Writing Prompt? Read the two NTSB accident reports located in the attachments sections? Write a paper discussing the possible sim

Crash After Encounter with Instrument Meteorological  Conditions During Takeoff from Remote Landing Site 

New Mexico State Police  Agusta S.p.A. A‐109E, N606SP 

Near Santa Fe, New Mexico  June 9, 2009 

Accident Report NTSB/AAR-11/04

PB2011-910404

National Transportation Safety Board

NTSB/AAR-11/04 PB2011-910404

Notation 8306 Adopted May 24, 2011

Aircraft Accident Report Crash After Encounter with Instrument Meteorological Conditions During Takeoff from Remote Landing Site

New Mexico State Police Agusta S.p.A. A-109E, N606SP

Near Santa Fe, New Mexico June 9, 2009

National Transportation Safety Board

490 L’Enfant Plaza, S.W. Washington, D.C. 20594

National Transportation Safety Board. 2011. Crash After Encounter with Instrument Meteorological Conditions During Takeoff from Remote Landing Site, New Mexico State Police Agusta S.p.A. A-109E, N606SP, Near Santa Fe, New Mexico, June 9, 2009. Aircraft Accident Report NTSB/AAR-11/04. Washington, DC. Abstract: This accident report discusses the June 9, 2009, accident involving an Agusta S.p.A. A-109E helicopter, N606SP, which 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 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. The National Transportation Safety Board (NTSB) is an independent federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials 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. 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, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2011-910404 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000 The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of NTSB reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

NTSB Aircraft Accident Report

Contents Figures …………………………………………………………………………………………………………………………. iv 

Abbreviations and Acronyms ………………………………………………………………………………………….v 

Executive Summary …………………………………………………………………………………………………….. vii 

1. Factual Information …………………………………………………………………………………………………….1  1.1  History of Flight ………………………………………………………………………………………………………..1  1.2  Injuries to Persons ……………………………………………………………………………………………………10  1.3  Damage to Aircraft …………………………………………………………………………………………………..10  1.4  Other Damage ………………………………………………………………………………………………………….10  1.5  Personnel Information ………………………………………………………………………………………………10 

1.5.1  The Pilot ………………………………………………………………………………………………………..10  1.5.1.1  Professional Background…………………………………………………………………….10  1.5.1.2  Pilot Personal Background and Medical History ……………………………………14  1.5.1.3  Pilot Schedule and Duties …………………………………………………………………..15  1.5.1.4  Pilot Recent and 72-Hour History ………………………………………………………..16 

1.5.2  The Spotter …………………………………………………………………………………………………….17  1.6  Aircraft Information …………………………………………………………………………………………………18 

1.6.1  General Information ………………………………………………………………………………………..18  1.6.2  Helicopter Seating and Restraints ……………………………………………………………………..19 

1.7  Meteorological Information ………………………………………………………………………………………20  1.7.1  General ………………………………………………………………………………………………………….20  1.7.2  Local Airport Weather Information …………………………………………………………………..21  1.7.3  Local Witness Reports …………………………………………………………………………………….21 

1.8  Aids to Navigation ……………………………………………………………………………………………………21  1.9  Communications ………………………………………………………………………………………………………22  1.10 Airport Information ………………………………………………………………………………………………….22  1.11 Flight Recorders ………………………………………………………………………………………………………22  1.12 Wreckage and Impact Information ……………………………………………………………………………..22 

1.12.1  Seats and Restraints ……………………………………………………………………………………….23  1.12.1.1  Pilot Seat (Right Front) and Restraint System ……………………………………..23  1.12.1.2  Aft, Forward-Facing Passenger Seats and Restraint Systems …………………23 

1.13 Medical and Pathological Information ………………………………………………………………………..23  1.14 Fire …………………………………………………………………………………………………………………………24  1.15 Survival Aspects ………………………………………………………………………………………………………25 

1.15.1 Postaccident Search and Rescue Efforts …………………………………………………………….25  1.16 Tests and Research …………………………………………………………………………………………………..27 

1.16.1 Emergency Locator Transmitter’s Distress Signal Information …………………………….27  1.16.2 Radar Study ……………………………………………………………………………………………………27 

1.17 Organizational and Management Information ……………………………………………………………..28  1.17.1  NMSP Aviation Section—General Information …………………………………………………28  1.17.2  NMSP Aviation Section Personnel and Chain of Command………………………………..28 

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NTSB Aircraft Accident Report

1.17.3 Aviation Section Policies, Procedures, and Practices …………………………………………..29  1.17.3.1  Flight Operations and Training ………………………………………………………….29  1.17.3.2  Pilot Flight and Duty Time ………………………………………………………………..30  1.17.3.3  SAR Helicopter Support Information …………………………………………………31 

1.17.3.3.1  Prelaunch Decision-Making …………………………………………………….. 31  1.17.3.3.2  Risk Management During SAR Missions ………………………………….. 32 

1.17.3.4  Crew Staffing and Equipment Practices ………………………………………………33  1.17.4 NMSP Aviation Section Staffing ………………………………………………………………………33  1.17.5  Postaccident NMSP Actions ……………………………………………………………………………34 

1.18 Additional Information ……………………………………………………………………………………………..35  1.18.1  New Mexico Search and Rescue Act and Plan …………………………………………………..35  1.18.2 Public Aircraft Operations ……………………………………………………………………………….36  1.18.3  Airborne Law Enforcement Association Standards …………………………………………….37  1.18.4  Safety Management System Programs ……………………………………………………………..38  1.18.5  Previously Issued Safety Recommendations ……………………………………………………..39 

1.18.5.1  Pilot Flight and Duty Time and Rest Period Limitations ……………………….39  1.18.5.2  Safety Management Systems …………………………………………………………….40  1.18.5.3  Risk Management and Assessment …………………………………………………….41  1.18.5.4  Flight Following and Dispatch Procedures ………………………………………….42  1.18.5.5  Helicopter Pilot Training for Inadvertent Encounters with IMC …………….43  1.18.5.6  FAA Oversight of Public Operations ………………………………………………….44 

2. Analysis …………………………………………………………………………………………………………………….45  2.1 General …………………………………………………………………………………………………………………….45  2.2  Pilot Decision-Making ……………………………………………………………………………………………..46 

2.2.1  Decision to Launch on the Mission …………………………………………………………………..46  2.2.2  Decision-Making During the Mission ……………………………………………………………….48 

2.3  Factors Affecting the Pilot’s Decision-Making …………………………………………………………….50  2.3.1   Fatigue…………………………………………………………………………………………………………..51  2.3.2   Self-Induced Pressure ……………………………………………………………………………………..53  2.3.3   Situational Stress …………………………………………………………………………………………….53  2.3.4  Summary of Factors Affecting the Pilot’s Decision-Making ………………………………..54 

2.4  Organizational Issues ……………………………………………………………………………………………….54  2.4.1  Risk Assessments and Safety Management Systems ……………………………………………54  2.4.2  NMSP Flight and Duty Time, Rest Period Limitations, and Staffing …………………….57 

2.5  Relationship with the Volunteer Search and Rescue Organization ………………………………….59  2.6  Instrument Flying …………………………………………………………………………………………………….60  2.7  Emergency Locating Equipment ………………………………………………………………………………..61 

3. Conclusions ……………………………………………………………………………………………………………….63  3.1  Findings ………………………………………………………………………………………………………………….63  3.2  Probable Cause ………………………………………………………………………………………………………..65 

4. Recommendations ……………………………………………………………………………………………………..66 

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NTSB Aircraft Accident Report

5. Appendixes ……………………………………………………………………………………………………………….68  Appendix A: Investigation and Public Hearing …………………………………………………………………..68 Appendix B: NMSP Aviation Section “Policies and Procedures” Document ………………………….69 

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NTSB Aircraft Accident Report

Figures Figure 1. Google Earth map showing pertinent helicopter radar data and other points of interest near the accident site. ………………………………………………………………………………………………………. 6 

Figure 2. View of the accident location. ……………………………………………………………………………. 7 

Figure 3. Aerial photograph showing the main fuselage wreckage location, circled in red, on the west side of the lake. ……………………………………………………………………………………………………….. 8 

Figure 4. Photograph showing the helicopter main fuselage wreckage. …………………………………. 9 

Figure 5. Photograph at ground view looking from the helicopter main fuselage wreckage location in a southerly direction up the ridge that the accident helicopter rolled down. ……………. 9 

Figure 6. Preaccident photograph of the accident helicopter. ……………………………………………… 18 

Figure 7. Google Earth image with a blue line showing the likely route that the SAR ground team took from the SAR IB (E) to the helicopter main wreckage location (C). ……………………… 26 

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NTSB Aircraft Accident Report

Abbreviations and Acronyms AC advisory circular

AFRCC U.S. Air Force Rescue Coordination Center

agl above ground level

ALEA Airborne Law Enforcement Association

ATC air traffic control

ATP airline transport pilot

AXX Angel Fire Airport

CFR Code of Federal Regulations

DPS Department of Public Safety

ELT emergency locator transmitter

EMS emergency medical services

FAA Federal Aviation Administration

FLIR forward-looking infrared

FSDO flight standards district office

G One G is equivalent to the acceleration caused by the Earth’s gravity (32.174 feet per second squared)

GPS global positioning system

HEMS helicopter emergency medical services

IACP International Association of Chiefs of Police

IB incident base

IFR instrument flight rules

IMC instrument meteorological conditions

METAR meteorological aerodrome report

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NTSB Aircraft Accident Report

MHz megahertz

msl mean sea level

MSP Maryland State Police

NASAO National Association of State Aviation Officials

nm nautical miles

NMSP New Mexico State Police

NOAA National Oceanic and Atmospheric Administration

NPRM notice of proposed rulemaking

NTSB National Transportation Safety Board

NWS National Weather Service

OCC operations control center

PIC pilot-in-command

PIO public information officer

PLB personal emergency locator beacon

SAF Santa Fe Municipal Airport

SAR search and rescue

SARSAT Search and Rescue Satellite-Aided Tracking

SIGMET significant meteorological information

SMS safety management system

SOP standard operating procedure

TAF terminal aerodrome forecast

USFS U.S. Forest Service

VFR visual flight rules

VMC visual meteorological conditions

vi

NTSB Aircraft Accident Report

vii

Executive Summary 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.

NTSB Aircraft Accident Report

1

1. Factual Information

1.1 History of Flight

On June 9, 2009, about 2135 mountain daylight time,1 an Agusta2 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 New Mexico State Police (NMSP) on a public search and rescue (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 (VMC); IMC prevailed when the helicopter departed the remote landing site about 2132.

The mission was initiated after a lost hiker used her cellular telephone to call 911, and the 911 operator transferred the call to an NMSP dispatcher about 1646.3 The hiker, who was a citizen of Japan, had difficulty communicating in English. However, during her initial and subsequent telephone calls, she told the dispatcher that she had become separated from her hiking companion (her boyfriend) and was lost in the Pecos Wilderness Area about 20 miles northeast of Santa Fe and was feeling very cold.4 The local district shift supervisor, who was present in the dispatch office, asked an NMSP patrol officer to initiate a SAR effort, and the patrol officer asked the dispatcher to notify the volunteer New Mexico SAR command, which the dispatcher did about 1715.5

While the SAR command was organizing the SAR effort, a district sergeant (the outgoing police shift supervisor) made the decision to have the dispatcher contact the accident pilot and ask him to initiate an aerial search for the lost hiker. Because there were no roads into the search area, ground SAR teams would have to hike in, which would delay the rescue. The outgoing shift supervisor stated that he believed that a more immediate helicopter SAR effort was needed.6 In the meantime, ground SAR personnel began to set up the incident base (IB) at a local ski resort; it was later determined that the IB was about 4 nautical miles (nm) from the hiker’s location. Per the sergeant’s instructions, the dispatcher called the accident pilot and, about 1756, put him on

1 All times in this report are mountain daylight time based on a 24-hour clock. 2 Agusta and Westland signed a joint venture agreement in 2001. In 2004, Finmeccania acquired a 50 percent

stake in the combined company. Agusta is now known as AgustaWestland. 3 Times are based on NMSP dispatch recordings, unless otherwise noted. The NMSP dispatch times are

corrected for an error of about 24 minutes. 4 The lost hiker had only a light jacket and no cold-weather survival gear. 5 For additional information regarding New Mexico SAR operations, see section 1.18.1. 6 Postaccident interviews indicated that, during the decision to launch the helicopter on the SAR mission,

several state police personnel expressed their concern that the hiker would not have been able to survive on the mountain overnight because she lacked warm clothing and other survival equipment.

NTSB Aircraft Accident Report

2

the line with the incoming police shift supervisor to discuss the proposed mission. According to NMSP dispatch recordings, the shift supervisor asked the pilot if he “[felt] like going up again” to support the SAR effort and described the general location of the search. Initially, the pilot responded that it was too windy to fly in the described area at that time of day, but he offered to fly the mission at first light or during the night (using night vision goggles) if the winds were calmer. The shift supervisor accepted the pilot’s decision, and they ended the telephone call. About 1800, the accident pilot called the dispatcher to further discuss the proposed mission. He indicated to the dispatcher that he had just checked the winds, and he thought that he probably could fly the helicopter to look for the hiker.

The accident pilot (who was the dispatcher’s husband) was the chief pilot for the NMSP’s aviation section and had already worked a full 8-hour shift (including three previous flights) that day. Postaccident interviews indicated that he contacted the other full-time NMSP aviation section helicopter pilot about flying the mission; when the other pilot was unavailable, the accident pilot accepted the mission himself.

The dispatcher stated that she connected the accident pilot with the patrol officer who had been designated as the mission initiator. The patrol officer requested and received the accident pilot’s permission to ride in the helicopter and act as spotter during the search. The patrol officer/spotter then photocopied a topographical map of the search area, gathered SAR-related paperwork (including contact numbers for SAR personnel), and drove to SAF to meet the accident pilot.

The spotter stated that he arrived at SAF and found the accident pilot already in the hangar office. According to the spotter, the pilot told him to “take all [his] gear off” because it was too bulky for him to wear in the cockpit. As a result, the spotter removed his uniform shirt, bulletproof vest, and other police equipment and stowed them in the hangar. The spotter stated that the pilot performed a preflight inspection of the helicopter, gave the spotter a safety briefing, and helped him fasten his safety harness. The spotter said the pilot warned him that it could be windy and/or bumpy in the mountains; he did not recall the pilot saying anything else about the weather or mentioning any other safety-related concerns about the flight. The spotter stated that it was warm7 and sunny and not very windy when they took off from SAF about 1850. There were few clouds, and there was little turbulence on the way to the search area (which was at a much higher elevation; the lake near which the hiker and her companion were hiking was located at 11,700 feet mean sea level [msl])8.

About 1851, the pilot radioed the dispatcher to indicate that he and the spotter had departed SAF and that they were en route to the search area. According to dispatch records, the pilot and spotter searched for the lost hiker for more than 1 hour and coordinated with the dispatcher (who was speaking with the hiker on her cellular telephone) to help identify the

7 The National Weather Service daily summary indicated that the high temperature at SAF at 1853 (about

3 minutes after the helicopter departed SAF) was 68° F. 8 Unless otherwise indicated, all altitudes in this report are msl. SAF, the helicopter’s departure point, was

located about 20 miles southwest of the landing site at an elevation of 6,348 feet.

NTSB Aircraft Accident Report

3

hiker’s location.9 Although the hiker told the dispatcher that she was able to hear the helicopter operating nearby relatively early during the search, she was unable to provide much information that could help narrow the search (such as describing her position relative to the sun, nearby landmarks, or terrain features). She told the dispatcher that she was in a small clearing surrounded by trees and could not identify any landmarks.

About 1927, the pilot advised the dispatcher, “We’re dealing with a lot of wind up here…not to worry because we’re going to hang out until we get eyes on [the hiker] and go from there.” About 15 minutes later, the hiker told the dispatcher that the helicopter was directly above her; the dispatcher relayed this information to the pilot, who then relayed the helicopter’s latitude and longitude coordinates back to the dispatcher. The pilot descended, flew in the vicinity of those coordinates, and continued searching until he and the spotter made visual contact with the hiker, which occurred about 2010.10 After locating the hiker, the pilot stated, “all we need to do now is find a place to land… .” About 2 minutes later, the pilot asked the dispatcher if the hiker was ambulatory, stating that the closest place he would be able to land was about 0.5 mile uphill from her. Initially, because the hiker was not physically injured, the dispatcher responded that the hiker was ambulatory. However, according to dispatch recordings, the hiker subsequently told the dispatcher that she could not walk uphill or very far because she was very cold. In addition, the hiker stated that she could not see very well and did not know which way to …

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,

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