Aviation Accident Report: Crash of Agusta S.p.A. A-109E helicopter, N606SP, near Santa Fe, NM, June 9, 2009

On May 24, 2011, the National Transportation Safety Board held a Board Meeting to discuss and adopt the Aviation Accident Report relating to the crash of Agusta S.p.A. A-109E helicopter, N606SP, near Santa Fe, NM, June 9, 2009.

Synopsis

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.

Conclusions

  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 rescue (SAR) personnel could 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 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.
  9. 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.
  10. An effective pilot flight and duty time program would address not only maximum flight and 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, the New Mexico State Police 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.
  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 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 transmitter (ELT) signals received from the 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 their occupants.

Probable Cause

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.

Recommendations

Recommendations to the Governor of the State of New Mexico:

  1. 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.
  2. 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 NMSP to provide its pilots with protected rest periods and defines pilot rest (in a manner consistent with 14 Code of Federal Regulations Section 91.1057) and ensures adequate pilot staffing levels and aircraft hours of availability consistent with the pilot rest requirements.
  3. 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.

Recommendations to the Airborne Law Enforcement Association:

  1. 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.
  2. 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.
  3. Encourage your members to install 406-megahertz emergency locator transmitters on all of their aircraft.
  4. Encourage your members to install flight-tracking equipment on all public aircraft that would allow for continuous flight tracking during missions.

Recommendations to the National Association of State Aviation Officials:

  1. 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.
  2. Encourage your members to develop and implement risk assessment and management procedures specific to their operations.
  3. Encourage your members to install 406-megahertz emergency locator transmitters on all of their aircraft.
  4. Encourage your members to install flight-tracking equipment on all public aircraft that would allow for continuous flight tracking during missions.

Recommendations to the International Association of Chiefs of Police:

  1. 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.
  2. Encourage your members to develop and implement risk assessment and management procedures specific to their operations.
  3. Encourage your members to install 406-megahertz emergency locator transmitters on all of their aircraft.
  4. Encourage your members to install flight-tracking equipment on all public aircraft that would allow for continuous flight tracking during missions.