On March 30, 2013, at 2320 Alaska daylight time, a Eurocopter AS350 B3 helicopter,
N911AA, impacted terrain while maneuvering during a search and rescue (SAR) flight near
Talkeetna, Alaska. The airline transport pilot, an Alaska state trooper serving as a flight observer
for the pilot, and a stranded snowmobiler who had requested rescue were killed, and the
helicopter was destroyed by impact and postcrash fire. The helicopter was registered to and
operated by the Alaska Department of Public Safety (DPS) as a public aircraft operations flight
under 14 Code of Federal Regulations Part 91. Instrument meteorological conditions (IMC)
prevailed in the area at the time of the accident. The flight originated at 2313 from a frozen pond
near the snowmobiler’s rescue location and was destined for an off-airport location about 16 mi
south.
After picking up the stranded, hypothermic snowmobiler at a remote rescue location in
dark night conditions, the pilot, who was wearing night vision goggles (NVG) during the flight,
encountered IMC in snow showers within a few minutes of departure. Although the pilot was
highly experienced with SAR missions, he was flying a helicopter that was not equipped or
certified for flight under instrument flight rules (IFR). The pilot was not IFR current, had very
little helicopter IFR experience, and had no recent inadvertent IMC training. Therefore,
conducting the flight under IFR was not an option, and conducting the night flight under visual
flight rules in the vicinity of forecast IFR conditions presented high risks. After the helicopter
encountered IMC, the pilot became spatially disoriented and lost control of the helicopter.
We determined that the probable cause of this accident was the pilot’s decision to continue flight under visual flight rules into deteriorating weather conditions, which resulted in the pilot’s spatial disorientation and loss of control. Also causal was the Alaska Department of Public Safety’s punitive culture and inadequate safety management, which prevented the organization from identifying and correcting latent deficiencies in risk management and pilot training. Contributing to the accident was the pilot’s exceptionally high motivation to complete search and rescue missions, which increased his risk tolerance and adversely affected his decision-making.
As a result of this investigation, the NTSB makes 3 safety recommendations to the FAA and 7 safety recommendations to the state of Alaska, 44 additional states, the Commonwealth of Puerto Rico, and the District of Columbia that conduct law enforcement public aircraft operations.
