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Safety Recommendation Details

Safety Recommendation A-11-055
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: 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.
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), Search and Rescue, Communication

Safety Recommendation History
From: NTSB
To: State of New Mexico
Date: 8/13/2014
Response: We note that, upon notification of a SAR mission, the TFO immediately contacts the SAR coordinator and incident commander to obtain mission details. We also note that, in flight, the TFO is the primary communicator with SAR personnel while the pilot-in-command is communicating over air traffic control frequencies. Further, all communications during SAR missions occur over a single dedicated SAR frequency, which ensures a direct and uninterrupted line among the incident base, the SAR team in the field, and the aircraft. These policies and practices satisfy Safety Recommendation A 11-55, which is classified CLOSED—ACCEPTABLE ACTION.

From: State of New Mexico
Date: 5/20/2014
Response: -From Susana Martinez, Governor: Some of the compliance measures addressed to recommendation #A-11-55 are also responsive to recommendations #A-11-53 and #A-11-54. The primary responsibility for SAR missions within the State of New Mexico rests with the NMSP. Thus, the NMSP command staff, and in particular the NMSP aircraft section, maintain a close working relationship with the respective SAR coordinators, incident commanders, and volunteer SAR teams throughout the state. In addition to frequent mission support opportunities, the NMSP aircraft section regularly attends SAR conferences throughout the state. These conferences afford both the aircraft section crews and SAR personnel a chance to integrate one-on-one in an academic setting. The two organizations provide specific training to one another covering topics such as aircraft/aircrew capabilities, aircrew rest policy, air-to-ground communications procedures, weather considerations, and effective use of airborne assets. The aircraft section staff has noted a greater efficiency and level of cooperation with regard to SAR missions due to these planned professional development interactions. Another change that has significantly improved air-to-ground communications during SAR missions is the institution of the TFO program set forth above. Upon notification of a SAR mission the TFO immediately contacts the SAR coordinator and incident commander to obtain mission details. This allows the pilot-in-command time to conduct mission planning, aircraft pre-flight inspection, chain-of-command notification, aircrew mission briefings, and a greater opportunity to make decisions prior to departure. In flight, the TFO will be the primary crew member in communication with SAR personnel while the pilot-in-command is communicating over air traffic control (ATC) frequencies. While the crew will work together, and the pilot-in-command will communicate with SAR personnel if required, the presence of the TFO reduces pilot workload and enhances both mission effectiveness and safety. It is also worth noting that all communications during SAR missions occur over a single dedicated SAR frequency. This ensures a direct line, uninterrupted by any other NMSP district radio traffic, between the incident base, the SAR teams in the field, and the aircraft. Additionally, with a staff of four full-time TFOs, most SAR missions will be flown with two TFOs on board (one in the cockpit, one in the cabin). This level of staffing reduces workload on the TFO in the cockpit and helps facilitate the search as well as air to ground communications. While it is clear that the NMSP command structure and the NMSP aircraft section have gone to great lengths to improve operations and safety at all levels, it is important to understand that neither entity feels its mission is complete. The NMSP aircraft section is constantly evolving and refining its tactics, techniques, policies, and procedures to ensure the highest quality of service to the people of the State of New Mexico without ever compromising safety. Every day, the personnel working in the NMSP execute their duties statewide, with the highest degree of professionalism, competence, and regard for the lives, property, and security of those within our borders. I wholeheartedly commend the NMSP leadership and the aircraft section for overcoming the aircraft and aircrew tragedy of June 2009 and recovering to bring themselves to the forefront of law enforcement operations in the United States. On behalf of the NMDPS and NMSP, I thank you for the recommendations made by your investigative team. Those recommendations and our responses to them have doubtlessly improved the operational effectiveness and safety of our aircrew and their aircraft. Together, we have made great strides toward minimizing, as much as reasonably possible, the chance that the tragic events of June 2009 will ever recur.

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: