Santa Fe, New Mexico
June 9, 2009
NTSB Number: AAR-11-04
NTIS Number: PB2011-910404
Adopted: May 24, 2011
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On June 9, 2009, about 2135 mountain daylight time, an Agusta S.p.A. A-109E helicopter, N606SP, impacted terrain following visual flight rules flight into instrument meteorological conditions 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 and operated by the New Mexico State Police (NMSP) on a public search and rescue mission under the provisions of 14 Code of Federal Regulations Part 91 without a flight plan. The helicopter departed its home base at Santa Fe Municipal Airport, Santa Fe, New Mexico, about 1850 in visual meteorological conditions; instrument meteorological conditions prevailed when the helicopter departed the remote landing site about 2132.
The National Transportation Safety Board determines 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 NMSP 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.
The safety issues discussed in this report include the pilot's decision-making, flight and duty times and rest periods, NMSP staffing, safety management system programs and risk assessments, communications between the NMSP pilots and volunteer search and rescue organization personnel, instrument flying, and flight-following equipment.
Recommendations to the Governor of the State of New Mexico
Require the New Mexico Department of Public Safety to bring its aviation section policies and operations into conformance with industry standards, such as those established by the Airborne Law Enforcement Association. (A-11-53)
Require the New Mexico Department of Public Safety to develop and implement a comprehensive fatigue management program for the New Mexico State Police (NMSP) aviation section pilots that, at a minimum, requires NMSP to provide its pilots with protected rest periods and defines pilot rest (in a manner consistent with 14 Code of Federal Regulations Section 91.1057) and ensures adequate pilot staffing levels and aircraft hours of availability consistent with the pilot rest requirements. (A-11-54)
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. (A-11-55)
Recommendations to the Airborne Law Enforcement Association
Revise your standards to define pilot rest and ensure that pilots receive protected rest periods that are sufficient to minimize the likelihood of pilot fatigue during aviation operations. (A-11-56)
Revise your accreditation standards to require that all pilots receive training in methods for safely exiting inadvertently encountered instrument meteorological conditions for all aircraft categories in which they operate. (A-11-57)
Encourage your members to install 406-megahertz emergency locator transmitters on all of their aircraft. (A-11-58)
Encourage your members to install flight-tracking equipment on all public aircraft that would allow for continuous flight tracking during missions. (A-11-59)
Recommendations to the National Association of State Aviation Officials
Encourage your members 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 Airborne Law Enforcement Association guidance. (A-11-60)
Encourage your members to develop and implement risk assessment and management procedures specific to their operations. (A-11-61)
Encourage your members to install 406-megahertz emergency locator transmitters on all of their aircraft. Encourage your members to install flight-tracking equipment on all public aircraft that would allow for continuous flight tracking during missions. (A-11-62)
Encourage your members to install flight-tracking equipment on all public aircraft that would allow for near-continuous flight tracking during missions. (A-11-63)
Recommendations to the International Association of Chiefs of Police
Encourage your members 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 Airborne Law Enforcement Association guidance. (A-11-64)
Encourage management procedures specific to their operations. (A-11-65)
Encourage your members to install 406-megahertz emergency locator transmitters on all of their aircraft. (A-11-66)
Encourage your members to install flight-tracking equipment on all public aircraft that would allow for near-continuous flight tracking during missions. (A-11-67)
