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Safety Recommendation Details

Safety Recommendation A-11-063
Details
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 NATIONAL ASSOCIATION OF STATE AVIATION OFFICIALS: Encourage your members to install flight-tracking equipment on all public aircraft that would allow for near-continuous flight tracking during missions.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Santa Fe, NM, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: 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: 6/11/2013
Addressee(s) and Addressee Status: National Association of State Aviation Officials (Closed - Acceptable Action)
Keyword(s): Helicopter Emergency Medical Services (Public Operators)

Safety Recommendation History
From: NTSB
To: National Association of State Aviation Officials
Date: 6/11/2013
Response: Your timely briefing of the NASAO Board of Directors, electronic publication of our recommendations, and e-mail distribution of our safety recommendation issuance letter satisfy the intent of Safety Recommendations A-11-60 through -63, which are classified CLOSED—ACCEPTABLE ACTION.