Attached to this question are the two accidents that need to be discussed on the similarities of error chains and how the dynamics of SMS (Safety
Attached to this question are the two accidents that need to be discussed on the similarities of error chains and how the dynamics of SMS (Safety Managment System) could have prevented the accidents. The paper needs to be in APA format and be 1000 words.
Write a 3-4 page response, double-spaced, using an average of 1,000 -words. Solid writing using APA mechanics and style are required. Support your answers and data with references, and cite your sources.
You should review and utilize the American Psychological Association’s Publication Manual, a required text for this course, as guidance for your submissions. A title and reference page are additional pages to the 3-4 page response. All other APA formatting applies.
Crash Following Encounter with Instrument Meteorological
Conditions After Departure from Remote Landing Site
Alaska Department of Public Safety
Eurocopter AS350 B3, N911AA
Talkeetna, Alaska
March 30, 2013
Accident Report
NTSB/AAR-14/03 PB2014-108877
National
Transportation
Safety Board
NTSB/AAR-14/03 PB2014-108877
Notation 8602 Adopted November 5, 2014
Aircraft Accident Report
Crash Following Encounter with Instrument Meteorological
Conditions After Departure from Remote Landing Site
Alaska Department of Public Safety
Eurocopter AS350 B3, N911AA
Talkeetna, Alaska
March 30, 2013
National
Transportation
Safety Board
490 L’Enfant Plaza, S.W.
Washington, D.C. 20594
National Transportation Safety Board. 2014. Crash Following Encounter with Instrument
Meteorological Conditions After Departure from Remote Landing Site, Alaska Department of Public
Safety, Eurocopter AS350 B3, N911AA, Talkeetna, Alaska, March 30, 2013. Aircraft Accident Report
NTSB/AAR-14/03. Washington, DC.
Abstract: This report discusses the March 30, 2013, accident involving a Eurocopter AS350 B3
helicopter, N911AA, operated by the Alaska Department of Public Safety, which impacted terrain while
maneuvering during a search and rescue 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. Safety issues
include inadequate pilot decision-making and risk management; lack of organizational policies and
procedures to ensure proper risk management; inadequate pilot training, particularly for night vision
goggle use and inadvertent instrument meteorological condition encounters; inadequate dispatch and
flight following; lack of a tactical flight officer program; punitive safety culture; lack of management
support for safety programs; and attitude indicator limitations. Safety recommendations are addressed to
the Federal Aviation Administration, the state of Alaska, 44 additional states, the Commonwealth of
Puerto Rico, and the District of Columbia.
The National Transportation Safety Board (NTSB) is an independent federal agency dedicated to promoting
aviation, railroad, highway, marine, and pipeline safety. Established in 1967, the agency is mandated by Congress
through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable
causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety
effectiveness of government agencies involved in transportation. The NTSB makes public its actions and decisions
through accident reports, safety studies, special investigation reports, safety recommendations, and statistical
reviews.
The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation,
“accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties … and
are not conducted for the purpose of determining the rights or liabilities of any person.” 49 C.F.R. § 831.4.
Assignment of fault or legal liability is not relevant to the NTSB’s statutory mission to improve transportation safety
by investigating accidents and incidents and issuing safety recommendations. In addition, statutory language
prohibits the admission into evidence or use of any part of an NTSB report related to an accident in a civil action for
damages resulting from a matter mentioned in the report. 49 U.S.C. § 1154(b).
For more detailed background information on this report, visit http://www.ntsb.gov/investigations/dms.html and
search for NTSB accident ID ANC13GA036. Recent publications are available in their entirety on the Internet at
http://www.ntsb.gov. Other information about available publications also may be obtained from the website or by
contacting:
National Transportation Safety Board
Records Management Division, CIO-40
490 L’Enfant Plaza, SW
Washington, DC 20594
(800) 877-6799 or (202) 314-6551
NTSB publications may be purchased from the National Technical Information Service. To purchase this
publication, order product number PB2014-108877 from:
National Technical Information Service
5301 Shawnee Rd.
Alexandria, VA 22312
(800) 553-6847 or (703) 605-6000
http://www.ntis.gov/
NTSB Aircraft Accident Report
i
Contents
Figures …………………………………………………………………………………………………………………………. iii
Tables ………………………………………………………………………………………………………………………….. iv
Abbreviations …………………………………………………………………………………………………………………v
Executive Summary …………………………………………………………………………………………………….. vii
1. Factual Information …………………………………………………………………………………………………….1 1.1 History of the Flight …………………………………………………………………………………………………..1
1.1.1 Mission Coordination …………………………………………………………………………………………1 1.1.2 Outbound Flight to Remote Rescue Location ………………………………………………………..2
1.1.3 Accident Flight ………………………………………………………………………………………………….4 1.2 Personnel Information ………………………………………………………………………………………………….7
1.2.1 Pilot ………………………………………………………………………………………………………………….7 1.2.1.1 Training and Performance at Alaska DPS …………………………………………………7 1.2.1.2 Work/Sleep/Wake History ………………………………………………………………………9
1.2.1.3 Previous Accident ………………………………………………………………………………..10 1.2.1.4 Schedule and Compensation ………………………………………………………………….10
1.2.1.5 Colleagues’ and Others’ Perceptions ………………………………………………………11 1.2.2 Flight Observer ………………………………………………………………………………………………..13
1.3 Helicopter Information……………………………………………………………………………………………….13
1.3.1 Maintenance …………………………………………………………………………………………………….15 1.3.2 Pilot’s Concerns about Maintenance …………………………………………………………………..16
1.4 Meteorological Information ………………………………………………………………………………………..16 1.4.1 Weather Information Available Before Departure ………………………………………………..17
1.4.2 Weather and Lighting Conditions at Accident Site and Time …………………………………18 1.5 Cockpit Image, Audio, and Data Recorder ……………………………………………………………………19 1.6 Wreckage and Impact Information ………………………………………………………………………………23
1.7 Medical and Pathological Information………………………………………………………………………….24 1.8 Organizational and Management Information ……………………………………………………………….24
1.8.1 General ……………………………………………………………………………………………………………24 1.8.2 Aircraft Section Policies and Procedures …………………………………………………………….26
1.8.2.1 Operational Control and Go/No-Go Decisions …………………………………………26 1.8.2.2 Flight and Duty Time Policies ……………………………………………………………….27
1.8.2.3 Preflight Risk Assessment and Weather Minimums …………………………………28 1.8.2.4 Safety Program…………………………………………………………………………………….28
1.8.3 Response to Pilot’s Previous Accident and Events ……………………………………………….30
1.8.3.1 Accident in 2006 ………………………………………………………………………………….30 1.8.3.2 Engine and Rotor Overspeed Event in 2009 …………………………………………….32 1.8.3.3 Overtorque Event in 2011 ……………………………………………………………………..33
1.8.4 Use of Flight Observers …………………………………………………………………………………….34 1.8.5 Use of MatCom Dispatch Services ……………………………………………………………………..35
NTSB Aircraft Accident Report
ii
1.8.6 Alaska DPS Changes Since This Accident …………………………………………………………..36
1.9 Previously Issued Safety Recommendations …………………………………………………………………38 1.9.1 Airborne Law Enforcement Association Safety Policies Guidance …………………………38 1.9.2 HEMS Operations …………………………………………………………………………………………….39
1.9.2.1 Pilot Training on Inadvertent IMC Encounters ………………………………………..39 1.9.2.2 Preflight Risk Assessment …………………………………………………………………….40
1.9.3 Inconsistencies Among Weather Information Products …………………………………………42
2. Analysis …………………………………………………………………………………………………………………….45 2.1 General …………………………………………………………………………………………………………………….45
2.1.1 Pilot Qualifications and Fitness for Duty …………………………………………………………….45 2.1.2 Helicopter Maintenance and Wreckage Examinations …………………………………………..45 2.1.3 Weather Conditions ………………………………………………………………………………………….46
2.2 Accident Flight………………………………………………………………………………………………………….47 2.3 Pilot’s Risk Management Considerations ……………………………………………………………………..50
2.3.1 Decision to Accept Mission ……………………………………………………………………………….50
2.3.2 Preparations for Departure …………………………………………………………………………………51 2.3.3 Decision to Continue Mission ……………………………………………………………………………53
2.4 Organizational Issues …………………………………………………………………………………………………54 2.4.1 Risk Assessment ………………………………………………………………………………………………54 2.4.2 Pilot Training …………………………………………………………………………………………………..56
2.4.3 Use of Trained Observers ………………………………………………………………………………….58 2.4.4 Safety Management and Safety Culture ………………………………………………………………59
2.5 Similarities with Other Public Aircraft Operations Accidents …………………………………………63 2.6 Attitude Indicator Limitations……………………………………………………………………………………..64 2.7 Investigative Benefits of Onboard Recorder………………………………………………………………….66
3. Conclusions ……………………………………………………………………………………………………………….69 3.1 Findings……………………………………………………………………………………………………………………69 3.2 Probable Cause………………………………………………………………………………………………………….71
4. Recommendations ……………………………………………………………………………………………………..72
References …………………………………………………………………………………………………………………….74
NTSB Aircraft Accident Report
iii
Figures
Figure 1. End of GPS flight track from Sunshine to landing site with flight track shown in
orange. …………………………………………………………………………………………………………………………… 3
Figure 2. Aerial photograph of helicopter landing site. . ……………………………………………………… 4
Figure 3. GPS-derived flight track of the accident flight (shown in orange). ………………………….. 5
Figure 4. Aerial view of the accident site with helicopter wreckage circled in red. …………………. 6
Figure 5. Preaccident photograph of the helicopter. ………………………………………………………….. 14
Figure 6. Appareo Vision 1000 unit from the accident helicopter. ………………………………………. 20
Figure 7. Accident site showing main wreckage. ……………………………………………………………… 23
Figure 8. Chain of command structure in place at the time of the accident. ………………………….. 25
NTSB Aircraft Accident Report
iv
Tables
Table 1. Pilot’s estimated potential sleep. ………………………………………………………………………… 10
Table 2. Summary of select information from Appareo images ………………………………………….. 21
Table 3. Summary of Alaska DPS safety improvements since the accident………………………….. 37
NTSB Aircraft Accident Report
v
Abbreviations
AAWU
Ag
Alaska Aviation Weather Unit
agl above ground level
ALEA Airborne Law Enforcement Association
AMPA Air Medical Physicians Association
AMRG Alaska Mountain Rescue Group
ANC Ted Stevens Anchorage International Airport
ASOS automated surface observing system
AST Alaska State Troopers
AWT Alaska Wildlife Troopers
CDI course deviation indicator
CFR Code of Federal Regulations
DPS Department of Public Safety
ELT emergency locator transmitter
EMS emergency medical services
FA area forecast
FAA Federal Aviation Administration
FLI flight limit indicator
FLIR forward-looking infrared
fpm feet per minute
FSS flight service station
HEMS helicopter emergency medical services
HSI horizontal situation indicator
IFR instrument flight rules
IMC instrument meteorological conditions
in Hg inches of mercury
METAR meteorological aerodrome report
min Minutes
NTSB Aircraft Accident Report
vi
msl mean sea level
NMSP New Mexico State Police
NTSB National Transportation Safety Board
NVG night vision goggles
NWS National Weather Service
OCC operations control centers
PAQ Palmer Municipal Airport
PED portable electronic device
PIC pilot-in-command
RCC Alaska Air National Guard Rescue Coordination Center
SAR search and rescue
SFAR special federal aviation regulation
SMS safety management system
TAF terminal aerodrome forecast
TFO tactical flight officer
TKA Talkeetna Airport
TSO technical standard order
VFR visual flight rules
NTSB Aircraft Accident Report
vii
Executive Summary
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.
At the time the pilot was notified of the mission and decided to accept it, sufficient
weather information was available for him to have determined that the weather and low lighting
conditions presented a high risk. The pilot was known to be highly motivated to accomplish SAR
missions and had successfully completed SAR missions in high-risk weather situations in the
past.
The investigation also identified that the Alaska DPS lacked organizational policies and
procedures to ensure that operational risk was appropriately managed both before and during the
mission. Such policies and procedures include formal pilot weather minimums, preflight risk
assessment forms, and secondary assessment by another qualified person trained in helicopter
flight operations. These risk management strategies could have encouraged the pilot to take steps
to mitigate weather-related risks, decline the mission, or stay on the ground in the helicopter after
rescuing the snowmobiler. The investigation also found that the Alaska DPS lacked support for a
tactical flight officer program, which led to the unavailability of a trained observer on the day of
the accident who could have helped mitigate risk.
Any organization that wishes to actively manage safety as part of an effective safety
management system must continuously strive to discover, understand, and mitigate the risks
involved in its operations. Doing so requires the active engagement of front-line personnel in the
reporting of operational risks and their participation in the development of effective risk
mitigation strategies. This cannot occur if a focus of the organization’s approach to dealing with
safety-related events is to punish those whose actions or inactions contributed to the event.
NTSB Aircraft Accident Report
viii
Although front-line personnel may, on rare occasions, be involved in intentional misdeeds, the
majority of accidents and incidents involve unintentional errors made by well-intentioned
personnel who are doing their best to manage competing performance and safety goals. An
organizational safety culture that encourages the adoption of an overly punitive approach to
investigating safety-related events tends to discourage the open sharing of safety-related
information and to degrade the organization’s ability to adapt to operational risks.
The Alaska DPS safety culture, which seemed to overemphasize the culpability of the
pilot in his past accident and events, appears to have had this effect. The pilot had adopted a
defensive posture with respect to the organization, and he was largely setting his own operational
limitations and making safety-related operational decisions in a vacuum, masking potential risks,
such as the risk posed by his operation of helicopter NVG flights at night in low IFR conditions.
This had a deleterious effect on the organization’s efforts to manage the overall safety of its SAR
operations. The investigation found that Alaska DPS had a punitive safety 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.
The National Transportation Safety Board (NTSB) determines 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.
It is important to note that the investigation was significantly aided by information
recovered from the helicopter’s onboard image and data recorder, which provided valuable
insight about the accident flight that helped investigators identify safety issues that would not
have been otherwise detectable. Images captured by the recorder provided information about
where the pilot’s attention was directed, his interaction with the helicopter controls and systems,
and the status of cockpit instruments and system indicator lights, including those that provided
information about the helicopter’s position, engine operation, and systems. Information provided
by the onboard recorder provided critical information early in the investigation that enabled
investigators to make conclusive determinations about what happened during the accident flight
and to more precisely focus the safety investigation on the issues that need to be addressed to
prevent future accidents. For example, the available images allowed the investigation to
determine that the pilot caged the attitude indicator in flight. This discovery resulted in the
development of important safety recommendations related to attitude indicator limitations.
Although the recording device on board the accident helicopter was not required and was
not a crash-protected system, the NTSB has a long history of recommending that the Federal
Aviation Administration (FAA) require image recording devices on board certain aircraft. Some
of these safety recommendations, which were either closed or superseded after the FAA
indicated that it would not act upon them, date as far back as 1999. The NTSB notes that, had the
FAA required all turbine-powered, nonexperimental, nonrestricted-category aircraft operated
under Parts 91, 135, and 121 to be equipped with crash-protected image recording system by
NTSB Aircraft Accident Report
ix
January 1, 2007 (as the NTSB had recommended in 2003), 466 aircraft involved in accidents
would have had image recording systems; in 55 of these accidents, the probable cause statements
contained some element of uncertainty, such as an undetermined cause or factor.
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.
NTSB Aircraft Accident Report
1
1. Factual Information
1.1 History of the Flight
On March 30, 2013, at 2320 Alaska daylight time, a Eurocopter AS350 B3 helicopter, 1
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 2 flight
under 14 Code of Federal Regulations (CFR) 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.
1.1.1 Mission Coordination
At 1935, the snowmobiler used his cell phone to call 911 to request rescue after his
snowmobile became stuck in a ditch under the Intertie (a major power transmission line) between
Larson Lake and Talkeetna. According to the MatCom 3 dispatcher who handled the call, the
snowmobiler reported that he bruised his ribs but was more concerned about developing
hypothermia if not rescued soon. After receiving notification from MatCom, the trooper on duty
at the Alaska State Troopers (AST) Talkeetna post tried to coordinate a ground rescue mission. 4
The trooper found that no local Alaska Wildlife Troopers (AWT) units were on duty and that
other local resources (residents with snowmobiles and SAR experience) did not want to
participate because of the distance involved and the deteriorating weather, which included rain
and poor snow conditions on the ground. After the trooper’s attempts to coordinate a ground
rescue were unsuccessful, at 2009, he telephoned the AST on-duty SAR coordinator, 5 and they
agreed that it would be appropriate to use the Alaska DPS’s primary SAR helicopter to retrieve
the snowmobiler.
1 Eurocopter is now known as Airbus Helicopters, a wholly owned subsidiary of the Airbus Group, which is
headquartered in France. 2 The term “public aircraft” refers to a subset of government aircraft operations that, as such, are not subject to
some of the regulatory requirements that apply to civil aircraft. Because public aircraft operators (like the Alaska
DPS) are exempted from certain aviation safety regulations, government organizations conducting public aircraft
operations supervise their own flight operations without oversight from the Federal Aviation Administration. 3 MatCom, a public safety dispatch center located in Wasilla, Alaska, is a division of the Wasilla Police
Department. 4 The Alaska DPS has two major divisions, the AST and the Alaska Wildlife Troopers (AWT). The AST is
charged with statewide law enforcement, prevention of crime, pursuit and apprehension of offenders, service of civil
and criminal process, prisoner transport, central communications, and SAR. The AWT is charged with enforcing
fish and game regulations; AWT troopers also enforce criminal laws and participate in SAR operations. 5 According to the Alaska DPS SAR protocol, the SAR coordinator handled all requests for the use of the
accident helicopter. If the SAR coordinator approved, then the coordinator would notify the pilot, who would
evaluate the weather and determine if the mission was acceptable.
NTSB Aircraft Accident Report
2
According to records from the pilot’s portable electronic device (PED), 6 at 2019, he
received an incoming call from the SAR coordinator. The SAR coordinator stated that he relayed
details of the situation to the pilot, and the pilot said he would check the weather. The pilot’s
spouse recalled that, immediately after the pilot received the call, he went upstairs to check the
weather. The pilot called the SAR coordinator soon after and said he would accept the mission. 7
The pilot’s spouse recalled that she asked her husband about the weather, and he said that it was
“good.” The pilot then drove to Ted Stevens Anchorage International Airport (ANC),
Anchorage
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