such that the course deviation indicator

(CDI) could be used for additional course guidance. The Garmin 296 unit was capable of

showing color-coded terrain elevation information and terrain alerts if selected by the pilot. The

helicopter had an AIM 1200 attitude indicator that was limited to indicating ± 25° of pitch (that

22

None of the Alaska DPS helicopters were IFR-certified. Helicopters that are certified for IFR operations are

typically more stable than VFR-only helicopters because the certification requirements are often met through the use

of stabilization and/or automatic flight control systems. According to chapter 10-1-1 in the FAA Aeronautical

Information Manual, the systems typically fall into categories that include aerodynamic surfaces that impart some

capability or control capability not found in the basic VFR configuration, stability augmentation systems, attitude

retention systems, and/or autopilot systems, among others. 23

The FLIR system was not operational at the time of the accident. The external components had been

removed.

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15

is, if the helicopter’s pitch exceeded the limitation, the pitch indicator would stop at the limit and

remain there until the helicopter’s pitch no longer exceeded the limit). 24

Modifications included high skid landing gear; inflatable skid floats; snow shoes; a

406-MHz ELT; an Appareo Systems Vision 1000 cockpit image, audio, and data recorder; 25

and

a lighting system that was compatible with the flight crew’s use of NVGs.

The helicopter also carried survival equipment and rescue gear. Aircraft section personnel

estimated the weight of this equipment at 275 lbs. The AMRG volunteer who frequently flew

with the pilot said that the survival equipment included two sleeping bags, a tent, a trauma kit,

food, a satellite phone, a personal locator beacon, and snowshoes.

1.3.1 Maintenance

Alaska DPS had operated and maintained the helicopter for about 10 years since

acquiring it new. A review of the helicopter logbooks revealed that, at the time of the departure

from ANC, the helicopter had accumulated 2,518.8 hours and 5,179 landings, and the engine had

accumulated 2,476.7 hours.

The last inspection that was performed on the helicopter was a 150-hour inspection on

March 17, 2013, and the helicopter had accumulated 2,518.8 hours at that time. A certified repair

station mechanic at the AST hangar performed the inspection. The helicopter was approved for

return-to-service and released for flight. The last 100-hour inspection was performed on

October 1, 2012, by the same mechanic who performed the last 150-hour inspection, and the

helicopter had accumulated 2,466.4 flight hours at that time.

A review of the helicopter logbook for the last 30 days revealed that all maintenance

write-ups had been cleared; there were no open or deferred items. All maintenance was listed as

accomplished in accordance with Eurocopter’s maintenance procedures, and the helicopter was

returned to service.

Witnesses reported that the pilot kept the turn-and-bank indicator disabled by pulling its

circuit breaker. No one was certain of the pilot’s reason for doing this. The AMRG observer said

that the turn-and-bank indicator worked but that there was “a problem with it.” Another of the

pilot’s colleagues thought that the pilot disabled the instrument when it was not needed to extend

its life by reducing wear. The most recent maintenance record related to the turn-and-bank

24

The operating manual for the AIM 1200 did not include information about its pitch and bank indicating range

limits. The manufacturer provided this information during the investigation. The AIM 1200 attitude indicator’s pitch

indication range met the requirements of the FAA’s technical standard order (TSO) for bank and pitch instruments,

TSO-C4c. TSO-C4c states that bank and pitch instruments manufactured for installation on civil aircraft after

April 1, 1959, shall meet the standards set forth in the Society of Automotive Engineers’ Aeronautical Standard

AS-396B, dated July 15, 1958. AS-396B states, under the heading “Indicating Range,” that “the range of indication

in pitch shall be at least plus or minus 25 degrees. The range of indication in bank shall be at least plus or minus

100 degrees.” Under the heading “Operating Range,” AS-396B states that “the instrument shall be operable

following maneuvers of 360 degrees in bank and 360 degrees in pitch.” 25

The recorder installation was accomplished as a modification under an FAA supplemental type certificate.

Airbus, which is the current type certificate holder for the AS350 models, equips all new AS350 helicopters with

Appareo units.

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16

indicator was from 2004. The record stated, “T&B makes noise in headset. Removed T&B to

facilitate testing, not able to duplicate problem. Note: T&B is powered from avionics [bus].” The

helicopter was signed off and returned to service on November 3, 2004, and no other records or

maintenance write-ups regarding the turn-and-bank indicator were found.

A review of the maintenance records revealed incident and inspection findings that

included an April 21, 2006, hard-landing accident; a May 13, 2009, main rotor overspeed 26

event; a March 23, 2011, tail rotor pitch change link replacement (due to a suspected crack); and

an April 15, 2011, overtorque 27

event.

1.3.2 Pilot’s Concerns about Maintenance

A friend of the pilot, who worked for the aviation section as a mechanic from 1988 to

2009, said that during a conversation with the pilot on March 22, 2013, the pilot said that he was

“disgusted” with the quality of the maintenance being done on the helicopter. In particular, the

pilot expressed his concern that some hoses had not been replaced within the specified time.

Another friend of the pilot, who worked for the aviation section as a mechanic from 2004 to

2007, said that the pilot “didn’t have any confidence in the department as far as their ability to

properly maintain the helicopter.” According to some of the pilot’s colleagues, the pilot did not

have a very good relationship with the helicopter’s lead mechanic and often disagreed with the

mechanic about how the maintenance should be performed and how long it should take.

The lead mechanic for the helicopter said that the pilot disliked not being in charge of the

helicopter’s maintenance. The mechanic said that he and the pilot did not get along well for

several years, but the relationship recently improved. He attributed the improvement, in part, to a

complaint that he made to the FAA about the pilot. (The complaint, discussed in section 1.8.3.3,

resulted in Alaska DPS disciplinary action against the pilot.) He also attributed the improvement

to an agreement in which the pilot was allowed to be responsible for the maintenance

recordkeeping for the helicopter.

1.4 Meteorological Information

There is no record of the pilot obtaining a weather briefing by calling FSS or accessing

the direct user access terminal service. 28

It is unknown what weather information sources the

pilot may have accessed before deciding to accept the mission. A former Alaska DPS relief pilot

said that the most relevant weather information for the search area that he would have checked

were the area forecast (FA) for Cook Inlet and Susitna Valley and the meteorological aerodrome

26

Overspeed is a condition in which an engine or rotor system operates at a speed (rpm) greater than the

maximum allowable. 27

Overtorque is a condition in which an engine produces more torque (power) than the maximum allowable. 28

According to chapter 7-1-4 of the Aeronautical Information Manual, an FSS is the primary source for

obtaining preflight briefings and inflight weather information. Flight service specialists are authorized to translate

and interpret available forecasts and reports directly into terms describing the weather conditions expected along a

pilot’s flight route and destination. These include, but are not limited to, reported weather conditions summarized

from all available sources (such as meteorological aerodrome reports [METAR], special METARs, and pilot

reports), the en route forecast for the proposed route, and the destination forecast for the estimated time of arrival.

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17

reports (METARs) and terminal aerodrome forecast (TAF) for the Talkeetna Airport (TKA) and

ANC (the departure airport). TKA was located 5 nautical mi west of the search area (and about

4 mi west of the accident site) at an airport elevation of 358 ft.

The current and former relief pilots for the accident helicopter both said that they

typically obtained weather information from the National Weather Service (NWS) Alaska

Aviation Weather Unit (AAWU) website 29

and followed up with a call to FSS to speak to a

briefer only if they had a concern about the weather. The current relief pilot said that the accident

pilot also used the AAWU website. The AAWU website displays links to various weather

information products for pilots, including FAs, METARs, and TAFs. Its default homepage

displays a map of Alaska with any AIRMET 30

advisory areas highlighted in yellow and

SIGMET 31

advisory areas highlighted in red. Hovering the cursor over these highlighted areas

produces a popup window displaying the text of an advisory.

1.4.1 Weather Information Available Before Departure

At the time that the pilot received the call about the mission (at 2019), the TAF for TKA

issued at 2008 (valid for the 20-hour period beginning at 2000) forecasted a calm wind, visibility

greater than 6 mi, light rain, a broken ceiling at 1,000 ft agl, broken clouds at 1,800 ft agl, and

overcast skies at 2,800 ft agl. The FA issued at 1745 forecasted scattered clouds at 2,000 ft,

scattered to broken clouds at 6,000 ft, broken to scattered clouds at 12,000 ft, and cloud tops to

flight level 180. 32

A widely scattered area of broken ceilings at 2,000 ft with light rain showers

was forecast. The forecast included isolated light rain and snow showers with visibility down to

4 mi at times. The FA contained no forecasted turbulence, icing, or IFR conditions, and there

were no AIRMETs for IFR conditions. 33

The NWS Office in Anchorage, Alaska, issued the updated Zone Forecast Product at

2015. The information about the search area and accident area had not been updated since 1600,

and it forecasted cloudy skies with scattered snow showers. Rain was forecasted to mix with

snow during the evening hours with light winds.

The observed weather conditions at TKA reported in the 1953 METAR were wind calm,

10 mi visibility, light rain, a broken ceiling at 1,000 ft agl, broken clouds at 1,800 ft agl, overcast

skies at 2,800 ft agl, temperature of 2° C, dew point temperature of 1° C, and an altimeter setting

of 30.20 in of mercury (in Hg).

29

The AAWU website can be accessed at http://aawu.arh.noaa.gov. 30

An AIRMET is an advisory that includes significant weather phenomena that contain details about IFR,

extensive mountain obscuration, turbulence, strong surface winds, icing, and freezing levels. AIRMETs describe

conditions at intensities lower than those that require the issuance of a SIGMET. 31

A SIGMET is an advisory that advises of nonconvective weather that is potentially hazardous to all aircraft.

These phenomena include severe icing not associated with thunderstorms, severe or extreme clear air turbulence not

associated with thunderstorms, dust storms or sand storms lowering surface visibilities to below 3 mi, volcanic ash,

and, in Alaska and Hawaii, tornadoes, lines of thunderstorms, embedded thunderstorms, and hail greater than or

equal to 3/4-in diameter. 32

A flight level is a standard nominal altitude of an aircraft, in hundreds of feet. This altitude is calculated from

the international standard pressure datum of 29.92 in of mercury, the average sea-level pressure. 33

The criteria for IFR conditions are a ceiling below 1,000 ft agl and/or less than 3 mi visibility.

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A review of weather radar imagery available at the time that the pilot received the call

about the mission showed scattered showers around the Palmer Municipal Airport (PAQ) in

Palmer, Alaska (PAQ is located 50 mi south-southeast of the accident site at an elevation of

242 ft), and the Wasilla Airport in Wasilla, Alaska. The imagery depicted these showers as

moving northward (toward TKA).

1.4.2 Weather and Lighting Conditions at Accident Site and Time

The accident occurred at 2320. Observed weather conditions at TKA reported in the 2253

METAR were wind calm, 6 mi visibility, light rain and mist, few clouds at 500 ft agl, a broken

ceiling at 1,500 ft agl, overcast skies at 2,400 ft agl, temperature of 1° C, dew point temperature

of 1° C, and an altimeter setting of 30.22 in Hg. The observed weather conditions at TKA

reported in the 2312 METAR were wind calm, 7 mi visibility, light snow, a broken ceiling at

900 ft agl, broken skies at 1,300 ft agl, overcast skies at 2,400 ft agl, temperature of 1° C, dew

point temperature of 1° C, and an altimeter setting of 30.22 in Hg. The remarks stated that

unknown precipitation began at 2310 and ended at 2312 and that snow began at 2312.

The NWS Surface Analysis Chart for 0100 on March 31, 2013, depicted a stationary

front north of the Alaska Range that stretched west to east into northwest Canada. The station

models around the accident site depicted temperature-dew point spreads of 4° F or less, light and

variable winds, cloudy skies, and light snow.

A review of weather radar imagery showed a line of echoes extending from PAQ to TKA

around the time of the accident. The imagery depicted this line of showers as moving northward

from PAQ (which had earlier surface reports of precipitation) through TKA and the accident site

around the time of the accident.

A witness, who regularly makes “go/no-go” decisions for SAR operations for the

National Park Service, was located 3 mi west of the accident site. He reported that the clouds

began lowering around 2020, with light rain mixed with sleet at times, and about 10 mi visibility.

He was located inside until 2300, when he walked to his vehicle and noticed that it was raining

with a temperature of 34° F reported on his vehicle. This witness began driving home in the rain

when it began to snow so heavily that he had to turn off his bright lights so that he could see. He

continued to drive and arrived at his home, located about 5 mi southwest of the accident site,

about 2315, and the heavy snow continued. Two witnesses 10 mi southwest of Larson Lake

reported a mix of rain and sleet with the temperature around freezing when the accident

helicopter flew overhead around 2130. One of those witnesses reported a changeover to snow

between 2130 and 2300 with the snow coming down like a “son of a gun.” This witness reported

4 in of new snow at 1,700 ft the next morning. A witness 2 mi northeast of Larson Lake reported

light freezing drizzle and rain around 2200 with 1 in of fresh “crusted up” snow around their

property the next morning.

Sunset was at 2043, the end of civil twilight was at 2130, and moonrise occurred the

following morning at 0104. According to the FAA, night VFR lighting conditions can be

classified as “high level” or “low level.” Low-level lighting conditions are present when clouds

cover at least 5/8 of the sky, the moon is below the horizon, or the moon is less than 50%

illuminated, and little significant cultural or reflected cultural lighting is present.

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The TAF for TKA issued at 2137 (valid for the 24-hour period beginning at 2200)

forecasted a calm wind, visibility greater than 6 mi, a broken ceiling at 900 ft agl, broken clouds

at 4,500 ft agl, and overcast skies at 6,000 ft agl. These forecasted IFR conditions were not

referenced in an AIRMET or an updated FA. (Typically, TAFs and FAs are consistent with each

other with regard to references to IFR conditions. During other accident investigations, the

NTSB noticed inconsistencies among other weather information products and issued safety

recommendations to address these issues. These recommendations are discussed in

section 1.9.3.)

1.5 Cockpit Image, Audio, and Data Recorder

The helicopter’s Appareo Systems Vision 1000 cockpit imaging and flight data

monitoring device was mounted on the cockpit ceiling. The self-contained unit is designed to

record cockpit images and two-track audio, and it has a GPS receiver for satellite-based time,

position, altitude, and groundspeed information. It also has a self-contained real-time inertial

measuring unit that provides three-axis accelerations as well as aircraft pitch, roll, and yaw

data. 34

The unit recovered from the accident helicopter showed damage on the exterior case and

power connector (see figure 6). The removable memory card was undamaged, and its data were

downloaded. Recovered data included about 2 hours of image and audio data and about

100 hours of parametric data.

Review of the data revealed that no external audio source (such as the helicopter’s

intercom or radios) was connected to audio track “one” for recording (which is an optional audio

link referred to by Appareo as the “ICS,” or “Intercom System”). Audio track “two” recorded

sound from the unit’s internal microphone, which captured only loud helicopter

engine/transmission sounds and no intelligible voices. Review of the data also revealed that the

unit’s internal attitude data were subject to inaccuracies. 35

The recorded images captured a view

of the cockpit from behind the pilot looking forward. Some navigation and system instruments

and displays, the helicopter’s master caution warning panel, a partial view out the cockpit

windscreen, and some of the pilot’s left arm and head motions (the pilot was seated in the right

seat) were visible at times.

34

The helicopter was not required to be equipped with a cockpit voice recorder or flight data recorder. The

optional device was not required to comply with TSO C197, “Information Collection and Monitoring Systems.” 35

The investigation found that the unit was not properly configured when it was installed. The Appareo

Systems Vision 1000 installation instructions (revision dated October 22, 2010) did not contain instructions for

configuring the unit; configuration instructions were contained in a separate publication. Appareo has since issued

revised installation instructions (dated October 29, 2013) that contain a section dedicated to configuring the unit.

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Figure 6. Appareo Vision 1000 unit from the accident helicopter.

Images from the flight from ANC to the remote rescue location (via the Sunshine site)

showed that, before departure from ANC, the pilot adjusted the Avalex display brightness down,

changed the type of map it displayed from a street map to a topographic map, and changed the

map orientation from “north up” to “track up.” The imagery showed that the helicopter’s

turn-and-bank indicator was not operating during the outbound flight from ANC or during the

accident flight. During the flight from ANC to the Sunshine site, the pilot raised, lowered, and

adjusted his NVGs several times. He lowered them before landing and used them during landing

at the Sunshine site. The pilot did not shut down the helicopter while at the Sunshine site. The

flight observer, who did not use NVGs, boarded and sat in the left seat, and the flight departed.

The pilot used the NVGs during liftoff from the Sunshine site and during landing at the remote

rescue location.

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Images for the accident flight showed that, before takeoff from the frozen pond, the pilot

turned on the “lip light” 36

attached to his helmet and kept it on during the entire flight. The light

cast an area of illumination about 1 ft in diameter that moved when the pilot moved his head.

The light at times illuminated parts of the helicopter’s instrument panel and flight controls. The

pilot also made inputs to the Garmin 296 unit, which displayed a track-up map and a magenta

course line that extended to the southwest, consistent with a direct route to Sunshine. The Avalex

display powered up and displayed a north-up street map. As the helicopter lifted off from the

frozen pond, no blowing snow was visible and, once the helicopter left the ground, no outside

lights or ground references were seen by the Appareo unit for the remainder of the flight. The

helicopter’s master caution warning panel and engine instruments (including the first limit

indicator [FLI], which displays engine power information) are visible at times. No warning or

caution lights from the helicopter’s master caution warning panel and no abnormal engine

instrument readings appear.

Table 2 summarizes some of the navigational instrument readings and other information

obtained from reviewing the imagery from the accident flight. Some pitch indications on the

attitude indicator are approximate. Pitch indications higher than about 17° could not be

accurately measured due to a combination of low image resolution, the dark night condition,

shadows, and the construction of the instrument.

Table 2. Summary of select information from Appareo images.

Time Altimeter (barometric)

Airspeed indicator

Comments

2310:19 Start of engine

2310:44 Avalex display is powering up

2310:54 Garmin entry screen is acknowledged

2310:57 Pilot selecting entry on Garmin 296

2312:11 Garmin 296 display changes to track heading screen

2312:45 Avalex display unit comes up in street map mode – north up orientation

2312:47 400 ft 0 kts

Attitude indicator shows 0° pitch, 0° roll, aircraft level line set at 0° pitch, vertical speed is 0 ft per min (fpm), turn indicator is at zero (where it remains for the entire flight)

2313:00

Helicopter is lifting off surface, no blowing snow, only light is from red position light, once aircraft leaves ground, no outside lights or ground references are seen during remainder of flight

2313:08 Garmin 296 display is showing a magenta course line about 30° to the right of the helicopter’s heading of 180°

2313:16 Pilot with NVG in down position

36

The pilot’s lip light consisted of a row of several LED bulbs embedded in plastic and attached to the pilot’s

boom microphone with a button on the back of the unit that the pilot could toggle on or off with his mouth.

According to other DPS helicopter pilots, the lip light helps a pilot see cockpit instrumentation and controls. When

using NVGs, the pilot could look through the NVG binoculars to see outside and could look below them to view the

cockpit instruments.

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Time Altimeter (barometric)

Airspeed indicator

Comments

2314:40 Helicopter starts left turn off of GPS track, 500 fpm climb, 20° left roll, 300 ft radio altimeter

2315:17 800 ft 20 kts 7° right roll, 150 ft radio altimeter

2317:23 1,050 ft 40 kts Level attitude, 300 fpm climb, 200 ft radio altimeter, on Garmin 296 course

2317:29 Two fingers from left seat observer are seen in front of Avalex screen (no buttons were pushed), 2.5° left roll, 0° pitch

2317:56

0° roll, 0° pitch, 15 knots indicated airspeed, 950 fpm climb, 450 ft radio altimeter, 9.5 FLI, 1,250 ft altimeter, Garmin 296 course line not visible

2318:02 10 kts 2.5° left roll, 5° up pitch, 1,400 ft altimeter, 1,000 fpm climb, 600-700 ft radio altimeter, 9.1 FLI

2318:07 1,410 ft 0 kts

Pilot’s left hand is visible adjusting CDI indicator, nav red flag is visible, 1,100 fpm climb, 2.5° right roll, 5° up pitch

2318:12 1,510 ft 0 kts

0° roll, 7.5° up pitch, 1,200 fpm climb, 550 ft radio altimeter, 10 FLI, T4 (turbine outlet/exhaust gas temperature) yellow underline, torque underline in yellow

2318:17 1,620 ft 0 kts 7.5° right roll, 10° up pitch, 900 ft radio altimeter, 1,200 fpm climb, 10 FLI, T4 yellow underline, torque underline in yellow

2318:20 1,700 ft 0 kts 5° right roll, 12.5° up pitch, 1,000 fpm climb, 10 FLI, 900 ft radio altimeter, Garmin 296 course line back in view

2318:21 0 kts 5° right roll, 12.5° up pitch, 900 fpm climb, 7.8 FLI

2318:24 Left seat observer pointing at Avalex display, 15° right roll, 12.5° up pitch

2318:27 12.5° right roll, 17.5° up pitch

2318:28 Pitch exceeds 17.5° from this time until 2318:40.

2318:40 0 kts Pilot cages the attitude indicator, 0° pitch, 0° roll, 800 fpm climb, 9 FLI

2318:43 1,800 ft 0° pitch, 20° left roll, 0 fpm vertical speed, 9.5 FLI

2319:06 1,790 ft 0 kts 85° right roll, 0° pitch, 500 fpm climb, 8 FLI,

2319:33 1,550 ft 0 kts 0° pitch, 30° right roll, 800 ft radio altimeter, 200 fpm descent, 7 FLI

2319:35 1,500 ft 0 kts 85° right roll, 0 fpm vertical speed, 7.5 FLI

2319:43 Attitude indicator tumbled

2319:48 1,500 ft 0 kts 30° left roll, 10° up pitch, 7 FLI, 0 fpm vertical speed, 600 ft radio altimeter

2319:48 1,500 ft 0 kts 30° right roll, 10° up pitch, 0 fpm vertical speed, 500 ft radio altimeter, 7.3 FLI, no warning/caution lights

2320:02 End of recording

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1.6 Wreckage and Impact Information

The helicopter was found on snow-covered, wooded terrain (see figure 7). The helicopter

was destroyed by impact forces and postcrash fire, and the ELT showed impact and fire damage.

The initial ground impact site was about 3 ft before the beginning of the wreckage debris field,

and the debris path measured about 75 ft long on a magnetic heading of 029°, which was also the

flightpath direction (in-line with the tree damage). A tree near the initial impact site exhibited

strikes with about a 60° angle (relative to the horizon and along the flightpath direction). The tree

branch ends were smooth and even.

The entire helicopter was accounted for at the crash site. The helicopter came to rest

inverted with the landing gear and tailboom forward of the main debris area. Fragments outside

the main debris crater were not fire damaged and had no soot streaks. The center section of the

fuselage was largely missing, with the main transmission case predominately consumed by fire.

The main transmission gears showed evidence of postcrash fire and did not exhibit missing gear

teeth, galled areas, or other evidence of mechanical malfunction.

Figure 7. Accident site showing main wreckage.

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24

Fragments of the cyclic, collective, and yaw controls were found loose in the debris.

Continuity could not be established due to the breaks in the system and missing portions of the

push-pull tubes; however, some breaks were matched and examined for evidence of malfunction

or failure. None was found. The breaks were examined and exhibited characteristics consistent

with overload fractures and melting. The damage to the flight control system was consistent with

ground impact and exposure to postimpact fire. The red, yellow, and blue main rotor blade hub

ends remained attached to the hub. The main rotor blades were broken, mostly thermally

consumed, and the spars were bent and twisted.

The tailboom was separated from the fuselage near the forward bulkhead, and the tail

rotor driveshaft was fractured at the junction of the tailboom and fuselage. Tail rotor control and

drive continuity were established from the tailboom separation at the fuselage to the flange of the

tail rotor gearbox drive coupling.

The engine was found upside down covered by the engine deck and in the proper

orientation to the tailboom (also upside down). The rear engine mount was broken away from the

engine, and the front engine mount was still connected to the coupling tube. The transmission

shaft was inside the coupling tube, and the engine side flexible coupling group was relatively

undamaged with the transmission side showing rotation and tension splaying. The tail rotor drive

flexible coupling displayed rotational splaying. The freewheel shaft functionality was verified to

be correct.

The reduction gearbox was removed in the field for inspection of the input pinion

slippage mark. The slippage mark was offset in the torqueing (tightening direction) about

0.10 in, which is consistent with significant power at the time the main rotor system struck the

ground and stopped.

1.7 Medical and Pathological Information

Autopsy reports provided by the State of Alaska Medical Examiner’s Office concluded

that the cause of death for each occupant was “blunt force and thermal injuries sustained during a

helicopter crash.”

The FAA’s Civil Aerospace Medical Institute performed toxicology testing on samples

from the pilot. The report indicated that no ethanol or drugs were detected in the samples tested.

1.8 Organizational and Management Information

1.8.1 General

The Alaska DPS aircraft section is a specialized unit of AWT responsible for maintaining

the department-owned aircraft fleet and for providing training to all department pilots, the

majority of whom are commissioned troopers. At the time of the accident, the DPS fleet included

38 airplanes and 4 helicopters (3 Robinson R-44s and the accident helicopter), and the aircraft

section had an assigned staff of 13 people consisting of 6 mechanics, 3 pilots, 2 administrative

assistants, the aircraft section supervisor, and the aircraft section commander. All aircraft section

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25

staff members had offices in the aircraft section’s hangar located in Anchorage. The aircraft

section supervisor’s position was vacant due to the March 8, 2013, retirement of the person who

held that job.

Each of the department’s aircraft is assigned to a particular AST or AWT section, and it

is considered to be an asset of that section, not of the aircraft section. The aircraft section directly

employs civilian pilots (such as the accident pilot) whose primary job functions are to operate

aircraft and provide flight training. When a trooper is designated as a pilot, their pilot duties are

performed in addition to their regular trooper duties, and that trooper remains assigned to their

detachment and is supervised by the detachment chain of command.

Figure 8 illustrates the chain of command structure that was in place at the time of the

accident, based on interviews with DPS personnel.

Figure 8. Chain of command structure in place at the time of the accident. (*Note: Although the SAR coordinator is part of the AST, the AST chain of command personnel are omitted because they are not discussed in this report.)

The aircraft section commander (lieutenant) said that the captain and major were not

pilots and that the AWT director was a pilot. He said that “generally he was able to go directly”

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to the AWT director, who made “a lot of the ultimate decisions.” He said that his position had

been created by the AWT director in August 2011 and that his function was to act as a liaison

between the aircraft section supervisor, who was a civilian, and the commissioned troopers. He

provided direction to the aircraft section supervisor who “ran the business” and oversaw the

aircraft section mechanics and administrative staff. Before the aircraft section commander joined

the aircraft section, the aircraft section supervisor would ask the AWT director for guidance

“when troopers in the field had questions about needing maintenance or an airplane or

something”; after the aircraft section commander came on board, he responded to troopers’

questions instead of the aircraft section supervisor asking the AWT director. Since the aircraft

section supervisor retired, the aircraft section commander had been filling that position as well as

his own. He said that he was planning to retire on September 27, 2013.

The recently retired aircraft section supervisor, who held the position from August 24,

2009, to March 8, 2013, said that she initially reported to the captain, then she reported to the

AWT director, and beginning in 2012 she reported to the aircraft section commander. She said

that she supervised the maintenance shop foreman, three pilots, and the administrative assistant;

the maintenance shop foreman supervised five mechanics, and the administrative assistant

supervised the office assistant. The recently retired aircraft section supervisor explained that she

was listed as the pilot’s supervisor, but “in reality” he was supervised by the AST SAR

coordinator, and she was not involved in any of his flights. The SAR coordinator contacted the

pilot directly regarding SAR missions. The aircraft section supervisor was responsible for

approving the pilot’s time cards and writing his performance appraisals, and she was involved if

he needed to purchase equipment for the helicopter.

According to the department’s aircraft operations manual, the aircraft section supervisor

is responsible for the content and currency of the manual. The recently retired aircraft section

supervisor stated that her positon “[did]n’t have any authority.” She explained that some of the

position’s duties are specified in the department’s aircraft operations manual, but that, in reality,

headquarters would direct or make the decisions. She said that if she made decisions the aircraft

section staff did not like, they would just bypass her to consult headquarters.

According to NTSB records, the Alaska DPS had 18 previous accidents that occurred

between July 1, 1999, and June 30, 2012. One accident was fatal, one resulted in a minor injury,

and 16 involved substantial aircraft damage but resulted in no injuries.

1.8.2 Aircraft Section Policies and Procedures

1.8.2.1 Operational Control and Go/No-Go Decisions

The Alaska DPS aircraft operations manual did not include requirements for anyone other

than the pilot to be involved in flight planning, risk analysis, and decision-making

responsibilities. The manual chapter titled “Pilot Responsibility and Authority” stated, in part,

“in preparation for every flight, pilots will evaluate aircraft performance, route of flight

information, and weather conditions in the context of their own abilities and experience and base

mission decisions on a totality of the information available to them.” Further, this section stated

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27

that “the PIC is responsible for the safe operation of the aircraft and is the ultimate decision

maker with regard to the conduct of the flight.”

The aircraft section commander said that the “ultimate responsibility” to go or not to go

on a flight rested with the pilot. He said that he had told the pilots during seminars and other

discussions, “if you don’t feel like going, for whatever your reasons, maybe it’s below

minimums for weather, or other conditions…then don’t go on the flight.” He said that during his

25-year career with DPS he had never seen any supervisor push back if a pilot decided not to go

on a flight. The relief pilot and a former relief pilot for the accident helicopter reported that they

did not feel pressed to fly, but two other former DPS personnel recalled one instance in 2009 in

which a pilot was pressured to fly. 37

The aircraft section commander said that the pilot did not normally call him when he

launched on a SAR mission and that many times, if a launch occurred on the weekend, he would

not know until the following Monday when he came to work that there had been a flight. He said

that the pilot did not need to obtain his permission to fly because he did not have control over the

helicopter. He explained that the helicopter was an AST asset and that the “go-to person” for

requesting it was the AST SAR coordinator.

The AST SAR coordinator explained that his job was to act as a central point of contact

for everything having to do with the resources that a trooper needed to conduct a SAR operation,

including aircraft, equipment, and volunteers. He said that, at the time of the accident, he and

two other people were taking turns as the on-call SAR coordinator after hours and on weekends

and holidays and that he was not on call the night of the accident. His normal procedure when he

received a request for assistance from a trooper was to evaluate whether sending the helicopter

would be the best tool for the job. If that was the case, he would call a pilot and ask him to

evaluate the weather, the location, and other factors to determine whether he could go or not. He

said that he relied on the pilots to determine whether or not they could safely accept the mission

and that “there was absolutely no pressure whatsoever” on pilots to accept a mission.

1.8.2.2 Flight and Duty Time Policies

The Alaska DPS aircraft operations manual stated that, for a single pilot, the maximum

duty period was limited to 12 hours, the maximum flight time within the duty period was limited

to 8 hours, and the rest period was 10 hours. During emergencies, which included SAR

operations, an extension of the maximum duty period to 15 hours, the maximum flight time

within the duty period to 10 hours, and the rest period to 12 hours was allowed with “the

approval of a DPS supervisor who is or has been a pilot and who can assess the need as well as

the pilot’s personal condition at the time.”

The recently retired aircraft section supervisor said that the pilots tracked their own time

and that they were “very good” about tracking it. When she first started, the accident pilot called

her a couple of times to let her know that he was going to exceed his duty time limit but then he

37

Two former Alaska DPS personnel described an event in 2009 in which the AWT director pressured a

fixed-wing pilot to accept a flight in weather conditions that the pilot felt were potentially unsafe. The pilot

completed the flight without incident.

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28

stopped, and she believed he was instead calling the colonel (AWT director). The AWT director

recalled that the pilot called him “a couple of times” to ask for an extension of his maximum

flight or duty time, as permitted by the Alaska DPS aircraft operations manual.

The aircraft section commander was unfamiliar with the details of the section’s flight and

duty time policy. When asked whether the AST SAR coordinator monitored the accident pilot’s

flight and duty time, he said “no” and added that “we leave almost all of that up to the pilot to

know to follow.” He said that the pilot was familiar with the policy because he had brought the

limits to his attention on several occasions. He said the pilot was “quite aware of the policy,” and

he followed it.

1.8.2.3 Preflight Risk Assessment and Weather Minimums

The Alaska DPS aircraft operations manual did not include a preflight risk assessment

procedure. The recently retired aircraft section supervisor said that she was in the initial stages of

developing a risk assessment procedure for the section when she retired. She had obtained a form

that looked like it could be modified to meet their needs, and she had discussed with the aircraft

section commander trying it out with the aircraft section pilots. She stated that the accident pilot

had vigorously objected to the proposed implementation of this procedure because he thought

that only the SAR pilot should be able to turn down a SAR mission.

The manual did not specify any weather minimums for the operation of DPS aircraft

other than the applicable FAA requirements. The aircraft section commander said that pilots’

minimums depended on their experience. Alaska DPS policy indicated that any change had to be

approved in writing by the aircraft section supervisor. The most recent Alaska DPS Flight

Authorizations/Limitations form for the pilot was completed in 2003, shortly after he was hired.

As discussed in section 1.2.1.1, it stated that the pilot’s night VFR NVG weather minimums

were a 500-ft ceiling and 2-mi visibility. The aircraft section commander stated, however, that by

the time of the accident, the pilot was expected only to comply with FAA weather minimums,

which did not require any minimum visibility or cloud clearance below 1,200 ft agl in

class G airspace. 38

However, there was no record of this change in the pilot’s file. The recently

retired aircraft section supervisor said the same but also stated that the pilot used his own

personal weather minimums. In a 2009 e-mail, the pilot wrote a colleague that his personal

minimums for NVG operations at night were a 200-ft ceiling and 5-mi visibility. 39

1.8.2.4 Safety Program

The recently retired aircraft section supervisor told investigators that the AWT captain in

the aircraft section’s chain of command asked her to get DPS involved in the Medallion

38

Title 14 CFR 91.155 specifies that, within 1,200 ft of the surface, “A helicopter may be operated clear of

clouds if operated at a speed that allows the pilot adequate opportunity to see any air traffic or obstruction in time to

avoid a collision.” 39

In the same e-mail, the pilot wrote, “Please note 7.06 NVG Operational Limitations, dated 3/12/07, gives no

specific limitation other than slowing down for the weather condition during the flight. In addition, you must have

sufficient ambient light (lums) to continue with flight.”

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29

Foundation, 40

and, beginning in 2010, she worked to develop Alaska DPS’s safety management

system (SMS). 41

This effort included the development of a hazard reporting system, safety

committee, and other safety mechanisms that enabled DPS to earn one of the Medallion

Foundation’s five stars, the safety star. 42

To pass the Medallion Foundation audit for the safety

star, Alaska DPS was required to have various safety policy components in place, including

procedures for safety reporting, hazard identification, risk assessment, safety committees, and

internal safety auditing. The hazard reporting system was designed to allow employees in all

departments to report accidents, incidents, and injuries and to make suggestions or voice

concerns. The reporting system was to be nonpunitive with an anonymous reporting option, and

reported hazards were to be evaluated for risk by a formal safety committee that met on a regular

schedule to use the information to make safety improvements.

In addition, the program was required to have a full or part-time safety manager with the

authority necessary to run the program and a direct report to a high-level manager who was held

accountable for safety performance. Interviews with DPS personnel indicated that all of these

elements were in place when the organization passed its initial Medallion Foundation audit in

January 2012 and followup audit in July 2012.

However, the recently retired aircraft section supervisor stated that the safety program

lacked high-level Alaska DPS support and, as a result, there was a lack of Alaska DPS pilot

confidence and participation in the program. She said that she had only received “a couple” of

pilot reports involving aircraft operations and that most of the reported issues had involved safety

hazards located in or near the aircraft hangar. In addition, she stated that the section did not have

enough money for training and that, in 2012, headquarters canceled the annual 3-day pilot safety

seminar because of a lack of funds. She said that she thought that it was important to have the

seminar every year because it was the only time when about 40 trooper pilots were brought

together from their stations around the state to receive information about safety issues.

Further, in 2012, her chain of command changed such that instead of reporting to the

colonel who was the AWT director (a high-ranking manager), she reported to the lieutenant who

40

The Medallion Foundation was formed by the Alaska Air Carriers Association in 2001 as a nonprofit

organization for the purposes of improving pilot safety awareness and reducing air carrier insurance rates. The

organization’s stated mission is to reduce aviation accidents by fostering a proactive safety culture and promoting

higher safety standards through one-on-one mentoring, research, education, training, auditing, and advocacy. 41

According to International Civil Aviation Organization and FAA guidance materials, a comprehensive SMS

program should contain four major components: safety policy, safety risk management, safety assurance, and safety

promotion. Safety policy defines the policies, procedures, resources, and organizational structures that provide a

foundation for the program’s functional elements. Safety risk management is a formal system for identifying hazards

and managing related risks. Safety assurance is a process for evaluating the effectiveness of existing risk controls.

Safety promotion involves the promotion of safety as a core value and the development of an organizational culture

that is conducive to safety management. 42

The Medallion Foundation describes its Five Star/Shield Program for aircraft operators as “a step-by-step

approach to building an [SMS] by providing program and process guidelines, specific training classes, one-on-one

company mentoring and auditing to determine if the applicant meets the specific program requirements.” To earn the

safety star, an operator is required to have implemented a safety program with commitment from top management

that includes a nonpunitive and anonymous safety reporting system, an emergency response plan, a safety

committee, and a viable safety information collection and distribution system. (See the Medallion Foundation

website at http://medallionfoundation.org.)

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30

served as the aircraft section commander, a lower-ranking new position. She said that this change

undermined her influence as safety manager and that trooper pilots and middle managers felt

comfortable ignoring the safety policies that she had attempted to put in place. When she made a

decision staff disagreed with, they would just go around her and appeal directly to headquarters.

She said that she decided to leave the organization after an AST supervisor directed a pilot to fly

an airplane that had been repaired by someone other than a qualified mechanic.

She said that she assumed that the aircraft section commander would take over as the

manager of the safety program when she left. However, the aircraft section commander said that

he was not well versed in the former aircraft section supervisor’s activities in her role as safety

manager, and that, since she left, he had not “been able to keep up with all that stuff.” A safety

policy statement posted in the main hangar that was signed by the AWT director stated, “A

safety manager who is experienced in safety programs will be appointed and will have the

responsibility and authority to manage the Alaska DPS aviation safety program. The safety

manager should be contacted in regards to any questions or recommendations.”

Three months after the aircraft section supervisor retired, no safety manager had been

formally appointed, and no safety committee meetings had been held. The AWT director said

that he realized that the civilian aircraft section supervisor ran the aircraft section safety program,

but, when she retired in March 2013, he delayed selecting her replacement because he was

retiring in May 2013 and wanted to allow his replacement to select the new aircraft section

supervisor to help facilitate any necessary operational changes.

1.8.3 Response to Pilot’s Previous Accident and Events

1.8.3.1 Accident in 2006

Following the pilot’s accident in 2006, the AWT director appointed an Aircraft Accident

Review Board that conducted an internal investigation separate from the NTSB’s. The review

board, which consisted of an AWT captain, the aircraft section supervisor, the former relief pilot

for the helicopter, and another AWT helicopter pilot (who later became the relief pilot), met on

April 28, 2006. A memorandum dated May 2, 2006, that documented the review board’s

investigation included the following “aggravating factors,” among others:

 The pilot was aware of the blowing snow, low visibility condition before takeoff.

 The pilot depended on a visual reference by using the edge of the lake.

 The pilot did not execute an instrument takeoff when confronted with a blowing snow condition and choose to hover and use a reference point.

 The pilot had worked for 18 days straight without a day off.

The memorandum stated:

The direct cause of the incident was the pilot’s loss of visual reference with the

ground while taking off. …The loss of visual reference was a direct result of

blowing snow caused from the rotor downwash as power was applied during

takeoff. The pilot’s landing site selection; positioning of the helicopter on landing;

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31

choice of VFR departure vs. an IFR instrument departure under the existing

weather conditions when linked together led to this incident. Based upon the

evidence presented it is this board’s determination that the incident was a result of

pilot error.

Under the heading “Recommendations,” the memorandum stated, in part, that “an

instrument departure under the weather conditions and night operations would have been

prudent.” Also, it stated that “[t]he intent of this board is not to provide any disciplinary action

on the employee, [the pilot], but rather to suggest avenues for him to return to flight status for the

Department.”

On May 2, 2006, the pilot successfully completed an Alaska DPS postaccident evaluation

check flight in a Robinson R-44. The check airman was one of the Alaska DPS pilots who had

given the pilot his initial NVG training in 2003. 43

On the form used to document the check flight,

the flight time was listed as 0.3 hour, and the remarks section of the form stated, “although no

blowing snow conditions were present, techniques used for blowing snow operations were

discussed and evaluated. Recommend continued status as PIC.” As noted in section 1.2.1.3, the

pilot also successfully completed the FAA-requested checkride on May 15, 2006.

A memorandum dated August 29, 2006, with the subject, “Memorandum of Warning,”

addressed to the pilot from the highest ranking member of the Aircraft Accident Review Board,

discussed the board’s findings. The memorandum stated, in part, that “the cause of the incident

was due to pilot error. Specifically your momentary distraction within the cockpit from your

instruments during the departure and the inability to transition from instrument to VFR flight

resulted in a momentary loss of aircraft control.”

Further, the memorandum stated that “the damage to the aircraft was significant,” and

“the cost and impact on the department being without its search and rescue helicopter…was also

significant.” The memorandum stated, “…[you] are hereby warned. Any future occurrence of a

similar incident may result in more severe disciplinary action.” The memorandum also noted that

“the fact that you took responsibility for the accident and showed great remorse weighs heavily

in how the department views this incident.”

The pilot’s performance evaluation report dated January 23, 2007, included the following

statement with regard to the accident:

Although the accident caused damage to the helicopter which has since been

repaired, no one was injured and both the Aircraft Section and [the pilot] learned

some very valuable lessons. His cooperation during the investigation allowed the

Alaska DPS to make significant changes to the aircraft operations manual and

address in the open the challenges that fatigue places upon flight crew during

extreme operational demand periods. The [manual] now provides clear guidance

for all flight crews on duty day and flight duty limitations aimed at making

aircraft section flight operations safer.

43

The check airman was also one of the members of the Aircraft Accident Review Board.

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32

1.8.3.2 Engine and Rotor Overspeed Event in 2009

The pilot was landing the accident helicopter at ANC on May 13, 2009, when an engine

and rotor overspeed occurred. 44

The former relief pilot suspected that the pilot had initiated the

event by moving the collective in an aggressive manner, and the AWT director requested that an

AST captain investigate the event. According to the report of the investigation prepared by the

AST captain, the pilot stated that he was attempting to land the helicopter on its ground cart

when the helicopter bounced slightly, and the pilot increased collective pitch to lift the helicopter

off the cart. The pilot told the AST captain that he did not move the collective in an aggressive

manner when landing on the cart.

The engine was removed and sent to Turbomeca for overspeed inspection and repair. The

Turbomeca report of the inspection indicated that the fuel metering needle had frozen in position,

and its findings noted corrosion contamination on the metering needle assembly and other

components, as well as wear on other components. The Turbomeca report concluded that it was

“probable that a combination of the findings observed led to the reported event.”

The “Conclusion” section of the Alaska DPS investigation report stated, in part, “the final

cause of the overspeed, based on the available information, is inconclusive.” According to the

Alaska DPS report, on the day of the incident, the pilot started work at 0800, had been on duty

for 12 hours when the event occurred, and had flown the helicopter 5.8 hours that day.

When interviewed by NTSB investigators, the AWT director recalled the overspeed event

and said that “ultimately it wasn’t determined that it was pilot error or a mechanical issue. It was

unclear.” The AWT director also said that another event involving the pilot occurred around the

same time as the overspeed event. In the other event, the pilot was flying a Robinson R-44

helicopter, and the tail rotor “may or may not” have struck water during a water landing. 45

The

AWT director said that the pilot denied that a water strike occurred. The AWT director also

mentioned the pilot’s 2006 accident and said that when the pilot was asked about any of these

events, “it was never his fault.” He said that there was nothing he could do to “take sanctions”

against the pilot without some reliable information to refute the pilot’s statements. The

combination of the overspeed and the R-44 events prompted the AWT director to ask the aircraft

section supervisor to research onboard monitoring equipment that could be installed in the

accident helicopter to monitor the pilot’s actions. Once the AWT director learned of the Appareo

system, he had it purchased and installed.

The AMRG observer stated that the pilot was “always worried” about losing his job. He

said that the pilot told him he thought he was going to be fired after the 2006 accident and that he

was being blamed for damaging the helicopter after the 2009 overspeed event. The pilot’s spouse

stated that the pilot “fought tooth and nail” to be exonerated of the event. According to the lead

mechanic and others, the pilot felt that everybody in the organization was against him.

44

This event was not investigated by the NTSB. 45

According to the Alaska DPS maintenance shop foreman, the Robinson R-44 sustained damage on the tail

rotor assembly that a manufacturer’s technical representative stated was consistent with a water strike. Inspection of

the tail rotor assembly by a manufacturer’s technical representative following a flight by the pilot indicated that the

damage could have resulted from a water strike.

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33

1.8.3.3 Overtorque Event in 2011

The pilot was conducting an external load operation in the accident helicopter at

Lake George, Alaska, about 1630 Alaska daylight time on April 15, 2011, when an overtorque

condition occurred. 46

In a written statement dated May 9, 2011, the pilot said that the purpose of

the flight was to recover a Piper PA-18 from a frozen lake using a sling and long-line. The pilot’s

statement said that, while the airplane was suspended beneath the helicopter, wind buffeted the

helicopter, which led him “to use more pedal, which robbed additional power from the main

rotor causing a momentary settling.” The pilot said that he reacted to the settling by increasing

collective and that this induced an overtorque event. After the pilot finished moving the airplane,

he checked the vehicle and engine multifunction display and found that it had recorded an

overtorque spike of 107% for 1 second. He performed an inspection of the rotor head and

transmission support arms, found no damage, and signed off the inspection on the helicopter’s

log sheet for the day.

The pilot did not inform the helicopter’s lead mechanic or the aircraft section supervisor

about the event. Maintenance personnel later saw the pilot’s signoff on the inspection sheet, and

the lead mechanic reported the discrepancy to the FAA, which sent inspectors to examine the

maintenance records. 47

Although the AWT asked the aircraft section to review the Appareo data

for the overtorque event, section staff discovered that the data card was not formatted and that no

data had been recorded during the flight.

A memorandum dated May 5, 2011, from the aircraft section supervisor to the pilot

addressed the overtorque incident stating, in part, the following:

The over-torque condition necessitated a manufacturer-required inspection of the

aircraft. You hold [an FAA] airframe & powerplant license and conducted this

inspection yourself. After you inspected the aircraft, you failed to ensure that the

incident was properly reported. ….

It was not until 04/27/11, that Aircraft Section maintenance staff was made aware

of the over-torque due to the discovery of the over-torque inspection

documentation in the aircraft logbook by an FAA inspector, and not until

04/28/2011, that I, as your immediate supervisor, was notified.

46

This event was not investigated by the NTSB. 47

FAA Program Tracking and Reporting System records for the helicopter indicated that on April 18, 2011, the

Anchorage Flight Standards District Office received an anonymous complaint via a safety hotline that a pilot was

performing maintenance on the helicopter without writing up the discrepancies. (The helicopter’s lead mechanic told

investigators that he made the anonymous complaint.) The FAA inspection determined that the pilot was qualified to

perform and sign off the inspection.

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34

The memorandum continued with a discussion of the pilot’s handling of a discrepancy

with the helicopter’s tail rotor pitch change links that he had found during a visual inspection on

March 23, 2011. It then stated the following:

As your immediate supervisor, it’s my expectation that you will notify me of any

condition which occurs to the aircraft that can affect the flight status of that

aircraft. By not notifying me as soon as practical that the over-torque condition

occurred or that there was a problem with the tail rotor pitch links, you did not

follow the appropriate…policy as outlined in Chapter 3.04(E).” [48]

You are also expected to notify the Aircraft Section shop foreman, either directly

or through me, of any problems or concerns regarding the DPS aircraft that you

fly.

The memorandum concluded by stating, “this letter is intended to be instructional in

nature, correct this type of behavior, and for you to follow the appropriate course of action with

respect to our rules and procedures in the future.”

1.8.4 Use of Flight Observers

The primary Alaska DPS SAR coordinator stated that the use of trained volunteer

observers was up to the pilots and based on their personal relationships with members of the

volunteer SAR community. Current and former relief pilots for the helicopter said that they liked

to have a trained observer in the left seat to operate the Garmin 430 and Avalex display for them,

especially when flying at night using NVGs. When the accident pilot used a trained observer, he

relied mostly on one particular individual from the AMRG; however, this AMRG observer was

out of town on the day of the accident. The AMRG observer estimated that he had flown over

300 SAR missions with the pilot, with the most recent flight in February 2013. Both the AMRG

observer and the Alaska DPS on-duty SAR coordinator said that, if the AMRG observer had

been available, he likely would have accompanied the pilot during the mission to rescue the

snowmobiler. The AMRG observer was trained in the use of NVGs.

The AMRG observer said that, if he had been on the helicopter during the accident

mission, he would have operated the Garmin 430 and Avalex displays for the pilot and

performed other tasks, including setting up navigational courses and selecting radio frequencies.

In addition, he said he would have been wearing NVGs and assisted the pilot by calling out

terrain and obstacles. He was also familiar with the pilot’s practice of disabling the

turn-and-bank indicator (which was located on his side of the center pedestal), and he knew how

to reset the circuit breaker to enable the instrument to function. The AMRG observer said that

operating the Garmin 430 and Avalex display required significant training and familiarization.

48

Chapter 3.04(E) of the Alaska DPS aircraft operations manual stated, “All mishaps involving a DPS aircraft

including any accident, incident, injury or ground damage associated with an aircraft in any way shall be

immediately reported verbally to the Aircraft Supervisor and the direct supervisor of the pilot responsible for the

aircraft followed as soon as possible by an email synopsis of the event.”

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35

A former Alaska State Trooper who served as the state SAR coordinator from 2004-07

and 2010-11 said that the pilot had, with his approval, developed a tactical flight officer (TFO) 49

training program. This training program was designed to familiarize volunteer TFOs with the

Avalex display, FLIR, spotlight, and the use of NVGs. The pilot planned to train six to eight

volunteer TFOs in the hangar during his normal duty hours so that a TFO would always be

available for helicopter SAR missions. However, after the former SAR coordinator left that role

in 2011, there was little management support for the TFO training program. Many missions

require law enforcement personnel, but the helicopter had a limited payload. Alaska DPS

management decided that, in many cases, it would be more appropriate to have the pilot pick up

an on-duty state trooper rather than fly with a SAR volunteer. Commissioned troopers generally

did not have the same level of training in helicopter operations as volunteer TFOs. The former

SAR coordinator stated that he believed that the Alaska DPS management did not adequately

consider the impact of this change on operational safety.

The former relief pilot for the helicopter said that the aircraft section had attempted to

train some troopers in the use of helicopter equipment but that those trained officers were often

unavailable for SAR missions due to scheduling conflicts. The current aircraft section

commander said that he had never met any of the volunteer observers, including the AMRG

observer who routinely flew with the accident pilot, and was not familiar with the training they

had received.

1.8.5 Use of MatCom Dispatch Services

The Alaska DPS contracts with MatCom for dispatch services. The MatCom dispatch

center for the geographic area that includes Talkeetna is located in Wasilla, Alaska. The Alaska

DPS did not perform any flight tracking or flight-following, and no one was aware that the

accident helicopter was overdue until the EMS personnel waiting at Sunshine contacted MatCom

dispatch to inquire about its estimated time of arrival.

Interviews with MatCom personnel revealed that dispatchers had clear guidance, training,

and defined responsibilities and duties for AST ground vehicle operations and could provide

very specific status and location information for every ground vehicle at any time. MatCom

dispatchers had no aircraft-specific training and were not provided any specific flight plan

information for the accident flight. 50

After EMS personnel inquired about the helicopter at 0039 on March 31, 2013, the

MatCom dispatcher attempted to locate it by radio and phone and by contacting personnel at

Sunshine and the Talkeetna FSS. The dispatcher was unable to provide the FSS personnel the

registration number of the helicopter (the dispatcher knew it only as “Helo-1”). At 0052, the

dispatcher received a call from a sergeant asking for contact information for the on-duty SAR

49

TFOs are typically law enforcement personnel trained to conduct a wide array of flight operation support

duties with a responsibility for assisting with flight safety. TFOs often assist with equipment operation (including

systems used for aviation navigation, mapping, recording, and tracking) and collision avoidance and serve in a

tactical decision-making capacity. 50

When the pilot departed on the previous flight from ANC to Sunshine, he told the MatCom dispatcher that he

had 2 hours 37 min of fuel on board and that his estimated time en route was 27 min. The pilot did not provide the

dispatcher with such information for the accident flight.

NTSB Aircraft Accident Report

36

coordinator for Alaska DPS; the sergeant told the dispatcher to stand by on contacting cell phone

providers to initiate “accident circumstance” procedures for locating the cell phones of the

helicopter occupants until the sergeant could talk with the SAR coordinator.

At 0109, the SAR coordinator called dispatch for contact information for the aircraft

section commander (so that he could obtain the helicopter’s satellite telephone number) and

asked for the coordinates for the snowmobiler’s location. At 0110, the dispatcher called a cell

phone provider to attempt to obtain coordinates from the pilot’s, flight observer’s, and

snowmobiler’s cell phones.

Over the course of the next several hours, the MatCom dispatch center changed shifts

three times from the start of the initial search and rescue call to the time in which the accident

site was located, and some difficulties with the transfer of information over multiple shifts

occurred.

1.8.6 Alaska DPS Changes Since This Accident

On August 7, 2014, representatives from the Alaska DPS met with NTSB investigators to

discuss the safety improvements the department has made since the accident. Among these was

the establishment of a new safety officer position, which incorporates a clear chain of command

to the AWT director, captain, and lieutenant for any safety-related program issues. The safety

officer, who is a pilot with aviation safety experience, is a dedicated full-time employee located

at the Alaska DPS aviation section headquarters in Anchorage. Also, a third-party maintenance

audit was completed in August 2014, an operations audit began in August 2014, and a training

audit is to follow. All audits include a safety component that is being included in the safety

program.

Table 3 summarizes the department’s improvements as of the date of this report. Many of

these improvements are consistent with safety issues identified in completed NTSB

investigations of accidents involving another law enforcement SAR helicopter, helicopter

emergency medical services (HEMS) operators, and public operators of EMS helicopters and the

safety recommendations that were issued as a result of those investigations. (See sections 1.9.1

through 1.9.3.)

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Table 3. Summary of Alaska DPS safety improvements since the accident.

Flight Operations

All active AS350 helicopter pilots have attended inadvertent IMC training from a commercial vendor

51 and will receive inadvertent IMC training from a department check

airman at least every 90 days. Airplane pilots received the training annually.

NVG operations are suspended until a formal NVG training program for pilots is implemented.

Pilots are adhering to standard operating procedures that specify that the maximum duty day for a single-pilot crew is 12 hours with 8 flight hours maximum and 10 hours rest. Exceptions during emergencies require approval.

Formal TFO program being developed; SAR aircraft availability reduced to meet current staffing level.

Night SAR operations are no longer being conducted. Situations involving loss of life or limb are evaluated case by case with regard to weather minimums.

Pilots are required to adhere to personal and department weather minimums. Satellite phones issued for communications at remote sites.

Operational Control

Safety officer reviews Appareo data monthly.

Clear chain of command established for personnel in a pilot’s chain of command. Nonaviation supervisors do not participate in mission go/no-go decision-making.

Formal risk assessments are used for all helicopter missions and are under development for remote airplane operations.

For flight-tracking, Spidertracks has been installed in about 34 of the 42 aircraft (plans are to equip all aircraft). Flight-following is being performed by the RCC, MatCom, and authorized supervisors.

Organizational Culture

Formal chain of command to AWT director, captain, and lieutenant established and enforced.

Safety officer periodically audits pilot flight and duty time limits and is authorized to communicate directly with aircraft section commander or director of public safety about safety-related findings.

Created a safety manager position that is a required part of the safety/management team.

Statewide pilot safety seminar planned for November 18-20, 2014.

SMS is being developed with plans to include “just culture.” 52

Third-party maintenance audit completed in August 2014. An operations audit began in August 2014, and a training audit is to follow.

Department participates in Airborne Law Enforcement Association, Medallion Foundation, and Helicopter Association International.

Maintenance Appareo system installation now includes use of the wire link to the aircraft intercom system to record voice audio.

Department reviewing options to meet recommendations from third-party audit to address maintenance turnaround times, staffing, and aircraft availability.

New responsibilities and roles are being established to ensure maintenance oversight.

51

Alaska DPS personnel stated to NTSB investigators during the August 2014 meeting that the pilots had

questions about the effectiveness of the training they received. 52

Just culture has been described as “an atmosphere of trust in which people are encouraged, even rewarded,

for providing essential safety-related information” (Reason 1997), and “a culture in which front line operators or

others are not punished for actions, omissions, or decisions taken by them that are commensurate with their

experience and training but where gross negligence, willful violations, and destructive acts are not tolerated”

(Chapter 1, Article 2 [k] of European Union regulation No. 691/2010).

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1.9 Previously Issued Safety Recommendations

1.9.1 Airborne Law Enforcement Association Safety Policies Guidance

The Airborne Law Enforcement Association (ALEA) was founded in 1968 as a nonprofit

association composed of local, state, and other public aircraft operators engaged in law

enforcement activities. The organization’s stated mission is to support, promote, and advance the

safe and effective use of aircraft by governmental agencies through training, networking,

advocacy, and educational programs.

On June 9, 2009, an Agusta S.p.A. A-109E helicopter operated by the New Mexico State

Police (NMSP) impacted terrain during a VFR flight into IMC during a SAR mission near

Santa Fe, New Mexico (NTSB 2011). As a result of the investigation, the NTSB issued several

safety recommendations, including Safety Recommendations A-11-57 to the ALEA, A-11-53 to

the state of New Mexico, A-11-60 to the National Association of State Aviation Officials, and

A-11-64 to the International Association of Chiefs of Police.

To the ALEA: Revise your accreditation standards to require that all pilots receive

training in methods for safely exiting inadvertently encountered instrument

meteorological conditions for all aircraft categories in which they operate.

(A-11-57, classified “Closed—Acceptable Action”)

In response to this recommendation, the Airborne Law Enforcement Accreditation

Commission revised Sections 04.03.01 and 04.03.02, “Pilot in Command Initial and Recurrent

Training,” of its accreditation standards to require pilot training in inadvertent encounters with

IMC during initial pilot training and at least annually during pilot recurrent training for both

fixed and rotary wing aircraft.

To the state of New Mexico: Require the New Mexico Department of Public

Safety to bring its aviation section policies and operations into conformance with

industry standards, such as those established by the Airborne Law Enforcement

Association. (A-11-53, classified “Closed—Acceptable Action”)

To the National Association of State Aviation Officials: Encourage your members

to conduct an independent review and evaluation of their policies and procedures

and make changes as needed to align those policies and procedures with safety

standards, procedures, and guidelines, such as those outlined in Airborne Law

Enforcement Association guidance. (A-11-60, classified “Closed—Acceptable

Action”)

To the International Association of Chiefs of Police: Encourage your members to

conduct an independent review and evaluation of their policies and procedures

and make changes as needed to align those policies and procedures with safety

standards, procedures, and guidelines, such as those outlined in Airborne Law

Enforcement Association guidance. (A-11-64, classified “Closed—Acceptable

Action”)

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In response to these safety recommendations, each of the addressees performed actions

that were responsive to the recommendations and satisfied their intent.

1.9.2 HEMS Operations

HEMS operations, like SAR operations conducted by law enforcement departments,

involve missions that require a high level of urgency to protect human life and are unpredictable

in terms of when, where, and in what weather conditions they occur. Because of these mission

similarities, many of the risks inherent in HEMS operations affect SAR operations as well. An

NTSB safety study identified that pressure to complete a mission, weather, nighttime flight,

spatial disorientation, and inadequate pilot training and experience were common risk factors for

HEMS operations (NTSB 1988). A study by the Air Medical Physicians Association (AMPA)

acknowledged these risks and cited additional risks such as unprepared landing sites,

complacency, and situational stress.

Safely operating in such a high-risk environment calls for systematic evaluation and

management of those risks. According to AMPA, an effective flight risk evaluation program

acknowledges and identifies threats, evaluates and prioritizes risks, considers the probability that

a risk will materialize, and mitigates loss. In a 2006 special investigation report, the NTSB found

that, in both the HEMS and airplane EMS environment, conducting a flight risk evaluation

requires the pilot and possibly another person (a manager, a flight dispatcher, or another flight

crewmember) to assess the situation without being influenced by the sense of urgency that can

come with an initial call requesting services (NTSB 2006).

1.9.2.1 Pilot Training on Inadvertent IMC Encounters

As a result of an NTSB public hearing on the safety of HEMS flights that revealed that

most HEMS pilots did not have adequate training to recognize the conditions that indicate when

they are encountering IMC, how to effectively avoid IMC encounters, and how to escape safely

should they encounter IMC, the NTSB issued Safety Recommendation A-09-87 to the FAA and

A-09-97 to the 40 public operators of HEMS flights.

Develop criteria for scenario-based helicopter emergency medical services

(HEMS) pilot training that includes inadvertent flight into instrument

meteorological conditions and hazards unique to HEMS operations, and

determine how frequently this training is required to ensure proficiency.

(A-09-87, classified “Closed—Unacceptable Action”)

Conduct scenario-based training, including the use of simulators and flight

training devices, for helicopter emergency medical services (HEMS) pilots, to

include inadvertent flight into instrument meteorological conditions and hazards

unique to HEMS operations, and conduct this training frequently enough to

ensure proficiency. (A-09-97)

In response to Safety Recommendation A-09-87, on February 21, 2014, the FAA

published a final rule, “Helicopter Air Ambulance, Commercial Helicopter, and Part 91

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Helicopter Operations,” which revised Section 135.293 to include the following new pilot testing

requirements 53

(among others):

(a)(9) … For rotorcraft pilots, procedures for aircraft handling in flat-light,

whiteout, and brownout conditions, including methods for recognizing and

avoiding those conditions….

(c) Each competency check given in a rotorcraft must include a demonstration of

the pilot’s ability to maneuver the rotorcraft solely by reference to instruments.

The check must determine the pilot’s ability to safely maneuver the rotorcraft into

visual meteorological conditions following an inadvertent encounter with

instrument meteorological conditions. For competency checks in

non-IFR-certified rotorcraft, the pilot must perform such maneuvers as are

appropriate to the rotorcraft’s installed equipment, the certificate holder’s

operations specifications, and the operating environment. …

(h) Rotorcraft pilots must be tested on the subjects in paragraph (a)(9) of this

section when taking a written or oral knowledge test after April 22, 2015.

Rotorcraft pilots must be checked on the maneuvers and procedures in

paragraph (c) of this section when taking a competency check after

April 22, 2015.

However, the FAA’s revisions to the regulation did not include criteria for scenario-based

training to address hazards unique to helicopter air ambulance operations, such as interfacility

helicopter air ambulance flights or remote helispot landings or takeoffs. As a result, on

September 11, 2014, the NTSB classified Safety Recommendation A-09-87 “Closed—

Unacceptable Action.”

Since Safety Recommendation A-09-97 was issued, many of the public HEMS operators

now provide the training discussed in the recommendation to their pilots, as well as other flight

crew, such as paramedics and flight nurses, involved in their HEMS flights. In recognition of this

training being provided to more than just HEMS pilots, Safety Recommendation A-09-97 is

classified “Closed—Exceeds Recommended Action” to 15 of the 40 public HEMS to which it

was issued.

1.9.2.2 Preflight Risk Assessment

The NTSB has issued several recommendations regarding formal preflight risk

assessment procedures and the involvement of another qualified helicopter pilot when making

launch decisions for HEMS missions. As a result of the 2006 special investigation on EMS

safety, Safety Recommendations A-06-13 and -14 were issued to the FAA. Safety

Recommendation A-06-13 addressed the importance of flight risk evaluation programs and

asked the FAA to do the following:

53

The final rule’s original effective date was April 22, 2014. On April 21, 2014, the FAA amended the final

rule to change the effective date to April 22, 2015, for certain sections, including 135.293 (a)(9) and (c).

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41

Require all emergency medical services (EMS) operators to develop and

implement flight risk evaluation programs that include training all employees

involved in the operation, procedures that support the systematic evaluation of

flight risks, and consultation with others trained in EMS flight operations if the

risks reach a predefined level. (A-06-13, classified “Open—Acceptable

Response”)

On August 1, 2005, the FAA published Notice 8000.301, “Operational Risk Assessment

Programs for Helicopter Emergency Medical Services,” which provided guidance to FAA

inspectors on promoting risk assessment, risk management tools, and training for HEMS

operations. The notice contained a formalized risk assessment matrix, which could be used by

HEMS crews when making decisions to launch or to continue a mission. When Safety

Recommendation A-06-13 was issued, the NTSB was aware of the notice but was not confident

that the new guidance would be widely adopted by EMS operators because most HEMS

operators examined during the 2006 special investigation did not have a decision-making or a

risk evaluation program in place as suggested by FAA guidance issued in 1991. FAA notices are,

by design, temporary documents that expire after 1 year.

On January 28, 2006, the FAA published Safety Alert for Operators 06001, “Helicopter

Emergency Medical Services Operations,” which included the information from the notice. On

May 1, 2008, the FAA incorporated the risk assessment information into FAA Order 8900.1,

“Flight Standards Information Management System.” 54

On February 21, 2014, the FAA

published a final rule titled “Helicopter Air Ambulance, Commercial Helicopter, and Part 91

Helicopter Operations,” which amended FAA regulations in Section 135.617 to require that all

helicopter air ambulance operators establish and document, in their operations manual, an

FAA-approved preflight risk analysis that includes management approval in situations where a

predetermined risk level is exceeded. The FAA incorporated guidance for developing risk

assessment matrix tools to determine risk level (such as “low,” “medium,” “serious,” and “high”)

for use in go/no-go decision-making into Section 5 of FAA Order 8900.1.

Safety Recommendation A-06-14 addressed the importance of formalized dispatch and

flight-following procedures. The NTSB recommended that the FAA do the following:

Require emergency medical services operators to use formalized dispatch and

flight-following procedures that include up-to-date weather information and

assistance in flight risk assessment decisions. (A-06-14, classified “Open—

Acceptable Response”)

In response to this recommendation, on May 5, 2008, the FAA issued Advisory

Circular 120-96, “Integration of Operations Control Centers [OCC] into Helicopter Emergency

Medical Services Operations,” which provided guidance on the establishment and operation of

an OCC by a HEMS operator. The February 21, 2014, final rule contains a requirement in

Section 135.619 for certificate holders with 10 or more helicopter air ambulances to establish

OCCs and document operations control specialist duties and training in their operations manuals.

54

FAA Order 8900.1 provides guidance to FAA inspectors to use when reviewing and approving the flight

operations programs of commercial operators.

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As a result of a public hearing the NTSB held on HEMS safety on February 3-6, 2009,

Safety Recommendation A-09-98 was issued to 40 public aircraft operations HEMS operators

that are not subject to FAA oversight:

Implement a safety management system program that includes sound risk

management practices. (A-09-98)

Among the 40 public operators receiving this recommendation was STAR Flight of

Austin-Travis County, Texas Emergency Medical Services, an operator that conducted both

HEMS and other public aircraft missions, including SAR. On October 20, 2009, STAR Flight

replied that it had implemented a risk assessment tool for HEMS operations in 2008 and that it

was, at that time, developing a risk assessment tool for its SAR, firefighting, and law

enforcement operations. On June 2, 2010, the NTSB replied that STAR Flight, by developing the

risk-assessment tool for various operations, exceeded the intent of the HEMS recommendation.

Consequently, Safety Recommendation A-09-98 to STAR Flight was classified “Closed—

Exceeds Recommended Action.”

As a result of the September 27, 2008, accident involving an Aerospatiale (Eurocopter)

SA365N1, registered to and operated by the Maryland State Police as a public HEMS flight in

District Heights, Maryland, the NTSB issued Safety Recommendations A-09-131 and -132 to the

40 public HEMS operators (NTSB 2009):

Develop and implement flight risk evaluation programs that include training for

all employees involved in the operation, procedures that support the systematic

evaluation of flight risks, and consultation with others trained in helicopter

emergency medical services flight operations if the risks reach a predefined level.

(A-09-131)

Use formalized dispatch and flight-following procedures that include up-to-date

weather information and assistance in flight risk assessment decisions. (A-09-132)

To date, 15 public HEMS operators have indicated to the NTSB that they have

implemented a flight risk evaluation program and use formalized dispatch and flight-following

procedures, including 5 state police departments.

1.9.3 Inconsistencies Among Weather Information Products

Recent NTSB accident investigations found instances in which nonaviation-specific

weather products from the NWS advised of conditions that were more severe than those

described in the NWS aviation weather products. As a result, on May 6, 2014, the NTSB issued

four safety recommendations to the FAA (Safety Recommendations A-14-13 through -16) and

five to the NWS (Safety Recommendations A-14-17 through -21). 55

The NTSB recommended

that the FAA do the following:

55

For more information about Safety Recommendations A-14-13 through -16, which are addressed to the FAA,

and Safety Recommendations A-14-17 through -21, which are addressed to the NWS, see the

Safety Recommendations search page, available on the NTSB website at www.ntsb.gov.

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Ensure that all [FAA] (and contracted) preflight weather briefings include any

products modified or created by the [NWS] in response to Safety

Recommendation A-14-17. (A-14-13)

Require that the [NWS] provide a primary aviation weather product (as

recommended in Safety Recommendation A-14-18 to the NWS) that specifically

addresses the potential for and existence of mountain wave activity and its

associated aviation weather hazards. (A-14-14)

In cooperation with the [NWS], revise the Interagency Agreement between the

[FAA] and the National Oceanic and Atmospheric Administration/NWS for the

center weather service units (CWSU) and its accompanying statement of work if

needed to add the new responsibilities of CWSU personnel in response to Safety

Recommendations A-14-17 and/or A-14-18 to the NWS, which are in addition to

the other responsibilities currently performed by the NWS under this

agreement. (A-14-15)

Include center weather advisories in the suite of products available to pilots via

the flight information services-broadcast data link. (A-14-16)

The NTSB also recommended that the NWS do the following:

Modify [NWS] aviation weather products to make them consistent with NWS

nonaviation-specific advisory products when applicable, so that they advise of

hazardous conditions including aviation hazards less than 3,000 square miles in

area that exist outside of terminal aerodrome forecast coverage areas. (A-14-17)

Provide a primary aviation weather product that specifically addresses both the

potential for and the existence of mountain wave activity and the associated

aviation weather hazards (as recommended in Safety Recommendation A-14-14

to the [FAA]). (A-14-18)

In cooperation with the [FAA], revise the Interagency Agreement between the

FAA and the National Oceanic and Atmospheric Administration/[NWS] for the

[CWSUs] and its accompanying statement of work if needed to add the new

responsibilities of CWSU personnel in response to Safety Recommendations

A-14-17 and/or A-14-18 to the NWS, which are in addition to the other

responsibilities currently performed by the NWS under this agreement. (A-14-19)

Establish a protocol that will enhance communication among meteorologists at

the [CWSUs], the Aviation Weather Center, and, as applicable, other [NWS]

facilities to ensure mutual situation awareness of critical aviation weather data

among meteorologists at those facilities. (A-14-20)

Establish standardized guidance for all [NWS] aviation weather forecasters on the

weighting of information reported in pilot reports (PIREPs) that will (1) promote

consistent determination of hazard severity reported in a PIREP and (2) assist in

aviation weather product issuance. (A-14-21)

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The NTSB notes that, at the time that the safety recommendations were issued, the NWS

in Alaska was already working to address consistency among weather advisory products in

Alaska. The FAA replied on July 24, 2014, and the NWS replied on July 29, 2014. Both

organizations stated that they were working together to take the actions recommended. On

September 16, 2014, Safety Recommendations A-14-13 through -16 were classified “Open—

Acceptable Response,” and, on September 26, 2014, Safety Recommendations A-14-17

through -21 were classified “Open—Acceptable Response.”

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2. Analysis

2.1 General

2.1.1 Pilot Qualifications and Fitness for Duty

The pilot had substantial experience flying helicopters and flying SAR missions for

Alaska DPS. All of the pilot’s SAR missions were flown under VFR, and he had a significant

amount of NVG experience. However, he had received no formal NVG training while employed

by Alaska DPS. (NVG training is discussed further in section 2.4.2.)

The pilot had relatively little instrument flying experience, and he was not current for

instrument flight. His most recent instrument helicopter flight was logged in 1986, and he had

received no instrument training within the past decade.

Toxicological tests were negative for impairing substances, and images from the onboard

recorder provided no indication that the pilot experienced any medical impairment or

incapacitation during the flight.

Information about the pilot’s recent activities provides no indication of sleep restriction

or circadian disruption in previous days. Further, the accident occurred well before the period of

the circadian trough (when alertness is lowest), so it is unlikely the pilot was fatigued. The pilot

spent about an hour on the ground with the trooper between flights, during which time the two

men searched for and retrieved the snowmobiler in deep snow. This entailed physical activity

and exposure to cold, wet weather. However, the pilot and helicopter were equipped with a wide

range of outdoor gear, and evidence suggests that the pilot and trooper used the snowmobiler’s

snowmobile to transport him to the helicopter. Thus, it is also unlikely that the pilot’s

performance was degraded as a result of his participation in the ground phase of the SAR

mission. The NTSB concludes that the pilot was qualified to fly SAR missions in VMC (but not

IMC) in the accident helicopter, and his performance was unlikely affected by medical factors,

fatigue, or physical activities associated with the ground portion of the rescue activity.

2.1.2 Helicopter Maintenance and Wreckage Examinations

Although some acquaintances of the pilot reported that he had voiced concerns about the

helicopter’s maintenance, some of these same people also noted that they thought that he would

not fly the helicopter if he believed it to be unsafe. Alaska DPS personnel stated that the pilot

and the helicopter’s mechanic were often in disagreement about issues such as how the

helicopter should be maintained and how long repairs should take. A review of the helicopter’s

maintenance records found that it was maintained in accordance with applicable regulations and

Eurocopter’s maintenance procedures. A review of the helicopter logbook for the 30 days before

the accident revealed that all maintenance write-ups had been cleared and that there were no

open or deferred items. Although the pilot was known to intentionally disable the turn-and-bank

indicator by pulling its circuit breaker, the reason he did this is uncertain (thus, it is unknown if

there was a problem with the instrument).

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The wreckage examinations found no anomalies with the flight controls and no

characteristics that were inconsistent with impact damage and exposure to postcrash fire.

Examination of the input pinion slippage mark found that the amount of offset in the torqueing

(tightening direction) was consistent with significant power at the time the main rotor system

struck the ground and stopped. In addition, images from the Appareo unit showed no instrument

readings or system status lights (from the master caution warning panel) that would indicate

problems with the helicopter’s engine or systems during the accident flight. The image

information provided confirmation that the helicopter was responding to the pilot’s control inputs

and that the engine was providing torque to the rotor drive system; for example, an engine power

increase (determined from engine instrument readings) correlated with the helicopter’s climb.

Additional investigative benefits of the onboard recording system are discussed in section 2.7.

The NTSB concludes that the in-flight image recording and wreckage examinations showed that

the helicopter and its engine were operating normally throughout the flight. No mechanical

abnormalities with the helicopter were identified.

2.1.3 Weather Conditions

It is not known what weather resources the pilot consulted for the flight; the information

that would have been available to him and its potential effect on his flight planning are discussed

in section 2.3.1.

A review of the available weather information found that the environment would have

been conducive for rain and snow shower activity, with reduced visibilities in heavy rain or snow

environments. TKA reported light rain and ceilings varying between VFR and IFR conditions in

the 2 hours before the accident with the changeover to snow occurring at 2312, as reported in the

2314 METAR observation. Weather radar images depicted a line of showers moving northward

from PAQ through TKA during the accident time. Also, the mountainous terrain in and around

the accident site would have acted to enhance any vertical motion associated with the shower

activity and help increase the strength of the showers; thus, worse surface conditions than were

observed at PAQ would have been expected at TKA and the accident site.

Based on the various weather observations and the nearby witness reports of light rain,

sleet, and snow, moderate or worse icing would have been likely in the vicinity of the accident

site. Although the cockpit image recording showed no evidence that it was snowing at the remote

landing site at the time that the helicopter departed (blowing snow, if present, should have been

visible), rain and sleet were likely present. The NTSB concludes that, soon after departure from

the remote landing site, the helicopter likely encountered IMC, which included low clouds,

heavy snow, and near-zero-visibility conditions.

The presence of sleet would also increase the likelihood of icing conditions above the

surface. Although encounters with such icing conditions can adversely affect helicopter

performance, the review of image data from the Appareo unit revealed no evidence of an

abnormal engine power reduction (as could occur with engine induction icing) or requirements

for more power to maintain flight (as could occur with the gradual accumulation of structural

icing). Therefore, the NTSB concludes that, although icing conditions were likely present during

the accident flight, the performance of the helicopter does not appear to have been degraded at

the time of the accident.

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Although the 2137 TAF for TKA forecasted a ceiling less than 1,000 ft agl at the airport,

an updated FA for the area surrounding TKA referencing a forecast for IFR conditions was not

issued, and there was no AIRMET issued for IFR conditions. Typically, these weather

information products should be consistent with each other with regard to references to IFR

conditions (as discussed in section 1.9.3); the omission of the AIRMET from the FA would also

be reflected in the graphical depictions of AIRMETs on the AAWU website. In this accident,

because the pilot was already en route at 2137 (when the TKA TAF was issued), it is unlikely

that this inconsistency in weather information products had any effect on his decision-making.

2.2 Accident Flight

The helicopter departed about 2313, and the flight lasted only about 7 min before it

crashed in a wooded area about 3 mi south of the remote landing site. According to images from

the Appareo unit, the pilot used his NVGs during the entire flight and had configured the

Garmin 296 GPS, which was in the “track up” orientation, to show a magenta course line that

extended southwest on the map display. The pilot did not make any adjustments to the

Garmin 430 GPS unit (including not slaving it to the HSI) or the Avalex system, and the

turn-and-bank indicator remained disabled for the flight. Three min after takeoff, the trooper

radioed the dispatcher that the helicopter was en route back to Sunshine, and he requested that an

ambulance meet the flight to receive the hypothermic snowmobiler. No further radio

communications were received from the flight.

After takeoff, the pilot initially climbed the helicopter to an altitude of about 700 ft msl

(about 250 ft agl in that area) and flew it southwest for about 1 min at a 60-knot groundspeed

then southeast for about 1 min. This course allowed the pilot to fly around a 1,000-ft-high hill

while remaining below the cloud ceiling. At times, the helicopter slowed to about 20 knots and

flew as low as about 100 ft agl.

The helicopter’s subsequent climb and acceleration over the Intertie, followed by its

descent to less than 100 ft agl, deceleration to ground speeds as low as 27 knots, and circuitous

route through a cluster of hills near the accident location indicate that the pilot likely encountered

deteriorating weather conditions and responded by flying the helicopter closer to trees and terrain

in an effort to maintain external visual references. As discussed previously, however, the

helicopter likely encountered very low clouds and near-zero visibility conditions near the

accident site, and these conditions likely degraded the pilot’s NVG image to the point where

continued flight under VFR was impossible.

The pilot was using a lip light throughout the accident flight, and this light was directed

at knobs and buttons on the instrument panel when the pilot manipulated them. In addition, the

movement of the lip light beam was suggestive of purposeful scanning inside the cockpit.

Although it was not possible to determine when the pilot was looking through his NVGs rather

than below them at the instrument panel, and, although it was not possible to determine where

the pilot was looking within the beam of light when it was directed at a particular area of the

instrument panel, the absence of the beam from the primary flight instruments was indicative of

periods when he was not closely attending to them. Thus, the lip light provided some indication

of the pilot’s visual attention inside the cockpit.

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About 3 min into the flight, as the pilot encountered deteriorating weather and rising

terrain, the pattern of the pilot’s lip light movement changed. Whereas the light had been

frequently on and off the instrument panel, it was now lingering in other locations, primarily the

lower right portion of the cockpit where the Garmin 296 was mounted. During the period that

this was occurring, the helicopter’s indicated airspeed dropped from about 60 to 25 knots, and

the helicopter slowly climbed from about 100 to 200 ft agl. (By comparison, the minimum

airspeed for IFR flight in comparable IFR-equipped helicopters ranges from 40 to 55 knots. 56

)

This indicates that the pilot’s attention was directed away from the primary flight instruments

just before the attempted transition to IFR flight and that the helicopter slowed down during this

time, making it less stable and more difficult to control in IMC.

After the pilot finished attending to the Garmin 296, the beam of the lip light resumed

frequent coverage of the primary flight instruments, and the pilot initiated the rapid climb. This

maneuver was not necessary to clear any immediate obstacle threat, but it was consistent with a

contingency plan for escaping zero-visibility conditions that the pilot had previously discussed

with the AMRG observer. Therefore, the NTSB concludes that the pilot experienced a total loss

of external visual references while operating in close proximity to terrain, which led him to

attempt to transition to instrument flight.

During the climb, which was executed with little forward airspeed, the helicopter turned

rapidly to the left. Although it is possible that the pilot initiated the turn (either to try to escape

the IMC or because he was aware of a 1,000-foot hill ahead along the original flightpath), it is

also possible that the left turn simply resulted from the pilot not applying enough right antitorque

pedal to counter the increased torque that accompanied his application of climb power. As the

helicopter turned away from its previous direction of travel, the magenta course line on the

Garmin 296 rotated out of sight at the bottom of the unit’s display screen. Shortly after this

occurred, the pilot adjusted the knob on the HSI so that the CDI needle was aligned with a

heading that pointed in the direction the helicopter had come from. The pilot, however, did not

take any action to halt the turn when the helicopter was pointing in the opposite direction.

Rather, the rapid left turn continued without pause. Thus, the turn may or may not have been

intentional, and the pilot may or may not have been attempting to reverse course. Regardless, the

pilot likely manipulated the knob on the HSI (which was rapidly spinning) to provide a course

reference that would aid his navigation. Thus, the pilot was attending to a navigational task

during the attempted transition to instrument flight, and this introduced some distraction from

primary control tasks that were already quite challenging, given the helicopter’s low speed and

the encounter with IMC.

About 17 seconds after the pilot adjusted the CDI, the trooper pointed at the Avalex

display, possibly attempting to assist the pilot’s navigation. Seconds after that, the helicopter

entered an uncoordinated maneuver, yawing left, rolling right, and pitching up as the pilot made

frequent inputs on the controls.

A 2011 simulator study of helicopter pilot performance during inadvertent flight into

IMC found that such episodes were marked by increased workload, as evidenced by pitch and

56

According to the flight limitations section of their corresponding flight manuals, the minimum speed for IFR

flight for the Agusta A-109C, Bell 430, and AS-355 helicopters is 40, 40, and 55 knots, respectively.

NTSB Aircraft Accident Report

49

bank angle oscillations of increasing amplitude and higher-frequency, higher-amplitude cyclic

control inputs (Krognale and Krebs 2011). Both of these features were apparent during the

pilot’s climbing turn, suggesting that, during the pilot’s attempted transition to instrument flight,

he experienced operational distractions, task saturation, and difficulties with aircraft control.

These difficulties may have been exacerbated by spatial disorientation, which is an inaccurate

perception of one’s own orientation and direction of motion that can result from the vestibular

sensations that accompany maneuvering flight in zero-visibility conditions.

Several seconds later (at 2318:40), with the helicopter at high pitch and roll angles, the

pilot pulled a knob on the instrument panel to cage the attitude indicator (which sets it to display

a level flight attitude). Caging an attitude indicator is meant to be performed only when an

aircraft is in a level flight attitude, such as on the ground or in straight-and-level, unaccelerated

flight. As an experienced pilot and mechanic, he would have understood the conditions under

which the attitude indicator could be safely caged. Therefore, the NTSB concludes that the

pilot’s action to cage the attitude indicator outside those conditions under which it could be

safely caged indicates that he distrusted the information he was seeing. (Possible reasons for this

distrust are discussed in section 2.6.) By caging the attitude indicator while the helicopter was at

high pitch and roll angles, the pilot caused the instrument to provide erroneous attitude

indications that would be difficult to ignore in a high-stress situation.

With external visual references gone and the attitude indicator providing erroneous,

misleading information, the pilot’s only possibility of maintaining control lay in using alternative

forms of attitude information from other flight instruments. During instrument helicopter

training, which the pilot had completed many years earlier, he was trained in partial-panel

techniques, including using the turn-and-bank indicator as a secondary source of obtaining

information about the helicopter’s bank attitude. However, the turn-and-bank indicator was

inoperative during the accident mission because the pilot had previously disabled it. Thus, this

source of bank information was not available to help the pilot determine the helicopter’s attitude

as he tried to maintain turn-and-bank control.

The absence of a functioning turn-and-bank indicator might have been moot because the

pilot had minimal (0.5 hour) helicopter actual instrument flying experience, lacked helicopter

instrument flying currency, and had no recent instrument training. Therefore, it is unlikely that

he would have been able to maintain control of the helicopter using partial-panel techniques

during the climbing turn, even with a working turn-and-bank indicator. Research involving

instrument-rated, fixed-wing pilots suggests that maintaining aircraft control following a

simulated attitude instrument failure in actual instrument conditions with a working

turn-and-bank indicator is extremely difficult and leads to loss of control in at least 10% of cases

(Roy and Beringer 2002). The success rate for a helicopter pilot during aggressive, low-speed

maneuvering in a nonIFR-certificated helicopter would likely be much lower, due to the

inherently unstable nature of such helicopters (compared to IFR-equipped helicopters) and the

even greater dependence of their pilots on external visual cues for maintaining helicopter control.

Therefore, the NTSB concludes that the pilot’s caging of the attitude indicator made it very

unlikely that he would regain control of the helicopter in IMC. The NTSB further concludes that

the helicopter’s erratic maneuvers are consistent with the pilot’s spatial disorientation, a loss of

control in flight, and his inability to recover the helicopter because of his lack of instrument

experience and the lack of accurate attitude information.

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2.3 Pilot’s Risk Management Considerations

2.3.1 Decision to Accept Mission

The pilot did not call a flight service specialist for a weather briefing, and the

investigation was unable to determine which weather information sources the pilot may have

examined before deciding to accept the mission. Based on the available weather information

products and the standard services provided by a qualified weather briefer, it is likely that, had

the pilot called for a briefing at the time that he was notified of the mission, the briefer would

have informed the pilot about the radar-depicted line of light-to-moderate echoes that was

moving toward TKA.

A review of the typical sources used by Alaska DPS pilots revealed that the FA

forecasted visibilities as low as 4 mi in places that included the search area with isolated rain and

snow showers, and the TKA TAF issued at 2008 forecasted a cloud ceiling of 1,000 ft agl at the

airport. Because the search area was only about 5 nautical mi east of TKA, the pilot likely

checked the TKA TAF, and this should have alerted him to the possibility of ceilings in the

search area between 350 and 950 ft agl (terrain elevations in the search area ranged from about

400 to 1,000 feet msl).

Low night VFR lighting conditions existed for the accident flight, which the pilot could

have determined based on the times of sunset and moonrise, the overcast clouds, and the lack of

ground lighting in the search area. Low lighting conditions can have a profound effect on the

safety of helicopter night VFR operations by compromising a pilot’s ability to maintain visual

contact with the horizon and to see and avoid clouds, obstacles, and terrain. 57

Alaska DPS did not apply across-the-board VFR weather minimums to its helicopter

pilots. Some personnel indicated that the pilots had individual weather minimums that may be

changed based on experience, whereas other personnel stated that pilots were expected to comply

only with the FAA requirements to remain clear of clouds. However, Alaska DPS had minimums

on file for the accident pilot. A form dated 2003 indicated that the pilot’s night VFR NVG

weather minimums were a 500-ft ceiling and 2-mi visibility, and the pilot indicated in a 2009 e-

mail to a colleague that his personal minimums for night NVG operations were a 200-ft ceiling

and 5-mi visibility. Therefore, the NTSB concludes that, when the pilot was contacted about the

mission, forecasts indicated that conditions in the search area would be IFR and that forecast

cloud ceilings and visibility would likely be below the pilot’s Alaska DPS weather minimums

and possibly below his last known personal weather minimums.

The risk of helicopter night VFR operations can be mitigated by use of NVGs, which the

pilot used routinely. However, NVGs have a number of limitations, including a reduced field of

57

Section 10-2-2, “Helicopter Night VFR Operations,” in the Aeronautical Information Manual states, in part,

“Even in conditions in which visibility and ceiling are determined to be visual meteorological conditions, the ability

to discern unlighted or low contrast objects and terrain at night may be compromised. The ability to discern these

objects and terrain is the seeing condition, and is related to the amount of natural and man-made lighting available,

and the contrast, reflectivity, and texture of surface terrain and obstruction features. In order to conduct operations

safely, seeing conditions must be accounted for in the planning and execution of night VFR operations.”

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51

view, reduced image resolution, and the presence of digital noise. Low lighting conditions can

result in a lower contrast NVG image and increased digital noise. Such images are more difficult

to interpret and may cause a tendency to fly lower in an effort to improve image quality. The

presence of meteorological obscurants like rain or snow has the potential to further degrade NVG

image quality. The effect of precipitation on image quality can be unpredictable and can change

with the nature and intensity of the precipitation. Thus, meteorological and astronomical

forecasts that included low light, rain, and snow indicated the potential for degraded NVG

effectiveness and increased risk of an inadvertent encounter with IMC. Therefore, the NTSB

concludes that, at the time the pilot was notified about the stranded snowmobiler, sufficient

information was available to indicate that the mission carried a high degree of risk due to the

weather and low lighting conditions.

The investigation revealed no evidence that Alaska DPS managers ever pressured the

pilot to accept or complete a flight. Thus, it does not appear that the pilot was subjected to any

direct management pressure to accept or continue SAR missions. However, the pilot was

described as having exceptionally high motivation for flying-related tasks, and he took great

pains to make sure that he and the helicopter were always available for any DPS missions. He

had frequent conflicts with maintenance personnel over the timeliness of required maintenance

and rarely took time off because he did not want to miss opportunities for flying. The pilot

reportedly enjoyed flying the helicopter and had achieved a high level of VFR helicopter flying

proficiency. Putting this skill to use likely provided some intrinsic satisfaction. The pilot’s

spouse said that the pilot was very close to his own family, and he appreciated being able to

bring other people safely back to theirs. In addition, records indicate that the pilot had received a

great deal of public recognition for past rescues. His personnel file contained many heartfelt

letters of thanks from people he had rescued, and he had received several high-profile awards. In

addition, a substantial amount of the pilot’s income came from being on call and flying missions

outside of his scheduled work hours. Colleagues and supervisors said that the pilot was very

sensitive to any changes in aircraft section operating policies that could reduce his pay, such as

reducing his standby time by using the relief pilot. The relief pilot said that the pilot feared being

replaced if other pilots were allowed to fly more missions. As a result of these multiple sources

of motivation, the pilot carefully guarded his role as the helicopter’s primary pilot.

The pilot’s exceptionally high motivation likely produced significant internal pressure to

accept and complete missions, and this motivation stemmed from multiple factors, such as his

awareness of the dire situations faced by the people he rescued, the way that his pay was

structured, and the way that he had been rewarded for completing previous high-risk SAR

missions. Thus, the NTSB concludes that the pilot’s exceptionally high motivation for

conducting SAR missions, which was influenced by multiple factors, likely played a part in his

acceptance of the accident mission.

2.3.2 Preparations for Departure

After spending about 1 hour on the ground to assist the snowmobiler and transport him to

the helicopter, the pilot had to decide whether to take off again. As mentioned previously, light

rain and sleet were likely present at the time of departure. The pilot’s PED showed that he did

not use that device to call for a weather update before departing the remote landing site;

however, it is uncertain whether cellular service was available to do so. At the time, TKA was

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52

reporting a changeover from rain to snow. This information about observed snow nearby would

have been available to the pilot via the radio on the TKA weather automated surface observing

system (ASOS) frequency (and by phone). It is not known if the pilot could have received the

TKA ASOS via the radio on the ground; however, in-flight capability was likely. The pilot’s

only other preflight means of assessing the ceiling, visibility, and obscuring precipitation was by

visual inspection of the surrounding area from the ground. However, it was dark and the remote

landing site was in a low-lying area surrounded by trees, so the pilot’s ability to visually assess

the weather conditions from the ground was probably limited.

After starting the helicopter, the pilot configured the Garmin 296 GPS so that it displayed

a magenta course line that extended southwest on the map display. The AMRG observer who

often flew with the pilot said that the pilot preferred using only the Garmin 296 for navigation.

The relief pilot said he also preferred using the Garmin 296 because its position in the cockpit

allowed him to easily glance down under his NVGs to see the display in flight. A disadvantage

of using the Garmin 296 (as opposed to the Garmin 430 in the center of the panel) was that the

pilot’s selected course information could not be displayed on the HSI via the CDI. In the event of

an encounter with IMC, the pilot’s workload would be increased because he would have to

alternate his visual attention between the lower right side of the cockpit (where the Garmin 296

was mounted) and the center of the instrument panel (where the primary instruments were

located) to both navigate and maintain primary control. (Using the Garmin 430, which can be

“slaved” to the HSI, enables the pilot to use the CDI to display course information for the course

selected on the Garmin 430, thereby supporting a centralized instrument scan.)

The pilot did not make any adjustments to the Garmin 430, which is consistent with his

reported preference for the Garmin 296 and with his not configuring the unit during the previous

flight from ANC. The pilot also did not make any adjustments to the Avalex system, which

powered up in the “north up” orientation and with a map that showed the outlines of rivers and

lakes. This is inconsistent with the pilot’s previous flight from ANC, for which he configured the

Avalex to show a “track up” orientation with a topographical map displayed. It is also

inconsistent with a statement made by the AMRG observer that he and the pilot had agreed that

they would always ensure that the Avalex display was powered up and configured properly

before takeoff in reduced visibility conditions so that it could be used to maintain awareness of

nearby terrain. This could be explained, however, by the fact that the Avalex unit was normally

configured and operated by an observer, but the trooper who was serving as an observer had not

been trained in its use.

The pilot also did not reset the circuit breaker to enable the turn-and-bank indicator,

which remained disabled for the flight. The only maintenance write-up regarding a reported

noise problem with the instrument occurred 9 years ago. Alaska DPS personnel could not say

with certainty why the pilot disabled the instrument.

Although Alaska DPS sometimes used trained observers who could operate the

Garmin 430 and Avalex displays and perform tasks for the pilot like setting up navigational

courses, selecting radio frequencies, or calling out terrain and obstacles, the trooper for the

accident mission had not been trained to use the helicopter’s navigational equipment. Therefore,

during the accident flight, the pilot configured the avionics and handled all navigational tasks

himself.

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53

2.3.3 Decision to Continue Mission

Before the accident flight, when the pilot first arrived in the search area about 2200, he

flew the helicopter between 1,100 and 1,200 ft msl, which suggests that the cloud ceiling was at

least 650 to 750 ft agl about the time that he landed at the remote rescue location. However, the

altitude that the pilot initially flew during the accident flight was about 700 ft msl (250 ft agl),

suggesting that the cloud ceiling and/or visibility in the area had deteriorated significantly during

the time the helicopter was on the ground. In addition, weather information and witness reports

indicate a strong possibility of icing.

The safest course of action at this point was to perform a precautionary landing. An

examination of the terrain along the helicopter’s ground track identified several open areas that

could have served as emergency landing areas for the helicopter. However, due to the changing

precipitation and low lighting conditions, it is uncertain whether the pilot could see these

potential landing areas well enough to determine whether they were suitable for landing.

Although it is possible that the condition of the snowmobiler created a sense of urgency

that prompted the pilot to push on in deteriorating conditions, there is insufficient evidence about

the seriousness of the snowmobiler’s medical condition to know how it might have been

perceived by the pilot and flight observer. Although the flight observer reported to a dispatcher

that the snowmobiler was hypothermic, he did not communicate any detailed information about

the snowmobiler’s condition, and hypothermia cases can range from mild to severe.

A factor that likely influenced the pilot’s continued VFR flight in deteriorating weather

was his high motivation for performing missions and accomplishing rescues. Although the pilot

was described by colleagues as being very safety oriented, the aircraft section commander had

expressed concern to the pilot about the riskiness of some flights, and the pilot had responded

that he agreed to do such things when he was hired and planned to continue doing them. As a

result of his conversations with the pilot, the aircraft section commander said he believed the

pilot appreciated the hazards associated with risky decisions but that he felt a self-imposed

obligation to take certain risks to accomplish rescues.

Another factor that likely influenced the pilot’s continued VFR flight into deteriorating

weather was an increased tolerance for risk as a result of successful past outcomes. Although the

pilot had experienced a takeoff accident 7 years earlier involving white-out conditions and loss

of visibility from snowfall and snow on the ground that billowed up in the rotor wash, he had not

experienced any other accidents since, despite conducting additional missions that often involved

high-risk activities, such as maneuvering through areas of poor weather at night and flying

inches above fast-moving bore tides. The success of these past missions, particularly those

involving poor weather, likely increased the pilot’s confidence that he could safely continue VFR

flight at night in marginal weather conditions.

A precautionary landing would have stranded the pilot, trooper, and hypothermic

snowmobiler in an uncomfortable (but probably survivable) situation until the weather improved

NTSB Aircraft Accident Report

54

or ground resources could assist them. 58

Executing a landing in the dark, reduced-visibility

conditions in an unfamiliar clearing with heavy snow on the ground might also damage the

helicopter. Continuing VFR flight, on the other hand, increased the pilot’s risk of experiencing a

weather-related accident, but the risk of this type of accident probably seemed remote to the

pilot, given his past experience. Thus, the pilot had to choose between two undesirable

alternatives: one that involved a high perceived likelihood of inconvenience and possible

helicopter damage and another that involved a low perceived likelihood of a serious accident.

The pilot chose the latter option, and the risk of a serious accident was realized. The NTSB

concludes that the pilot’s exceptionally high motivation for SAR missions and past successes

likely increased his risk tolerance and influenced his decision to continue flying in deteriorating

weather conditions and risk a weather-related accident rather than accept the certain

inconveniences and potential hazards associated with a precautionary landing.

2.4 Organizational Issues

2.4.1 Risk Assessment

The accident helicopter was a single-engine, nonIFR-certified platform and was crewed

by a single pilot who was not instrument-current and had NVGs. This meant that the

equipment/crew pairing was capable of operating in dark night VMC conditions but not in IMC.

Inadvertent encounters with IMC would result in a high risk. One prudent organizational strategy

for managing this risk should have entailed establishing minimum VFR weather requirements

that provide some degree of separation between the helicopter and weather conditions that could

obscure a pilot’s view of the natural horizon, with or without NVGs. However, as discussed

previously, the Alaska DPS did not apply across-the-board VFR weather minimums to its

helicopter pilots, other than FAA requirements.

The Part 91 regulations that applied to Alaska DPS flights required only that the

helicopter be operated clear of clouds below 1,200 ft. In contrast, for HEMS operations

conducted under Part 135, the FAA established NVG weather minimums. These minimums,

which are part of a HEMS-specific operations specification, range from an 800-ft ceiling and

3-mi visibility for a local flight in nonmountainous terrain to a 1,000-ft ceiling and 5-mi visibility

for cross-country flights in mountainous terrain. Neither the pilot’s stated personal weather

minimums for night NVG VFR helicopter operation (200 ft and 5-mi visibility) nor the

minimums that Alaska DPS had on file for him (500 ft and 2-mi visibility) provided an adequate

safety margin for the night SAR mission, particularly considering the adverse effects of

precipitation and low light on both NVG image quality and the pilot’s ability to see and avoid

clouds. The pilot’s lack of instrument currency and actual instrument experience in helicopters,

as well as the helicopter’s VFR-only platform, further increased the risk.

The pilot was not required to complete any standardized preflight risk assessment

process, either before accepting a mission or while conducting a mission to help evaluate risk as

new variables (such as deteriorating weather conditions) were introduced. In addition, Alaska

58

Although the outside air temperature was near freezing, survival gear reported to be on board the helicopter

included sleeping bags, and the cabin heater could be used when the helicopter’s engine was running.

NTSB Aircraft Accident Report

55

DPS did not ensure that anyone with suitable aviation expertise other than the accident pilot was

overseeing the go/no-go decision for each mission. Although an Alaska DPS SAR coordinator

was required to authorize every mission for the accident helicopter, the SAR coordinator

generally was not involved in weather-related decision-making. The SAR coordinator who

authorized the accident mission was a low-time (about 150 hours of flight experience),

fixed-wing pilot who had no helicopter experience. He did not discuss weather conditions with

the pilot, and he said that he and the other Alaska DPS SAR coordinators normally relied on the

pilots to decide whether it was appropriate for them to accept a mission. The accident pilot was

not required to fill out any kind of operational risk form, and no Alaska DPS supervisor or

manager was required to review or approve a pilot’s decision to accept a mission, even if a

mission was determined to be high risk.

As previously discussed, information available at the time the pilot was notified indicated

that the mission was potentially high risk, and this risk increased during the mission as weather

conditions deteriorated. One way for the Alaska DPS to mitigate the risk would be to assign two

pilots or one pilot and one trained observer or TFO who could assist with aeronautical

decision-making and other tasks that could ease the pilot’s workload. Alternatively, the Alaska

DPS could have decided that the helicopter and pilot were not appropriate assets for this

particular mission. In that case, the SAR coordinator could have organized a ground search party

and, if air assets were deemed essential for the mission, referred it to the RCC. The RCC could

then have requested a more appropriate platform from the Alaska Air National Guard, such as an

IFR-capable HH-60 helicopter equipped with a two-pilot, IFR-trained and current crew.

Although the Alaska Air National Guard was capable of flying under IFR in zero-visibility

conditions, it followed Air Force training weather minimums of a 700-ft ceiling and 2-mi

visibility for night NVG flights (a more conservative ceiling minimum than the accident pilot’s),

so its pilots might have deferred the mission as well.

In this case, the pilot was not required to perform a formal, systematic risk assessment

before or during the mission, and no one else assisted the pilot in evaluating mission-related risk.

Thus, the NTSB concludes that the Alaska DPS lacked organizational policies and procedures to

ensure that operational risk was appropriately managed, such as formal pilot weather minimums,

preflight risk assessment forms, or secondary assessment by another qualified person trained in

helicopter flight operations that would have encouraged the pilot to decline the mission or take

steps to mitigate weather-related risks.

The development of formal risk assessment procedures and the involvement of another

qualified helicopter SAR professional who is one step removed from the launch decision (similar

to the procedures the NTSB has previously recommended for HEMS operators) could help

Alaska DPS pilots systematically identify hazards and ensure that launch decisions are

appropriate, any hazards are appropriately mitigated before the start of a mission, and the hazards

are continuously evaluated as the mission progresses.

Alaska DPS has made some progress since the accident by implementing the use of

formal risk assessments for every helicopter mission. These measures are important

improvements that can help enhance the safety of DPS flight operations. The NTSB, however, is

concerned that these efforts do not ensure that employees who are supporting the flight crews in

the systematic evaluation of flight risks are adequately trained and knowledgeable about aviation

NTSB Aircraft Accident Report

56

operations. Therefore, the NTSB recommends that the state of Alaska develop and implement a

flight risk evaluation program that includes training for all employees involved in the operation

and procedures that support the systematic evaluation of flight risks and consultation with others

trained in flight operations if the risks reach a predefined level.

In addition, although the MatCom dispatchers who were communicating with the

accident flight were highly trained and capable of precisely tracking AST ground vehicle

operations, they were not trained in aviation operations, did not handle aircraft flight plans, and

could not provide up-to-date weather information or assist with other flight-risk assessment

tasks. The Alaska DPS has taken measures since the accident to equip most aircraft with

flight-tracking capability and to provide for flight-following using the RCC, MatCom, and

authorized supervisors. The NTSB concludes that the Alaska DPS’s reliance on

nonaviation-trained dispatchers for dispatch and flight-following support does not ensure that

flight crews have adequate access to up-to-date weather information and qualified assistance

with flight risk assessment tasks. For example, although it is unknown if the pilot had cell

coverage at the remote landing site to call for updated weather information, the flight made radio

contact with dispatch 3 min after departure. Had the pilot or the flight observer been

communicating with an aviation-trained dispatcher dedicated to providing up-to-date weather

information, flight-following, and assisting with other flight risk assessment tasks, it is possible

that such a resource would have been aware that the weather conditions observed at TKA

included a changeover to snow occurring at 2312 as reported in the 2314 special METAR and

notified the flight, which had just departed. Also, the delays that occurred between the time that

the helicopter crashed and when someone noticed that it was missing, and the difficulties in the

passdown of accurate information on its status and its whereabouts, could have had severe

consequences had there been survivors awaiting help. Therefore, the NTSB recommends that the

state of Alaska use formalized dispatch and flight-following procedures that include up-to-date

weather information and assistance with flight risk assessment decisions.

2.4.2 Pilot Training

Although the FAA requires certain commercial operators to receive FAA approval before

conducting NVG operations, the Alaska DPS, as a public aircraft operator, was not subject to

such requirements and did not have a formal NVG training program. The former relief pilot for

the accident helicopter said that the accident pilot was the only person he had “ever qualified

within the department to fly goggles and that was based on his previous military NVG

qualification.” Investigators could find no record that the pilot received formal NVG training in

the military.

Formal NVG training emphasizes the limits of NVG capability, including the sudden and

unpredictable effects that precipitation can have on NVG image quality and the tendency to fly

lower when NVG images degrade. The pilot’s personal weather minimums and his actions

during the accident flight suggest a lack of awareness or appreciation of these hazards. This

might have been rectified through completion of a comprehensive NVG training course. The

pilot’s accident in 2006 occurred while he was using NVGs, and a goal listed on his

January 2010 performance evaluation was to update his training in the NVG environment by

attending a commercial initial NVG course. However, the pilot’s 2011 performance evaluation

indicated that this goal was reconsidered due to the cost of the course.

NTSB Aircraft Accident Report

57

The NTSB concludes that the Alaska DPS did not provide the pilot with training that

could have helped him recognize the hazards that precipitation and low light conditions pose to

NVG operations. Such training could improve safety, for the reasons discussed above,

particularly for helicopter SAR operations. Further, such training is available from commercial

vendors. The Alaska DPS reported that it has suspended NVG operations until a formal training

program is implemented. Therefore, the NTSB recommends that the state of Alaska provide all

pilots who will perform NVG operations with formal NVG ground and flight training and require

them to complete this training on an annual basis to remain on flight status.

The pilot also had not received any IFR helicopter training from Alaska DPS, and he was

not IFR-current in the helicopter. In addition, he had not received simulator training on strategies

and techniques for recognizing, avoiding, and escaping inadvertent encounters with IMC. This

lack of training was problematic for an operation without conservative weather minimums where

operations at night and in close proximity to clouds greatly increased the risk of inadvertent

encounters with IMC. Research indicates that inadvertent IMC training can improve pilot control

and increase the likelihood of surviving such encounters. Such training might have recalibrated

the pilot’s risk tolerance for situations involving continued VFR flight in IFR conditions,

motivated him to avoid them, and helped him to maintain control of the helicopter in the event of

an inadvertent encounter with IMC.

The NTSB investigated a previous accident in which a state law enforcement helicopter

pilot lost control of a helicopter operated by the NMSP after inadvertently encountering IMC and

was unable to safely escape the conditions. That pilot was not instrument qualified in helicopters.

The NTSB concludes that pilots involved in SAR missions could benefit from initial and

recurrent training on how to recognize, avoid, and safely recover from inadvertent flight into

IMC. Although the Alaska DPS informed NTSB investigators that, since the accident, all of its

active AS350 helicopter pilots attended inadvertent IMC training, its plans for ensuring ongoing

training were unclear. Therefore, the NTSB recommends that the state of Alaska require all

pilots who perform state law enforcement SAR missions to receive, on an annual basis,

scenario-based simulator training in inadvertent IMC that includes strategies for recognizing,

avoiding, and safely escaping the conditions.

In the course of this investigation, investigators had difficulty identifying research

validating the effectiveness of currently available commercial helicopter inadvertent IMC

training programs or identifying guidelines on best practices for helicopter inadvertent IMC

training programs. For example, the FAA’s Helicopter Instructor’s Handbook does not include

any information on inadvertent IMC training. Feedback received from the Alaska DPS since the

accident indicates that DPS pilots who participated in an inadvertent IMC training program

(through a commercial vendor) had questions about its effectiveness. The NTSB concludes that

operators lack adequate information about best practices for helicopter inadvertent IMC training.

Beginning in 2015, helicopter inadvertent IMC training will be required for all helicopter pilots

conducting operations under Part 135. It is essential that the effectiveness of this training be

evaluated and that the most effective strategies for conducting such training be identified.

Therefore, the NTSB recommends that the FAA work with operators, training providers, and

industry groups to evaluate the effectiveness of current training programs for helicopter pilots in

inadvertent IMC, and develop and publish best practices for such training.

NTSB Aircraft Accident Report

58

2.4.3 Use of Trained Observers

The AMRG volunteer who often flew with the pilot was unavailable on the day of the

accident. When flying with the accident pilot, he typically would have operated the Garmin 430

and Avalex displays and performed other tasks, including setting up navigational courses,

selecting radio frequencies, resetting the circuit breaker to enable the turn-and-bank indicator, or

calling out terrain and obstacles. Current and former relief pilots for the accident helicopter said

that they liked to have a trained observer in the left seat to operate the Garmin 430 and Avalex

for them, especially when flying at night using NVGs. The AMRG volunteer also had been

trained to use NVGs and, if he had been with the pilot, likely would have been wearing NVGs.

This would have been an additional person who could have helped to assess weather conditions

and maintain visual contact with the ground.

Operating the Garmin 430 and Avalex display requires significant training and

familiarization. The trooper who was on the accident mission had no such exposure and,

therefore, could not assist the pilot with such tasks. Also, the trooper was not trained on or

equipped with NVGs; thus, he would not have been able to maintain visual contact with the

ground or help visually identify obstacles. As discussed previously, the pilot had to handle all

navigational tasks himself during the accident flight, and he did not optimally configure the

helicopter’s navigational equipment and flight instruments before departure. A second

crewmember trained in the use of the helicopter’s navigational and communications systems

could have assisted with operating the systems and performing other flight-related tasks. This

could have reduced the pilot’s workload and, thereby, reduced his potential for distraction and

risk of spatial disorientation, particularly during his attempted transition to instrument flight.

Aside from operating the onboard equipment, a second crewmember (such as a TFO)

trained in aeronautical decision-making could have assisted the pilot by helping him obtain

updated weather information on the ground or in the air, encouraging him to defer his departure

from the remote landing site, or urging him to land when the helicopter encountered extremely

low ceilings and visibility. A TFO could also evaluate other courses of action such as choosing a

route over lower terrain, which may have been free from clouds or afforded more emergency

landing opportunities. Thus, the pilot’s decision-making could have been enhanced during the

accident flight through the support of a trained observer or TFO. Therefore, the NTSB concludes

that a TFO who was capable of assisting the pilot with aeronautical decision-making and

operating the helicopter’s navigational systems and displays could have helped mitigate risk.

The primary Alaska DPS SAR coordinator stated that the decision to use trained

volunteer observers was totally up to the pilot and was based on the pilot’s personal relationships

with members of the volunteer SAR community. The former relief pilot for the helicopter said

that the aircraft section had attempted to train some troopers in the use of helicopter equipment

such as the FLIR but that those trained officers were often unavailable for SAR missions due to

scheduling conflicts. The current aircraft section commander said he had never met any of the

volunteer observers, including the AMRG observer, and was not familiar with the training they

had received.

A former Alaska state trooper who served as the state SAR coordinator from 2004-07 and

2010-11 said that the pilot had, with his approval, developed a TFO training program. This

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59

training program was designed to familiarize volunteer TFOs with the Avalex display, FLIR,

spotlight, and the use of NVGs. The pilot planned to train six to eight volunteer TFOs in the

hangar during his normal duty hours so that a trained observer would always be available for

helicopter SAR missions. However, after the former SAR coordinator left that role in 2011,

management support for the TFO training program waned and the training program faded away.

Because the helicopter had a limited payload and many missions required law enforcement

personnel, Alaska DPS management decided that in many cases it would be more appropriate to

have the pilot pick up an on-duty state trooper rather than fly with a SAR volunteer.

Commissioned troopers generally did not have the same level of training in helicopter operations

as volunteer TFOs, and the former SAR coordinator believed Alaska DPS management did not

adequately consider the impact of this change on operational safety.

Following the accident, the Alaska DPS reported that it has reduced its SAR aircraft

availability to meet the current staffing levels of the aircraft section and that it is developing a

formal TFO training program. However, the NTSB notes that the pilot’s efforts to start such a

program in the past were unsuccessful. The NTSB concludes that, although a TFO program had

been recognized by Alaska DPS personnel as a means of improving the safety of helicopter SAR

operations, inadequate support for the program at various levels of the organization led to the

unavailability of a TFO or other trained observer on the day of the accident. Therefore, the

NTSB recommends that the state of Alaska create a formal TFO training program that includes

training on aeronautical decision-making, crew resource management, and operating aircraft

navigational and communications equipment, and use TFOs during SAR operations.

2.4.4 Safety Management and Safety Culture

The Alaska DPS investigations of the pilot’s previous accident and other events involving

the pilot and the accident helicopter provided some insight into the organization’s approach to

safety management and its underlying safety culture. During its internal review of the pilot’s

accident with the helicopter in 2006, in which the pilot became disoriented when his vision

became obscured by blowing snow during a night NVG takeoff from a frozen lake, the Alaska

DPS cited the choice of a VFR departure versus an IFR instrument departure as causal to the

accident.

This determination that the accident resulted, in part, from the pilot’s decision to perform

a VFR rather than an IFR takeoff, was inappropriate and failed to acknowledge critical

underlying safety issues. Because the pilot was not IFR current in helicopters and the helicopter

was not certificated or equipped for IFR flight, performing an IFR takeoff was not an option.

Had the Alaska DPS’s investigation been more focused on identifying systemic safety issues, it

may have identified that it had not provided the pilot with simulator training in IFR flying or

inadvertent IMC encounters and had not imposed adequate weather minimums to maintain

separation between the VFR-only operation and IMC. As a result, the Alaska DPS missed an

opportunity to identify and correct some of the latent safety deficiencies that again presented

themselves in the 2013 accident. Without improvements to pilot training and operational

policies, the risk of another inadvertent IMC accident remained high.

DPS investigations of other events also narrowly focused on the actions of the pilot while

disregarding the organization’s management of flight-related risks. For example, although the

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Alaska DPS investigations of the pilot’s 2006 accident and the 2009 engine and rotor overspeed

event both mentioned the pilot’s work schedule, in 2013, the pilot was still allowed to schedule

himself for long workdays and extended periods without a day off. 59

Thus, the Alaska DPS did

not effectively manage its flight time and duty policies or evaluate the adequacy of its staffing

levels to support around-the-clock, on-call SAR availability (or reduce the helicopter’s

availability based on the available staff). The NTSB concludes that the Alaska DPS’s

investigation and analysis of the pilot’s previous accident and other events were focused on the

actions of the pilot and did not adequately identify and address systemic factors that could reduce

the likelihood of a recurrence.

The Alaska DPS investigations of the pilot’s aircraft accident and other events were

focused on apportioning blame or liability. After a committee appointed by the AWT director

completed its investigation of the pilot’s 2006 accident, the pilot received a memorandum of

warning informing him that the accident was due to “pilot error,” specifically, his momentary

distraction and inability to transition to instrument flight. The memorandum stressed the cost of

the accident and warned the pilot that future events could lead to more severe disciplinary action.

It stated, “the fact that you took responsibility for the accident and showed great remorse weighs

heavily in how the department views this incident,” indicating that the pilot’s acceptance of

liability was considered an important part of the investigation. The AMRG observer indicated

that the pilot was concerned about losing his job in the wake of the accident.

The Alaska DPS investigation of the 2009 overspeed event also focused extensively on

the culpability of the pilot. Although the pilot reported that a malfunction of the fuel control had

initiated the event, the former relief pilot suspected that the pilot had initiated it by moving the

collective in an “aggressive manner,” and he arranged to have a captain from an outlying post

lead an investigation of the incident. The AMRG observer said the pilot was again concerned

about losing his job, and the pilot’s wife said that he “fought tooth and nail” to be exonerated.

Physical findings from a manufacturer’s inspection of engine components suggested that a

corroded fuel metering needle had frozen in place, initiating the event. However DPS officials

determined the cause of the incident to be “inconclusive.” After that, the pilot felt distrustful of

his colleagues in the aircraft section. According to the lead mechanic and others, the pilot felt

that everybody in the organization was against him.

Although the Appareo unit provided the NTSB’s investigation with valuable information

(discussed in section 2.7), the Alaska DPS management had not installed it for safety-related

purposes, such as image and data reviews by the safety officer to monitor the safety of flight

operations. 60

Around the time of the 2009 overspeed event, the AWT director suspected that the

pilot had tried to conceal his role in some damage that was done to the tail rotor of a

Robinson R-44 helicopter. Inspection of the tail rotor assembly indicated that the damage could

have resulted from a water strike, but the pilot denied that he had experienced a water strike. The

AWT director said that when the pilot was questioned about events like the overspeed or the

damaged tail rotor, “it was never his fault” and there was nothing that the AWT director could do

59

Shortly before the accident, the AWT deputy director proposed that the relief pilot serve as the primary pilot

for the helicopter 2 days a week to give the pilot regularly scheduled days off. However, the accident occurred

before this schedule could be implemented. 60

The Alaska DPS reported in August 2014 that such reviews now occur.

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61

to “take sanctions” against the pilot. As a result, the AWT director told the aircraft section

supervisor to research onboard monitoring equipment that could be installed in the helicopter. As

a result, the AWT director learned about the Appareo recorder, and he insisted that it be

purchased and installed.

Thus, Alaska DPS investigations of the pilot’s past incidents and accident appeared to be

punitive in nature. As a result, it appears that the pilot was motivated to conceal safety-related

information. After experiencing a brief overtorque event in the helicopter in 2011, for example,

the pilot inspected the helicopter, determined that costly repairs were not needed, and signed off

the inspection without notifying his supervisor or the helicopter’s maintenance personnel.

Maintenance technicians later discovered the pilot’s sign-off in the helicopter’s maintenance

logbook, and one of them called an FAA safety hotline, prompting an FAA inspection of the

helicopter’s maintenance records. Although the FAA determined that the pilot (as an airframe

and powerplant mechanic) was qualified to perform and sign off the inspection, the pilot’s

handling of the matter prompted a meeting between the pilot and the AWT director, as well as

the issuance of a formal letter by the Alaska DPS stating that the pilot should report any similar

future events to the maintenance department in a timely manner.

Any organization that wishes to actively manage safety as part of an effective SMS must

continuously strive to discover, understand, and mitigate the risks involved in its operations. This

includes establishing a just culture in which mutually agreed principles are established to draw a

clear line between acceptable and unacceptable employee behaviors and in which employees are

not punished for most unintentional errors. Closely related to just culture is the concept of a

reporting culture in which employees are encouraged and even incentivized to participate in the

reporting of hazards. Also important is a flexible culture that is capable of adapting to shifting

demands and a learning culture that fosters change as a result of information generated by

SMS-related activities, including the internal review of past accidents. All of these activities can

foster the open sharing of safety-related information that can be used to implement more

effective strategies for mitigating related risks. However, an effective SMS requires the active

engagement of front-line personnel in the reporting of operational risks and their participation in

using the information obtained to develop effective risk mitigation strategies. This cannot occur

if a focus of the organization’s approach to dealing with safety-related events is to punish those

whose actions or inactions contributed to the event. Although front-line operators may, on rare

occasions, be involved in intentional misdeeds, the majority of accidents and incidents involve

unintentional errors made by well-intentioned operators who are doing their best to manage

competing performance and safety goals. An organizational safety culture that encourages the

adoption of an overly punitive approach to investigating safety-related events tends to discourage

the open sharing of safety-related information and degrade the organization’s ability to adapt to

operational risks.

The Alaska DPS safety culture, which seemed to overemphasize the culpability of the

pilot in his past accident and events, appears to have had this effect. The pilot had adopted a

defensive posture with respect to the organization and was concealing—rather than openly

sharing—safety-related information. He was largely setting his own operational limitations and

making safety-related operational decisions in a vacuum, masking potential risks, such as the risk

posed by his operation of helicopter NVG flights at night in low IFR conditions. This had a

deleterious effect on the organization’s efforts to manage the overall safety of its SAR operations

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and hindered its ability to implement more effective strategies for mitigating related risks, such

as the development of SAR prelaunch and midlaunch risk assessment protocols. Therefore, the

NTSB concludes that the Alaska DPS had a punitive culture that impeded the free flow of

safety-related information and impaired the organization’s ability to address underlying safety

deficiencies relevant to this accident.

The recently retired aircraft section supervisor identified other cultural and structural

deficiencies in the organization’s approach to safety management. She told investigators that an

Alaska DPS captain asked her to get the DPS involved in the Medallion Foundation and that,

beginning in 2010, she devoted considerable effort to developing Alaska DPS’s SMS program in

accordance with Medallion Foundation guidelines. This effort included the development of a

hazard reporting system and safety committee. Although the development of these and other

safety mechanisms were sufficient to earn a Medallion Foundation star, the aircraft section

supervisor told investigators that the safety program lacked high-level Alaska DPS support and,

as a result, there was a lack of Alaska DPS pilot confidence and participation in the program.

Trooper pilots did not see the value in participating in the program and would only

participate if directed to do so by their supervisors, but the recently retired aircraft section

supervisor had little authority to encourage their participation. She was not a uniformed trooper,

so she was not in their chain of command and trooper pilots did not report to her. Further, the

chain of command for her position was modified in 2012 so that instead of reporting to a

high-ranking manager (the colonel who was the AWT director), she reported to the lieutenant

who served as the aircraft section commander, a lower-ranking new position. This undermined

her influence as safety manager. As a result, trooper pilots and middle managers felt comfortable

ignoring the safety policies that she, as safety manager, attempted to put in place.

In addition, the recently retired aircraft section supervisor had very little control over the

aircraft section’s budget. In 2012, for example, headquarters canceled the annual pilot safety

seminar because of a lack of funds. The recently retired aircraft section supervisor said that she

felt that the 3-day seminar was important because it was the only time when about 40 trooper

pilots were brought together from their stations around the state to receive information about

safety issues. However, she had little budgetary control and could not directly countermand this

or other decisions affecting safety resources. As a result of these and other factors, she felt that

the impact of the safety program on the safety of Alaska DPS aircraft operations was limited.

The recently retired aircraft section supervisor said that she assumed that the aircraft

section commander would take over as the manager of the safety program when she left.

However, the aircraft section commander said that he was not well versed in the aircraft section

supervisor’s activities in her role as safety manager. A safety policy statement posted in the main

hangar that was signed by the AWT director stated, “A safety manager who is experienced in

safety programs will be appointed and will have the responsibility and authority to manage the

Alaska DPS aviation safety program. The safety manager should be contacted in regards to any

questions or recommendations.” However, 3 months after the aircraft section supervisor’s

retirement, no safety manager had been formally appointed, no safety committee meetings had

been held, and the Alaska DPS safety program had effectively ceased operating. The NTSB

concludes that, as a result of inadequate high-level management support, the Alaska DPS lacked

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63

a safety program that was capable of correcting latent deficiencies identified in this accident,

including deficiencies in training and risk management.

Correcting these deficiencies can be accomplished by ensuring high-level management

support, dedicating sufficient resources to safety, and modifying Alaska DPS’s safety program

structure, policies, and procedures so that they are in line with industry best practices and

tailored to the department’s mission. Research indicates that the involvement of senior

management in sponsoring and supporting safety policies and related resources is key to the

continued success of organizational safety programs (Smith and others 1978; Shannon, Mayr,

and Haines 1997). Through their policies and actions, senior managers also play a key role in

fostering an organizational safety culture that is conducive to the development of an effective

SMS.

In recent years, the International Civil Aviation Organization (through its Safety

Management Manual), the FAA (through its Safety Management Systems for Aviation Service

Providers advisory circular), the International Helicopter Safety Team (through its Safety

Management System Toolkit), ALEA (through its Safety Management System Toolkit), and the

NTSB (through accident investigations and safety recommendations [NTSB 2007, 2009]) have

encouraged aviation service providers to adopt SMS programs. As noted in the NTSB’s Safety

Recommendation A-11-53 to the state of New Mexico, suitable guidance tailored to the needs of

law enforcement agencies conducting public aircraft operations is available from organizations

such as ALEA. Therefore, the NTSB recommends that the state of Alaska develop and

implement a comprehensive SMS for aircraft operations that (1) holds senior state personnel

accountable for the safety of state law enforcement aircraft operations, (2) is tailored to the

department’s missions, and (3) is based on industry best practices. Since the accident, the Alaska

DPS had a third-party maintenance audit conducted and, at the time of this report, had scheduled

operation and training audits. The Alaska DPS stated that all audits include a safety component

for inclusion in the safety program. The NTSB is encouraged by such progress and believes that

ongoing reviews are vital to ensuring the program’s effectiveness, improvement, and success.

Therefore, the NTSB recommends that the state of Alaska arrange for an audit of the SMS

implemented in response to Safety Recommendation A-14-105 to be conducted every 3 years by

an outside organization.

2.5 Similarities with Other Public Aircraft Operations Accidents

As referenced in sections 1.9.2 and 1.9.3, the NTSB has investigated previous accidents

involving state law enforcement helicopters that crashed while conducting public aircraft

operations, such as during SAR or HEMS missions (as with the NMSP and Maryland State

Police accidents, respectively). Because of the similarities between the safety issues identified in

those accidents and this accident, the NTSB is concerned that the problems may be widespread.

The NTSB concludes that all law enforcement agencies of each state, territory, and the District

of Columbia that conduct public aircraft operations 61

can benefit from an effective flight risk

evaluation program, formalized dispatch and flight-following procedures, NVG and inadvertent

61

An NTSB review found that, at the time of this report, the law enforcement agencies of the following states

and territories do not conduct public aircraft operations: Hawaii, Idaho, Rhode Island, Vermont, Wyoming, Guam,

American Samoa, US Virgin Islands, and Northern Mariana Islands.

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64

IMC training for pilots, a formal TFO program, and a comprehensive SMS. Therefore, the NTSB

recommends that, in addition to Alaska, 44 states, the Commonwealth of Puerto Rico, and the

District of Columbia do the following:

Develop and implement a flight risk evaluation program that includes training for

all employees involved in the operation and procedures that support the

systematic evaluation of flight risks and consultation with others trained in flight

operations if the risks reach a predefined level.

Use formalized dispatch and flight-following procedures that include up-to-date

weather information and assistance with flight risk assessment decisions.

Provide all pilots who will perform NVG operations with formal NVG ground

and flight training and require them to complete this training on an annual basis to

remain on flight status.

Require all pilots who perform state law enforcement SAR missions to receive, on

an annual basis, scenario-based simulator training in inadvertent IMC that

includes strategies for recognizing, avoiding, and safely escaping the conditions.

Create a formal TFO training program that includes training on aeronautical

decision-making, crew resource management, and operating aircraft navigational

and communications equipment, and use TFOs during SAR operations.

Develop and implement a comprehensive SMS for aircraft operations that

(1) holds senior state personnel accountable for the safety of state law

enforcement aircraft operations, (2) is tailored to the department’s missions, and

(3) is based on industry best practices.

Arrange for an audit of the SMS implemented in response to Safety

Recommendation A-14-105 to be conducted every 3 years by an outside

organization.

2.6 Attitude Indicator Limitations

As discussed in section 2.2, about 40 seconds after the helicopter entered IMC, the pilot

caged the attitude indicator, likely because he distrusted the information the instrument was

displaying. Although the reason the pilot distrusted the information cannot be known, the

investigation considered two possible explanations.

One possible explanation is that the pilot might have distrusted the attitude display

because he was spatially disoriented. Maneuvering flight without external visual references can

lead to a variety of illusions of motion, which can result in inaccurate perceptions of an aircraft’s

attitude and trajectory. A number of risk factors for spatial disorientation preceded the pilot’s

operation of the caging knob. These included the pilot’s lack of instrument flying currency, the

loss of external visual references, his unplanned transition to instrument flight, aggressive

maneuvering, and operational distractions related to setting up the navigational instruments for

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65

flight in IMC. Research indicates that spatial disorientation can result in false perceptions of

instrument malfunction. In a 2002 spatial disorientation survey, for example, 18% of US Air

Force pilots operating rotary wing aircraft reported having experienced at least one instance of

illusory instrument malfunction (Matthews and others 2002).

Another possible explanation is related to the instrument’s limitations. According to

information provided by the attitude indicator’s manufacturer, the AIM 1200 attitude indicator is

limited to indicating ± 25° of pitch. Thus, if an aircraft were to operate at a pitch that exceeded

the limitation, the pitch indicator would stop and remain at the limit until the pitch no longer

exceeded the limitation. Image evidence shows that, during the first 30 seconds after the

helicopter entered IMC, the pitch increased from about 0° to at least 17° nose up. Although pitch

indications on the attitude indicator higher than about 17° could not be accurately measured from

the cockpit images, the images show that the indicated pitch remained above 17° from 2318:28

to 2318:40. This is consistent with the attitude indicator stopping at 25° and remaining there as

the helicopter continued pitching up. Although the operating manual for the AIM 1200 did not

include information about the pitch indicating range limits, even if it had, and the pilot were

aware of it, it is uncertain whether the pilot would have immediately understood this instrument

behavior upon encountering it in a high-stress, high-workload situation. Therefore, it is possible

that the helicopter’s attitude indicator reached its pitch limit and stopped moving, and the pilot

interpreted this as a malfunction and instinctively attempted to “unstick” the instrument by

pulling the caging knob.

The AIM-1200, a model commonly installed in many airplanes and helicopters, meets the

FAA’s technical standard order (TSO) for bank and pitch instruments, which requires a pitch

indication range of at least ± 25°. However, the instrument’s operating manual did not note the

pitch indication limits. Further, a review the FAA’s Helicopter Flying Handbook, Instrument

Flying Handbook, and Pilot’s Handbook of Aeronautical Knowledge revealed that they do not

inform pilots that attitude indicators have pitch and bank indication limits, that the pitch

indicating range is required to be at least ± 25°, and that if an aircraft operates at a pitch that

exceeds the indicating limits, the pitch indicator may stop and remain at the limit until the pitch

no longer exceeds the limitation, or the pitch indicator may tumble.

Further, the NTSB’s review of the information on attitude indicators in the Pilot’s

Handbook of Aeronautical Knowledge revealed that it contains information on attitude indicator

limitations that is unclear and may be misleading. The handbook states the following:

The pitch and bank limits depend upon the make and model of the instrument.

Limits in the banking plane are usually from 100° to 110°, and the pitch limits are

usually from 60° to 70°. If either limit is exceeded, the instrument will tumble or

spill and will give incorrect indications until realigned.

It is unclear whether this passage is discussing operating limits or indicating limits. This

could mislead a pilot into concluding that attitude indicators commonly have pitch indication

ranges from ±60° to 70°, although the TSO requirement is only from ±25°. Further, the passage

suggests that if an indication limit is reached, the instrument will tumble, rather than stop moving

as the AIM-1200 does.

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Although it is uncertain whether knowledge of the attitude indicator’s limitations would

have changed the pilot’s actions in this accident, the NTSB believes that it is critical for pilots to

have a complete understanding of how each flight instrument functions to safely conduct flight in

IMC. As stated in the FAA’s Helicopter Flying Handbook (FAA-H-8083-21A, Chapter 12,

Attitude Instrument Flying, page 12-2), “when attitude instrument flying, it is crucial for the pilot

to understand how a particular instrument or system functions, including its indications and

limitations.” Without knowledge of the limitations of the attitude indicator, an instrument

essential for maintaining aircraft control during instrument flight, pilots who encounter these

limitations during a high-workload, high-stress situation may react improperly, as the accident

pilot may have, by caging the attitude indicator.

The NTSB concludes that because of the lack of accurate, comprehensive information

about attitude indication limitations in FAA publications, such as the Helicopter Flying

Handbook, Instrument Flying Handbook, and Pilot’s Handbook of Aeronautical Knowledge,

pilots are likely unaware that attitude indicators have pitch indication ranges that may be limited

to ± 25°. Therefore, the NTSB recommends that the FAA issue guidance to pilots explaining that

attitude indicators have pitch and bank indication limits, that the pitch indicating range is

required to be at least ± 25°, and that, if an aircraft operates at a pitch that exceeds the indicating

limits, the pitch indicator may stop and remain at the limit until the pitch no longer exceeds the

limitation, or the pitch indicator may tumble. Further, the NTSB recommends that the FAA

revise the Pilot’s Handbook of Aeronautical Knowledge to clarify the information it contains on

attitude indicator pitch and bank limitations to explain that attitude indicators have pitch and

bank indication limits, that the pitch indicating range is required to be at least ± 25°, and that, if

an aircraft operates at a pitch that exceeds the indicating limits, the pitch indicator may stop and

remain at the limit until the pitch no longer exceeds the limitation, or the pitch indicator may

tumble.

2.7 Investigative Benefits of Onboard Recorder

Although the helicopter’s onboard Appareo unit was not a crash-resistant flight recorder

system, it provided valuable information about the accident flight that helped investigators

identify safety issues that would not have been otherwise detectable. Images captured by the

recorder provided information about where the pilot’s attention was directed, his interaction with

the helicopter controls and systems, and the status of cockpit instruments and system indicator

lights, including those that provided information about the helicopter’s position (like the attitude

indicator), engine operation, and systems. Because of these images, the investigation was able to

determine precisely how the cockpit navigational displays were configured and that the pilot

caged the attitude indicator in flight.

The images, combined with the wreckage examination, also enabled the investigation to

conclusively determine that icing was not a factor in the accident and that there were no

mechanical anomalies with the helicopter. The NTSB concludes that the information provided by

the onboard recorder provided critical information early in the investigation that enabled

investigators to make conclusive determinations about what happened during the accident flight

and to more precisely focus the safety investigation on the issues that need to be addressed to

prevent future accidents.

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67

Because the unit was not a required installation, it was not required to comply with

TSO C197. The Alaska DPS did not have the Appareo ICS optional audio link to the helicopter’s

intercom connected, so voice audio was not recorded. Also, the unit had not been calibrated

correctly, which subjected the internal attitude data to inaccuracies. The NTSB believes that

voice audio information and accurate sensor data would have been helpful to the investigation

and notes that Alaska DPS now uses the optional audio link, and Appareo has revised its

installation instructions to include the calibration procedures.

The NTSB has previously addressed the need for recording information on aircraft. On

May 6, 2013, the NTSB issued Safety Recommendation A-13-13, which asked the FAA to do

the following:

Require all existing turbine-powered, nonexperimental, nonrestricted-category

aircraft that are not equipped with a flight data recorder or cockpit voice recorder

and are operating under 14 [CFR] Parts 91, 121, or 135 to be retrofitted with a

crash-resistant flight recorder system. The crash-resistant flight recorder system

should record cockpit audio and images with a view of the cockpit environment to

include as much of the outside view as possible, and parametric data per aircraft

and system installation, all as specified in [TSO] C197, “Information Collection

and Monitoring Systems.” [62]

On December 10, 2013, the NTSB classified Safety Recommendation A-13-13 “Open—

Unacceptable Response” because the FAA stated that it had not found any compelling evidence

to require installation of cockpit image recording systems. The FAA stated that it planned no

further action to mandate flight deck image recording systems and considered its actions for this

recommendation complete. In an August 14, 2014, letter, the FAA repeated to the NTSB its

decision not to act, citing costs to the industry, its inability to estimate the number of lives that

could be saved or accidents that could be prevented, and its position of promoting and

incentivizing the voluntary equipage of such recording systems. Despite the FAA’s position, the

NTSB continues to support the required installation of flight recorder systems because they

enable accident investigators to identify safety issues that may not otherwise be detectable,

which is critical to the prevention of future accidents.

On October 23, 2014, the NTSB reiterated Safety Recommendation A-13-13 following

its investigation of the November 10, 2013, fatal accident involving a Mitsubishi MU-2B-25

airplane. 63

The airplane, which crashed after the pilot reported “a control problem” and “a left

engine shutdown” to an air traffic controller, was not equipped with any type of recording

device. The lack of available data significantly increased the difficulty in determining the safety

issues that led to the accident. Specifically, the reasons for the pilot’s loss of control of the

airplane and the engine shutdown could not be determined. Postaccident examination and testing

did not reveal evidence of any malfunction that would have precluded normal operations.

62

On that date, the NTSB also issued Safety Recommendation A-13-12, which asked the FAA to require the

installation of such recorders on all newly manufactured turbine-powered, nonexperimental, nonrestricted-category

aircraft. Safety Recommendation A-13-12 is also classified “Open—Unacceptable Response.” 63

More information about this accident, NTSB cases number CEN14FA046, is available at

www.ntsb.gov/aviationquery/index.aspx.

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Without any onboard recording devices, the investigation lacked valuable insight on the pilot’s

control inputs, the airplane’s motions (such as pitch, bank, and yaw), and the time that the pilot’s

reported control and engine problems began.

The NTSB notes that it has a long history of recommending that the FAA require image

recording devices on board certain aircraft. 64

The NTSB notes that, had the FAA required all

turbine-powered, nonexperimental, nonrestricted-category aircraft operated under Parts 91, 135,

and 121 to be equipped with crash-protected image recording system by January 1, 2007 (as the

NTSB had recommended back in 2003), hundreds of aircraft involved in accidents would have

been equipped with crash-resistant recording devices that may have provided investigators with

valuable safety information. For example, a review of NTSB accident data shows that, since

January 1, 2007, there were 466 accidents involving such aircraft, and these accidents claimed

246 lives. In addition, in 55 of these accidents, the probable cause statements contained some

element of uncertainty, such as an undetermined cause or factor.

64

Safety Recommendation A-13-13 superseded Safety Recommendation A-03-64, which was issued on

December 22, 2003, and asked the FAA to “[r]equire all turbine-powered, nonexperimental, nonrestricted-category

aircraft that are manufactured prior to January 1, 2007, that are not equipped with a cockpit voice recorder, and that

are operating under 14 [CFR] Parts 91, 135, and 121 to be retrofitted with a crash-protected image recording system

by January 1, 2007.” That safety recommendation (which superseded Safety Recommendation A-99-60) was

superseded by Safety Recommendation A-09-10 and, therefore, was classified “Closed—Unacceptable

Action/Superseded” on February 9, 2009.

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3. Conclusions

3.1 Findings

1. The pilot was qualified to fly search and rescue missions in visual meteorological conditions (but not instrument meteorological conditions) in the accident helicopter, and his

performance was unlikely affected by medical factors, fatigue, or physical activities

associated with the ground portion of the rescue activity.

2. The in-flight image recording and wreckage examinations showed that the helicopter and its engine were operating normally throughout the flight. No mechanical abnormalities with the

helicopter were identified.

3. Soon after departure from the remote landing site, the helicopter likely encountered instrument meteorological conditions, which included low clouds, heavy snow, and

near-zero-visibility conditions.

4. Although icing conditions were likely present during the accident flight, the performance of the helicopter does not appear to have been degraded at the time of the accident.

5. The pilot experienced a total loss of external visual references while operating in close proximity to terrain, which led him to attempt to transition to instrument flight.

6. The pilot’s action to cage the attitude indicator outside those conditions under which it could be safely caged indicates that he distrusted the information he was seeing.

7. The pilot’s caging of the attitude indicator made it very unlikely that he would regain control of the helicopter in instrument meteorological conditions.

8. The helicopter’s erratic maneuvers are consistent with the pilot’s spatial disorientation, a loss of control in flight, and his inability to recover the helicopter because of his lack of

instrument experience and the lack of accurate attitude information.

9. When the pilot was contacted about the mission, forecasts indicated that conditions in the search area would be instrument flight rules and that forecast cloud ceilings and visibility

would likely be below the pilot’s Alaska Department of Public Safety weather minimums

and possibly below his last known personal weather minimums.

10. At the time the pilot was notified about the stranded snowmobiler, sufficient information was available to indicate that the mission carried a high degree of risk due to the weather and

low lighting conditions.

11. The pilot’s exceptionally high motivation for conducting search and rescue missions, which was influenced by multiple factors,

likely played a part in his acceptance of the accident

mission.

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12. The pilot’s exceptionally high motivation for search and rescue missions and past successes likely increased his risk tolerance and influenced his decision to continue flying in

deteriorating weather conditions and risk a weather-related accident rather than accept the

certain inconveniences and potential hazards associated with a precautionary landing.

13. The Alaska Department of Public Safety lacked organizational policies and procedures to ensure that operational risk was appropriately managed, such as formal pilot weather

minimums, preflight risk assessment forms, or secondary assessment by another qualified

person trained in helicopter flight operations that would have encouraged the pilot to decline

the mission or take steps to mitigate weather-related risks.

14. The Alaska Department of Public Safety’s reliance on nonaviation-trained dispatchers for dispatch and flight-following support does not ensure that flight crews have adequate access

to up-to-date weather information and qualified assistance with flight risk assessment tasks.

15. The Alaska Department of Public Safety did not provide the pilot with training that could have helped him recognize the hazards that precipitation and low light conditions pose to

night vision goggles operations.

16. Pilots involved in search and rescue missions could benefit from initial and recurrent training on how to recognize, avoid, and safely recover from inadvertent flight into instrument

meteorological conditions.

17. Operators lack adequate information about best practices for helicopter inadvertent instrument meteorological conditions training.

18. A tactical flight officer who was capable of assisting the pilot with aeronautical decision-making and operating the helicopter’s navigational systems and displays could have

helped mitigate risk.

19. Although a tactical flight officer (TFO) program had been recognized by Alaska Department of Public Safety personnel as a means of improving the safety of helicopter search and rescue

operations, inadequate support for the program at various levels of the organization led to the

unavailability of a TFO or other trained observer on the day of the accident.

20. The Alaska Department of Public Safety’s investigation and analysis of the pilot’s previous accident and other events were focused on the actions of the pilot and did not adequately

identify and address systemic factors that could reduce the likelihood of a recurrence.

21. The Alaska Department of Public Safety had a punitive culture that impeded the free flow of safety-related information and impaired the organization’s ability to address underlying

safety deficiencies relevant to this accident.

22. As a result of inadequate high-level management support, the Alaska Department of Public Safety lacked a safety program that was capable of correcting latent deficiencies identified in

this accident, including deficiencies in training and risk management.

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23. All law enforcement agencies of each state, territory, and the District of Columbia that conduct public aircraft operations can benefit from an effective flight risk evaluation

program, formalized dispatch and flight-following procedures, night vision goggles and

inadvertent instrument meteorological conditions training for pilots, a formal tactical flight

officer program, and a comprehensive safety management system.

24. Because of the lack of accurate, comprehensive information about attitude indication limitations in Federal Aviation Administration publications, such as the Helicopter Flying

Handbook, Instrument Flying Handbook, and Pilot’s Handbook of Aeronautical Knowledge,

pilots are likely unaware that attitude indicators have pitch indication ranges that may be

limited to ± 25°.

25. Information provided by the onboard recorder provided critical information early in the investigation that enabled investigators to make conclusive determinations about what

happened during the accident flight and to more precisely focus the safety investigation on

the issues that need to be addressed to prevent future accidents.

3.2 Probable Cause

The National Transportation Safety Board determines that the probable cause of this

accident was the pilot’s decision to continue flight under visual flight rules into deteriorating

weather conditions, which resulted in the pilot’s spatial disorientation and loss of control. Also

causal was the Alaska Department of Public Safety’s punitive culture and inadequate safety

management, which prevented the organization from identifying and correcting latent

deficiencies in risk management and pilot training. Contributing to the accident was the pilot’s

exceptionally high motivation to complete search and rescue missions, which increased his risk

tolerance and adversely affected his decision-making.

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4. Recommendations

As a result of this investigation, the National Transportation Safety Board makes the

following recommendations:

To the state of Alaska, 44 additional states, the Commonwealth of Puerto Rico, and

the District of Columbia:

Develop and implement a flight risk evaluation program that includes training for

all employees involved in the operation and procedures that support the

systematic evaluation of flight risks and consultation with others trained in flight

operations if the risks reach a predefined level. (A-14-100)

Use formalized dispatch and flight-following procedures that include up-to-date

weather information and assistance with flight risk assessment decisions.

(A-14-101)

Provide all pilots who will perform night vision goggle (NVG) operations with

formal NVG ground and flight training and require them to complete this training

on an annual basis to remain on flight status. (A-14-102)

Require all pilots who perform state law enforcement search and rescue missions

to receive, on an annual basis, scenario-based simulator training in inadvertent

instrument meteorological conditions that includes strategies for recognizing,

avoiding, and safely escaping the conditions. (A-14-103)

Create a formal tactical flight officer (TFO) training program that includes

training on aeronautical decision-making, crew resource management, and

operating aircraft navigational and communications equipment, and use TFOs

during search and rescue operations. (A-14-104)

Develop and implement a comprehensive safety management system for aircraft

operations that (1) holds senior state personnel accountable for the safety of state

law enforcement aircraft operations, (2) is tailored to the department’s missions,

and (3) is based on industry best practices. (A-14-105)

Arrange for an audit of the safety management system implemented in response to

Safety Recommendation A-14-105 to be conducted every 3 years by an outside

organization. (A-14-106)

To the Federal Aviation Administration:

Work with operators, training providers, and industry groups to evaluate the

effectiveness of current training programs for helicopter pilots in inadvertent

instrument meteorological conditions, and develop and publish best practices for

such training. (A-14-107)

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Issue guidance to pilots explaining that attitude indicators have pitch and bank

indication limits, that the pitch indicating range is required to be at least ± 25°,

and that, if an aircraft operates at a pitch that exceeds the indicating limits, the

pitch indicator may stop and remain at the limit until the pitch no longer exceeds

the limitation, or the pitch indicator may tumble. (A-14-108)

Revise the Pilot’s Handbook of Aeronautical Knowledge to clarify the

information it contains on attitude indicator pitch and bank limitations to explain

that attitude indicators have pitch and bank indication limits, that the pitch

indicating range is required to be at least ± 25°, and that, if an aircraft operates at

a pitch that exceeds the indicating limits, the pitch indicator may stop and remain

at the limit until the pitch no longer exceeds the limitation, or the pitch indicator

may tumble. (A-14-109)

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BY THE NATIONAL TRANSPORTATION SAFETY BOARD

CHRISTOPHER A. HART ROBERT L. SUMWALT Acting Chairman Member

MARK R. ROSEKIND Member

EARL F. WEENER

Member

Adopted: November 5, 2014