Board Says Organizational Culture Was A Contributing Factor

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.

File Photo

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.

FMI: www.ntsb.gov/events/2011/Santa_Fe_NM/synopsis.htm