Often we all get too focused on the goal without taking time to assess the hazards.
The accident occurred in steep, rocky terrain approximately 15 mi. northeast of Santa Fe near Mount Baldy, located in the Pecos Wilderness area. The initial impact point (first strike) was not located. The second impact point was located at an elevation of 12,069 ft. MSL. The ground strike evident at this point was a divot in the soil or talus along the fall line of the slope. After the second impact the helicopter descended down an open slope covered in large boulders and scattered trees before coming to rest. Portions of the wreckage were located along the debris path. The tail boom was located at an altitude of 11,960 ft. MSL. The farthest wreckage from the second impact site, the fuselage, was located almost a mile northeast of the peak of Santa Fe Baldy at an elevation of about 11,484 ft. MSL.
Investigators were able to establish continuity of all flight control systems. All powerplant, rotor and flight control systems had been functioning correctly at the time of the crash. The aircraft had been well maintained and had accumulated 1,729 hr. and 3,014 landings prior to the accident flight.
The 36-year-old chief pilot had lived at home with his wife and two young children just 4 mi. from Santa Fe Airport. His last vacation was a weekend away from home with his wife six months before the accident. She could not recall his having an entire day off that was free of all work-related responsibilities since that vacation weekend. The NMSP's full-time helicopter pilot said that the chief pilot had a day off once in a while, but it was rare for an entire weekend to pass without the chief pilot doing any work. He stated, “Whether it was self-induced or department-induced, [the chief pilot] worked a lot.”
An NMSP part-time helicopter pilot said that the chief pilot had complained that he did not get many days off but that he loved flying and he was grateful that the state police had given him the opportunity to fly.
The chief pilot was hired by the NMSP in 1995 and spent two years as a patrol officer and then transferred to the state police academy where he worked as an instructor. In November 2002, he was transferred to the aviation section, where he received pilot training and worked as a pilot until the time of the accident. In February 2007, he was promoted from patrol officer to sergeant and assigned the additional duty of serving as a public information officer for the state police. In January 2009, he was appointed chief pilot of the aviation division. So, he wore three hats — line pilot, chief pilot and NMSP PIO.
He held a commercial pilot certificate with airplane single-engine and multiengine land and airplane instrument ratings. He also held a rotorcraft rating. He had received ground and flight training for the Agusta A109E and completed an initial ground and flight training course for the ITT F4949 Aviator Night-Vision Goggle system.
A July 23, 2008, memo from the public safety secretary to the chief pilot stated that the chief pilot was authorized to operate the Agusta in VFR conditions: (a) with passengers in daylight, (b) for all law enforcement missions and (c) for SAR missions below 9,000 ft., but he was required to be accompanied by a more-experienced pilot when operating above 9,000 ft. MSL or in mountainous terrain. Although his supervisors told investigators that the 9,000-ft. restriction had been lifted later, they could not produce paperwork relative to the release.
The chief pilot had accumulated 1,331 total flight hours; 482 flight hours in helicopters, and all but 71 hr. of that in the Agusta A109E. He metinstrument currency requirements for fixed-wing airplanes and was current for night flight operations. There was no requirement for pilots in the aviation section to have a helicopter instrument rating.
State police pilots who had flown with him described the chief pilot's helicopter flying skills favorably. The full-time helicopter pilot said the chief pilot was “a very skilled manipulator of the controls . . . for his experience level,” who was proactive and “very aware” of what was coming up next.
The aviation section's fixed-wing pilot said the chief pilot's fixed-wing flying skills were comparable to those of other pilots with similar levels of experience (850 hr. fixed wing). He said, however, that he had some concerns about the chief pilot's instrument flying skills, in particular his “scan and situational awareness.”
The accident pilot, according to his wife and fellow pilots, believed the PIO assignment overburdened him, especially when he found himself on weekend standby for both PIO and aviation missions. He tried on several occasions unsuccessfully to be relieved of the PIO duties but eventually stopped pushing for fear that the NMSP would relieve him of his flying duties instead — a job he loved. Other pilots in the aviation section agreed that the PIO assignment was incompatible with the chief pilot's responsibilities as a pilot. The full-time helicopter pilot said the PIO assignment imposed too many additional responsibilities.
Investigators asked the NMSP chief if there were mechanisms in place to prevent the chief pilot's PIO assignment from interfering with his ability to get adequate rest. The chief said, “It's up to [the chief pilot] to say, 'Hey, I didn't get enough rest last night.'” He added that flying missions would take priority over PIO missions on weekends when the pilot was standing by for both.
Asked how the chief pilot was supposed to balance the two on-call assignments and get enough rest when the aircraft missions and the PIO calls were unpredictable, the chief said, “He's the chief pilot. That's his responsibility . . . if he feels like he's not rested as the chief pilot or as a pilot, for that matter, if you're not rested, why are you flying? And, again, we're not going to know if he's rested if he's not reporting it, because we're not sitting there with a monitor in his home looking at him.”
Asked whether he had any concerns about the chief pilot's dual roles being too burdensome, the chief said, “No. Look at the number of hours they fly and divide that by the number of pilots. . . he's flying a couple hundred hours a year out of 2,080. He didn't have too many responsibilities for the number of missions that our department flies.”
The public safety secretary, who was the police chief's supervisor, had been chief pilot of the aviation section at one time. When asked whether he had had any concerns about the chief pilot working as both chief pilot and PIO, he said no, “[the chief pilot] seemed to relish it . . . and anytime I flew with him, it never showed that this was having any detrimental effect on his flying performance.” Asked whether he was aware that the chief pilot had complained to top managers and asked for relief, he said, “No, I don't recall that anybody brought that to my attention.”
Asked whether the department had any mechanisms in place to ensure that the PIO role did not interfere with the chief pilot's ability to get adequate rest, he answered, “Oh, yeah . . . He still had to have his crew rest. He still couldn't fly more than he was required to fly.” The secretary added that he himself had performed numerous extra duties when he served as chief pilot, including PIO work and special investigations. He stated, “I only did these things when pilot duties didn't require me to [fly missions], and if I had been up doing these other things for a long period of time, and a flying mission came up, if I couldn't do it, I didn't do it . . . another pilot would have to do it or the mission wouldn't be flown.”