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1000 word APA paper discussing the possible similarities of error chains and how the dynamics of SMS may have prevented the accidents attached to this question

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

i

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

NTSB Aircraft Accident Report

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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

NTSB Aircraft Accident Report

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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

NTSB Aircraft Accident Report

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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

NTSB Aircraft Accident Report

v

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

vi

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

NTSB Aircraft Accident Report

vii

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.

NTSB Aircraft Accident Report

viii

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

NTSB Aircraft Accident Report

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.

NTSB Aircraft Accident Report

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.

NTSB Aircraft Accident Report

2

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,

arr

1000 word APA paper discussing the possible similarities of error chains and how the dynamics of SMS may have prevented the accidents attached to this question

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 

 
 
 

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 

i

NTSB Aircraft Accident Report

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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NTSB Aircraft Accident Report

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

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NTSB Aircraft Accident Report

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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NTSB Aircraft Accident Report

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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2

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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3

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

1000 Word APA Paper Discussing The Possible Similarities Of Error Chains And How The Dynamics Of SMS May Have Prevented The Accidents Attached To This Question

Attached to this question are the two accidents that need to be discussed on the similarities of error chains and how the dynamics of SMS (Safety Managment System) could have prevented the accidents. The paper needs to be in APA format and be 1000 words.

Write a 3-4 page response, double-spaced, using an average of 1,000 -words. Solid writing using APA mechanics and style are required. Support your answers and data with references, and cite your sources. 

You should review and utilize the American Psychological Association’s Publication Manual, a required text for this course, as guidance for your submissions. A title and reference page are additional pages to the 3-4 page response. All other APA formatting applies.