AGUSTA SPA A109E near Santa Fe, NM — 2009-06-10

Probable cause

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-imposed 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.

Contributing factors

Contributing to the accident were an organizational culture that prioritized mission execution over aviation safety and the pilot's fatigue, self-imposed 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.

NTSB narrative

The Safety Board’s full report is available at http://www.ntsb.gov/publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-11/04. 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.

NTSB coding

• VFR encounter with IMC · Maneuvering-low-alt flying
• Decision Making / Judgment

Evidence available

• ATC audio
• Photos
• 36 docket documents

Docket documents36

• Operations 2 and Human Performance 14 - Attachment 3D, Radio Communication Transcripts (Local District Radio Dispatch Calls)atc
• Medical Records Informationform
• Operations 2 and Human Performance 13 - Attachment 9, Excerpts from the Chief Pilot’s Training Recordsform
• Operations 2 and Human Performance 14 - Attachment 1, Interviewsform
• Operations 2 and Human Performance 14 - Attachment 10, The Chief Pilot's Citations for Braveryform
• Operations 2 and Human Performance 14 - Attachment 14, NMSP Breakdown of N606SP Flights by Mission Typeform
• Operations 2 and Human Performance 14 - Attachment 15, NMSP Organizational Chartform
• Operations 2 and Human Performance 14 - Attachment 16, NMSP Aviation Policies and Proceduresform
• Operations 2 and Human Performance 14 - Attachment 17, NMSP Aviation Budget Informationform
• Operations 2 and Human Performance 14 - Attachment 19, NMSP Memo Describing Post-Accident Safety Improvementsform
• Operations 2 and Human Performance 14 - Attachment 2, Letter from the Former Chief Pilotform
• Operations 2 and Human Performance 14 - Attachment 4, Notes From the Major Who Authorized the Accident Missionform
• Operations 2 and Human Performance 14 - Attachment 5, Notes Taken by the Search and Rescue Area Commanderform
• Operations 2 and Human Performance 14 - Attachment 6, Excerpts from the Chief Pilot's Day Plannerform
• Operations 2 and Human Performance 14 - Attachment 8, The Chief Pilot's PIO Scheduleform
• Operations 2 and Human Performance 14 - Atttachment 18, ALEA Standardsform
• Operations 2 and Human Performance 14 - Factual Report of Group Chairmenform
• Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1form
• Search And Rescue 17 - Attachment 1 - Timeline of Eventsother
• Search And Rescue 17 - Attachment 2 - AFRCC Mission Logother
• Search And Rescue 17 - Attachment 4 - NM SAR Act & Planother
• Airworthiness Factual Report Appendix 1 (includes 8 photographs)photos
• Airworthiness Factual Report Appendix 2 - N606SP Wreckage Observations (12 photos)photos
• Operations 2 and Human Performance 14 - Attachment 12, Pilot Fixed Wing Logbook (80 imbedded photos)photos
• Operations 2 and Human Performance 14 - Attachment 13, Maintenance Discrepancy Logbook 35 (7 photos)photos
• Operations 2 and Human performance 14 - Attachment 11, Pilot Helicopter Logbook (49 photos)photos
• Survival Factors Specialist's Factual Report of Investigation (includes 11 photographs)photos
• Airworthiness Factual Report of Group Chairmanreport
• Meteorology 5 - Factual Report of Group Chairmanreport
• Pilot Toxicological Reportreport
• Search And Rescue 17 - Attachment 3 - NOAA Site Masking Analysis Reportreport
• Search And Rescue 17 - Attachment 5 - NMSP Report and Recommendations to the New Mexico Search and Rescue Review Boardreport
• Search And Rescue 17 - Specialist's Factual Reportreport
• Operations 2 and Human Performance 14 - Attachment 3A, Radio Communication Transcripts (Aden Hill Radio Calls)transcript
• Operations 2 and Human Performance 14 - Attachment 3B, Radio Communication Transcripts (CAD-1, 911 Calls)transcript
• Operations 2 and Human Performance 14 - Attachment 3C, Radio Communication Transcripts (CAD-2, 911 Calls)transcript

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