WASHINGTON – The National Transportation Safety Board today determined that
the March 30, 2013 crash of an Alaska Department of Public Safety helicopter was
caused by the pilot's decision to continue flying into deteriorating weather
conditions as well as the department's "punitive culture and inadequate safety
The crash occurred on a mission to rescue a stranded snowmobiler near
Talkeetna, Alaska. The pilot, another state trooper and the snowmobiler were all
fatally injured. 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, the Board found.
Among the recommendations the NTSB made today as a result of the
investigation was for Alaska and other states to develop and implement a flight
risk evaluation program.
"These brave few take great risks to save those in harm's way,'' said NTSB
Acting Chairman Christopher A. Hart. "There needs to be a safety net for them as
Among the Board's findings was that the Alaska Department of Public Safety
(DPS) lacked policies and procedures to ensure that risk was managed, such as
formal weather minimums, formal training in night vision goggle operations and
having a second person familiar with helicopter rescue operations involved in
the go/no-go decision.
During the investigation of this accident, the Board found that the pilot had
been involved in a previous accident. The Board found that the DPS's internal
investigation of the earlier accident was too narrowly focused on the pilot and
not enough on underlying risks that could have been better managed by the
The Board concluded that DPS had a "punitive culture that impeded the free
flow of safety-related information and impaired the organization's ability to
address underlying safety deficiencies relevant to this accident."
Since 2004, the NTSB has investigated the crashes of 71 public helicopters
responsible for 27 deaths and 22 serious injuries.
"Public agencies are not learning the lessons from each other's accidents,"
Hart said. "And the tragic result is that we have seen far too many accidents in
public helicopter operations."
As a result of the investigation, the Board made recommendations to Alaska,
44 additional states, Puerto Rico, the District of Columbia and the Federal