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Safety Recommendation Details

Safety Recommendation A-11-054
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 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 91.1057) and ensures adequate pilot staffing levels and aircraft hours of availability consistent with the pilot rest requirements.
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): Fatigue, Helicopter Emergency Medical Services (Public Operators), Staffing

Safety Recommendation History
From: NTSB
To: State of New Mexico
Date: 8/13/2014
Response: We are pleased to learn that the NMSP aviation section has implemented crew rest standards that it has documented in its standard operating procedures. We are also pleased that the NMSP has supplemented these procedures with a tool to ensure that pilots and tactical flight officers (TFOs) do not exceed maximum flight/work hours and are afforded adequate rest periods at appropriate times. We note that, in order to protect crewmember rest periods, non flying members of the chain of command receive flight requests; if they approve a request, they notify the aircraft section commander, and the ultimate decision about whether to fly or not is made by the pilot-in-command. We also note that the NMSP aviation section conducts search and rescue flights with at least one, and sometimes two, TFOs, who are trained to assist the pilot. Accordingly, Safety Recommendation A-11-54 is classified CLOSED—ACCEPTABLE ACTION.

From: State of New Mexico
Date: 5/20/2014
Response: -From Susana Martinez, Governor: The compliance measures taken in response to recommendation #A-11-54 also apply to recommendation #A-11-53. These measures take into account that during airborne law enforcement operations the workload always shifts to the pilot. Consequently, to ensure proper pilot staffing levels, the use of untrained patrol officers as ad hoc observers, as was the previous norm, needed to be addressed and rectified. In order to properly staff an effective airborne law enforcement unit, the leadership cannot just fill it with people. It is essential to identify, hire, train, and equip the "right" people for a job as critical as this. Therefore, in line with industry standards, and as endorsed by the ALEA, the NMSP aircraft section researched, created, and implemented a comprehensive Tactical Flight Officer (TFO) program. While a TFO is not a pilot, the TFO is a trained and effective airborne law enforcement crew member. The TFO's primary responsibilities are the operation of the Forward Looking Infra-Red (FUR) system, use of the external search light, and air-to-ground communication/coordination. All assigned TFOs are required to attend monthly aircrew professional development training and are fully integrated members of the crew. The TFO program has significantly enhanced the safety and operational capabilities of the aircraft section. Additionally, while the TFO program has been a great step forward in the continued development of the NMSP aircraft section, the NMSP leadership has continued to identify and hire quality pilots. While it took a long time to find pilots with the appropriate experience, the unit will be hiring two new pilots into the section. As of August 2014, the staffing levels at the NMSP aircraft section will include four full-time pilots, four full-time TFOs, and one full-time aircraft mechanic. This will allow the NMSP aircraft section to expand hours of availability and operation to near 24/7 operations without compromising flight or operational safety. Aircraft hours of availability are adjusted as necessary depending on aircrew availability and crew rest. In accordance with 14 CFR 91.1057 and 14 CFR 91.1059, the NMSP aircraft section has implemented crew rest standards that apply to all crew members (pilots & TFOs) assigned full-time or part-time. These requirements are clearly identified in the NMSP aircraft section's Standard Operating Procedures (SOP). Compliance with this requirement is the individual aircrew member's responsibility and is monitored closely by the aircraft section commander and assistant commander. The crew rest standards in the SOP are supplemented with a "Fighter Management" program similar to that used by the US Army. Each crew member now will fill out a daily worksheet that identifies work hours, flight hours, and rest periods. These standards ensure individual crew members do not exceed maximum flight/work hours and are afforded adequate rest periods at appropriate times. This is another comprehensive tool for the individual crew member, as well as the section leadership, to monitor and account for the onset of fatigue in order to assist in sound operational decision making. In terms of "protected rest periods," as identified in recommendation #A-11-54, notifications have gone out to all NMSP districts, supervisors, and officers instructing them not to directly contact aircrew members during rest periods. The NMSP command staff has gone to great lengths to protect aircrew rest by funneling all requests for aviation support to non-flying members of the chain-of-command. These individuals will screen the requests and notify the aircraft section commander or assistant commander (the two current section pilots) if a prospective mission has been approved. This notification marks the point at which their respective duty day begins for crew rest purposes. It is also essential to emphasize that the non-flying chain-of-command's approval of a mission request is not meant to be, nor is it understood to be, any form of pressure to fly that particular mission. The ultimate decision to fly, not fly, modify, or terminate a particular mission rests with the pilot-in-command.

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: