Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation A-11-066
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 INTERNATIONAL ASSOCIATION OF CHIEFS OF POLICE: Encourage your members to install 406-megahertz emergency locator transmitters on all of their aircraft.
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: 5/13/2013
Addressee(s) and Addressee Status: International Association of Chiefs of Police (Closed - Acceptable Action)
Keyword(s): Emergency Locator Transmitter, Helicopter Emergency Medical Services (Public Operators)

Safety Recommendation History
From: NTSB
To: International Association of Chiefs of Police
Date: 5/13/2013
Response: We appreciate the IACP’s posting on its website the text of Safety Recommendations A 11-64 through -67, the link to the associated NTSB accident report, and the link to the standards of the Airborne Law Enforcement Accreditation Commission. These actions satisfy the intent of Safety Recommendations A-11-64 through -67, which are classified CLOSED—ACCEPTABLE ACTION.

From: NTSB
To: International Association of Chiefs of Police
Date: 6/19/2012
Response: The NTSB is pleased that the IACP has included on its website the text of Safety Recommendations A-11-64 through -67, as well as a link to the associated NTSB accident report. However, we point out that the intent of these recommendations is not only for the IACP to notify its members of the recommendations but also to develop guidance and to disseminate this information to the law enforcement community. We believe that the IACP could use its annual conferences, training, educational partnerships, and/or IACP’s Police Chief magazine, for example, to advocate for these much-needed safety improvements. Therefore, pending our receipt and review of further information regarding actions the IACP takes to encourage its members to adopt the safety improvements recommended, Safety Recommendations A-11-64 through -67 are classified OPEN—ACCEPTABLE RESPONSE.

From: International Association of Chiefs of Police
Date: 1/18/2012
Response: -From Don Roby, Chairman of the International Association Chiefs of Police Aviation Committee: In response to the NTSB recommendations for the IACP after the NMSP crash, the association has released the report and recommendation to all US and international members. The announcement can be viewed at: I have already received three calls from Chiefs of Police from across the country to discuss this issue. The text on the above link reads: IACP Aviation Committee NTSB Issues Recommendations to Law Enforcement Agencies Operating Aircraft On June 9, 2009, a state-owned aircraft responded to the scene of an active search and rescue operation. After affecting the rescue of the victim, the law enforcement helicopter crashed into mountainous terrain. The pilot (law enforcement officer) and the victim were killed, and the aerial observer (law enforcement officer) was seriously injured. As a result of the investigation, the National Transportation Safety Board (NTSB) has issued specific recommendations to the IACP concerning law enforcement agencies that operate aircraft. The NTSB recommendations follow: 1. Encourage IACP members that operate aircraft to conduct an independent review and evaluation of their policies and procedures and make changes as needed to align those policies and procedures with safety standards, procedures, and guidelines, such as those outlined in the Airborne Law Enforcement Accreditation Commission standards. (These standards are available for review at 2. Encourage IACP members that operate aircraft to develop and implement risk assessment and management procedures specific to their operations. 3. Encourage IACP members that operate aircraft to install 406-megahertz emergency locator transmitters on all aircraft. 4. Encourage IACP members that operate aircraft to install flight-tracking equipment on all public aircraft (law enforcement aircraft) that would allow for near-continuance flight tracking during missions. The above recommendations were presented to the IACP Aviation Committee on October 22, 2011, in Chicago, IL, by NTSB personnel. The full NTSB aircraft accident report can be viewed at .