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Accident Report Detail

 
​Crash Following Encounter with Instrument Meteorological Conditions After Departure from Remote Landing Site Alaska Department of Public Safety Eurocopter AS350 B3, N911AA

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.
 
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 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 makes3 safety recommendations to the FAA and 7safety 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.

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.

Accident Location: Talkeetna , AK    
Accident Date: 3/30/2013
Accident ID: ANC13GA036

Date Adopted: 11/5/2014
NTSB Number: AAR-14-03
NTIS Number: PB2014-108877