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Safety Recommendation Details

Safety Recommendation A-11-053
Synopsis: These recommendations, which address safety standards, policies, and procedures; fatigue management programs; and communication between airborne and ground search and rescue (SAR) personnel, are derived from the NTSB’s investigation of the June 9, 2009, aviation accident in which a New Mexico State Police (NMSP) Agusta A-109E helicopter crashed in mountainous terrain during a public SAR operation and are consistent with the evidence we found and the analysis we performed. As a result of this investigation, the NTSB has issued 15 safety recommendations, 3 of which are addressed to the governor of the state of New Mexico. Information supporting the recommendations is discussed below. The NTSB would appreciate a response from you within 90 days addressing the actions you have taken, or intend to take, to implement our recommendations. On June 9, 2009, about 2135 mountain daylight time, an Agusta 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 NMSP on a public 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; IMC prevailed when the helicopter departed the remote landing site about 2132. The NTSB determined 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 New Mexico State Police 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.
Recommendation: 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.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Santa Fe, NM, United States
Is Reiterated: No
Is Hazmat: No
Accident #: CEN09PA348
Accident Reports: Crash After Encounter with Instrument Meteorological Conditions During Takeoff from Remote Landing Site New Mexico State Police Agusta S.p.A. A-109E, N606SP
Report #: AAR-11-04
Accident Date: 6/9/2009
Issue Date: 6/10/2011
Date Closed: 8/13/2014
Addressee(s) and Addressee Status: State of New Mexico (Closed - Acceptable Action)
Keyword(s): Helicopter Emergency Medical Services (Public Operators)

Safety Recommendation History
From: NTSB
To: State of New Mexico
Date: 8/13/2014
Response: We note that the NMSP aviation section implemented a flight risk evaluation program that incorporates predetermined levels of risk and requires management approval if the risk reaches an established level. We also note that all members of the aviation section are members of the airborne law enforcement association (ALEA) and are encouraged to attend ALEA’s annual conference. These actions satisfy the intent of Safety Recommendation A-11-53, which is classified CLOSED—ACCEPTABLE ACTION.

From: State of New Mexico
Date: 5/20/2014
Response: -From Susana Martinez, Governor: The NMSP command staff has empowered the subordinate leadership chain to implement necessary aircrew professional development training in order to strengthen aviation safety, policies, and operations to meet or exceed common airborne law enforcement standards. The aircraft section has developed and implemented a structured, objective, and composite risk management checklist. This checklist identifies potential hazards in the areas of mission profile, weather factors, human factors, crew complement, crew fatigue/personnel distractions, crew duty time, and NVG illumination. This process applies to both fixed and rotary wing operations with separate risk management forms for both airframe types. The objectivity built into this system requires the pilot-in command to place a number on the checklist corresponding to the respective elements of concern within each individual area. Additionally, the pilot-in-command then accounts for each crew member's own assessment of their fatigue level, which is also noted on the form. Upon completion, the pilot-in-command then adds up all the numbers to obtain the "Total Risk" value. This value is then inserted into a range which identifies the objective "Risk Level" and, consequently, the required level of supervisor approval. A risk assessment identified as "LOW" requires approval only by the pilot-in-command with notification of the aircraft section commander. A risk assessment identified as "MODERATE" requires approval of the aircraft section commander. A risk assessment identified as "HIGH" requires the NMSP Special Operations Bureau commander's approval and "SEVERE" will require specific approval at a higher level. This program provides a real-time assessment of the potential risks involved in an individual mission thereby providing the pilot-in-command the opportunity to reassess the mission, modify the plan, adjust the mission time, or even cancel the mission all together. The current NMDPS/NMSP command staff fully supports this course of action and never imposes any undue influence upon the pilot-in-command to accept any mission that he may deem unsafe, regardless of the situation. Another change the NMSP aircraft section made since the NTSB investigation concluded was the establishment of an aircrew professional development program. The NMSP aircraft section conducts academic and hands-on training for all members (full and part time) on a monthly basis. Subjects include weather interpretation, mountain/high-altitude operations, brown-out/white-out operations, aircrew survival, land navigation, night vision goggle operations, etc. The total yearly program consists of 44 different subjects that are all directly applicable to aircraft operations and safety. This training program has significantly enhanced the safety and operational ability of the section. Finally, in response to recommendation A-11-53, the NMSP has provided every member of the NMSP aircraft section a membership to the ALEA. Additionally, the NMSP provides the opportunity (through time, transportation, and funding) for every member of the NMSP aircraft section to attend annual ALEA conferences around the country. These superb training opportunities improve unit operations and bring the unit closer to compliance with industry standards.

From: NTSB
To: State of New Mexico
Date: 12/18/2012
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation–railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we conduct special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members impacted by major transportation disasters. This letter addresses Safety Recommendations A-11-53 through -55, which the NTSB issued to the state of New Mexico on June 10, 2011, as a result of our investigation of the June 9, 2009, accident involving an Agusta S.p.A. A 109E helicopter operated by the New Mexico State Police (NMSP) that crashed in mountainous terrain during a search and rescue operation. To date, the NTSB has received no information regarding any actions that the state of New Mexico has taken to address these Safety Recommendations, and we would appreciate receiving a reply regarding any actions that the state has taken or planned to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. A copy of our June 10, 2011, letter issuing Safety Recommendations A-11-53 through 55 is enclosed for your convenience, and the full NTSB report of the NMSP accident investigation (Report Number NTSB/AAR-11/04) is available on our website at We encourage you to respond electronically to this letter and to submit future updates regarding your progress in addressing Safety Recommendations A 11 53 through 55 at the following e mail address: