The NTSB’s final report on the fatal 2009 accident that killed a New Mexico State Police (NMSP) helicopter pilot and the hiker he had just rescued is sharply critical of the department’s flight policies and the pilot’s decision-making. On June 9, 2009, the police helicopter, an Agusta A109E light twin, crashed in mountainous terrain at 9:35 p.m. near Santa Fe while taking off after picking up the lost hiker. The police spotter, the only other person aboard, sustained serious injuries.
The NTSB faulted the NMSP for a management style “that is not consistent with a safety-focused organizational culture.” Specifically, the Board criticized the NMSP for management decisions that “emphasized the acceptance and completion of all missions, regardless of conditions.” This manifested itself in “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” around the clock; “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.”
The Board criticized the pilot for flying in IMC without a helicopter instrument rating. It also noted that he prepared inadequately for the mission by failing to mitigate risks by bringing readily available equipment such as cold-weather survival gear and night-vision goggles. “The pilot exhibited poor decision-making when he chose to take off from a relatively secure landing site at night and attempt a visual flight rules flight in adverse weather conditions,” the NTSB said, adding, “Because the accident pilot did not have a helicopter instrument rating, experience in helicopter instrument operations or training specific to inadvertent helicopter IMC encounters, he was not prepared to react appropriately to the loss of visual references that he encountered shortly after takeoff.”