NTSB -- POOR DECISIONS AND ORGANIZATIONAL CULTURE CAUSED NEW MEXICO STATE POLICE HELICOPTER CRASH

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NTSB PRESS RELEASE

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National Transportation Safety Board

Washington, DC 20594

FOR IMMEDIATE RELEASE: May 24, 2011

SB-11-17

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POOR DECISIONS AND ORGANIZATIONAL CULTURE CAUSED NEW MEXICO

STATE POLICE HELICOPTER CRASH

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WASHINGTON - The National Transportation Safety Board (NTSB)

today 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 the 2009 fatal crash. 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 9:35 pm (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.

A synopsis of the NTSB report, including the probable cause,

conclusions and safety recommendations, is available on the

NTSB's website at:

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

The NTSB's full report will be available on the website in

several weeks.

NTSB Media Contact: Keith Holloway, (202) 314-6100

hollowk@xxxxxxxx

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