The March 2013 fatal crash of an Alaska State Troopers (Alaska Department of Public Safety or DPS) Airbus Helicopters AS350B3, otherwise known as Helo-1, near Talkeetna was the result of the pilot’s decision to continue flying into deteriorating weather conditions as well as the department’s “punitive culture and inadequate safety management,” according to the NTSB’s final report, issued on November 5, 2014.
The NTSB principal investigator’s report reveals a web of overlapping circumstances that all served as potential contributing factors to the crash. They included the pilot’s lack of actual instrument experience and currency; the role of lucrative overtime pay in motivating pilots to accept flights and fly long hours; the continued difficulties Alaskan pilots face in obtaining accurate weather data; gaps in emergency responder communications; and a failure to use safety management processes and procedures uniformly.
Helo-1 crashed and burned following a brief period of uncontrolled flight in marginal weather conditions after rescuing a stranded snowmobiler at night. The pilot, Trooper observer and rescued civilian were all killed. Data and images from cellphones, the onboard GPS and an Appareo Vision 1000 video recording system were used to reconstruct the accident.
Seven-minute Flight
In its final minutes, Helo-1 engaged in dramatically erratic pitch, altitude and heading changes indicative of pilot spatial disorientation after inadvertent flight into instrument meteorological conditions (IMC). Helo-1 picked up the snowmobiler, took off at 11:13 p.m. and followed a true course of 209 degrees; at 11:14 p.m. the helicopter turned left to a heading of about 139 degrees. One minute later it turned right and flew south for about 30 seconds. It then turned right to a heading of about 190 degrees and continued on this heading for about two minutes. At 11:17 it was at an altitude of 1,060 feet (a height of about 200 feet agl) with a groundspeed of 16 knots. The helicopter then entered a climbing left turn that continued through 360 degrees; this was followed by a series of erratic turns, climbs and descents.
The helicopter crashed at 11:20 p.m., three miles south of the point from which it had taken off. The duration of the flight was seven minutes.
The NTSB could not find corroborating evidence that the pilot obtained a weather briefing before making the flight. The forecast for Talkeetna Airport issued at 8:08 p.m. local expected calm wind, visibility greater than six miles, light rain, a broken ceiling at 1,000 feet agl, broken clouds at 1,800 feet agl and overcast at 2,800 feet agl. The reported weather conditions at Talkeetna Airport at 7:53 p.m. were wind calm, 10 miles visibility, light rain, a broken ceiling at 1,000 feet agl, broken clouds at 1,800 feet agl, overcast at 2,800 feet agl, temperature of 2 degrees Celsius (C), dew point temperature of 1 degree C, and an altimeter setting of 30.20.
Citing weather conditions at the time, Talkeetna-area residents contacted by the State Troopers declined to search for the stranded snowmobiler before Helo-1 was dispatched. One resident within six miles of Talkeetna reported overcast sky with rain and snow at 7:50 p.m.
Pilot Involved in Previous Accident
The accident pilot had logged 10,693 flight hours, 8,452 hours of them in helicopters. From October 1984 to January 1985, he attended a U.S. Army Rotary Wing Qualification Course at Fort Rucker, Ala., and received a helicopter instrument rating on the basis of this military training in 1985. The pilot’s logbooks revealed 38.3 hours total instrument time, of which only 0.5 hours was actual instrument time. He had last logged helicopter instrument time in 1985 in a Bell 47G2A and had not received any helicopter instrument training since joining the Troopers in 2000. His last check ride was on March 18, 2013, in a Robinson R44. The instructor said that instrument maneuvers were not part of it.
The pilot’s failure to use instrument procedures was cited as a factor in a prior helicopter accident in 2006 during an attempt to take off during whiteout conditions caused by blowing snow at night. The DPS’s investigation of and communications with the pilot after that accident in part triggered the NTSB’s remarks about “punitive culture.” While the pilot attempted to perform the takeoff and regain visual reference, the helicopter’s tail rotor guard and vertical stabilizer struck the surface of a lake. The takeoff was aborted and there were no injuries, but the helicopter sustained significant damage. The NTSB determined that the probable cause of that accident was “the pilot’s failure to maintain adequate altitude/clearance from terrain during an aborted takeoff in whiteout conditions, which resulted in an in-flight collision with terrain. A factor associated with the accident was whiteout conditions.”
A separate DPS investigation found, among other things, that the pilot “did not execute an instrument takeoff when confronted with a blowing snow condition and choose to hover and use a reference point” and “did not use a cross-check method and monitor his radar altimeter to verify his height above the ground.”
The investigation resulted in a DPS memorandum in the pilot’s personnel file. In read in part, “You are hereby warned. Any future occurrence of a similar incident may result in more severe disciplinary action. A copy of this memorandum will be placed in your personnel file for consideration at your next evaluation. You are hereby advised of your rights under your Collective Bargaining Agreement.”
At the time of the 2006 accident, the pilot had worked for 18 straight days without a day off. The NTSB found that the pilot relied on overtime pay for nearly 40 percent of his gross compensation from DPS. The NTSB found that this overtime pay structure likely contributed to the pilot’s “exceptionally high motivation to complete search-and-rescue missions,” which increased his risk tolerance and adversely affected his decision-making with regard to the 2013 crash.
The NTSB also faulted the DPS’s investigation of the 2006 accident for being “too narrowly focused on the pilot and not enough on underlying risks that could have been better managed by the organization.” The Board said this contributed to a “punitive culture that impeded the free flow of safety-related information and impaired the organization’s ability to address underlying safety deficiencies relevant to this (2013) accident.”
NTSB acting chairman Christopher Hart noted, “Public agencies are not learning the lessons from each other’s accidents and the tragic result is that we have seen far too many accidents in public helicopter operations.”