Board Says Organizational Culture Was A Contributing
The NTSB said Tuesday it has determined that a New Mexico State
Police (NMSP) helicopter pilot's decision to take off from a remote
landing site, without conducting a thorough assessment of the
weather and night time conditions, was the primary cause of a 2009
fatal accident. Contributing to the accident was an organizational
culture within the New Mexico State Police that emphasized mission
completion over safety, as well pilot fatigue, stress, and the
pilot's self-induced pressure to complete the rescue mission.
On June 9, 2009, at about 2135 MDT, an Agusta S.p.A. A-109E
helicopter, N606SP, crashed in mountainous terrain near Santa Fe,
New Mexico. The flight was part of a search and rescue mission and
had just taken off after picking up a lost hiker. The NMSP pilot
and the rescued hiker were fatally injured, and a highway
patrolman, who was acting as a spotter onboard the helicopter, was
seriously hurt. The aircraft was substantially damaged.
"One thing we learned from this accident is that if safety is
not the highest organizational priority, an organization may
accomplish more missions, but there can be a high price to pay for
that success," said NTSB Chairman Deborah A.P. Hersman.
While the Board found no evidence of any direct pressure on the
pilot by NMSP or the New Mexico Department of Public Safety to
complete this particular mission, the Board noted evidence of
previous management decisions that emphasized acceptance and
completion of all missions, regardless of conditions. This is not
consistent with a safety-focused organizational culture.
The Board also identified a number of safety-related
deficiencies in the NMSP's aviation policies. Some of these
deficiencies included the lack of a requirement for a risk
assessment at any point during a mission; inadequate staffing
levels to safely provide search and rescue coverage 24 hours a day,
7 days a week; the lack of an effective fatigue management program
for pilots; and the lack of procedures and equipment to ensure
effective communication between airborne and ground personnel
during search and rescue missions.
As a result of this accident investigation, the NTSB issued
recommendations addressing pilot decision-making, flight and duty
times and rest periods, staffing levels, safety management system
programs and risk assessments, personnel communications, instrument
flying procedures, and flight-following equipment. The
recommendations were issued to the Governor of New Mexico, the
Airborne Law Enforcement Association, and the National Association
of State Aviation Officials.