In today's business aviation world — and that includes civil government operations such as law enforcement — strict safety management is required to balance the risks versus benefits of any tactical operation. The New Mexico State Police (MNSP) aviation section has successfully reformed itself after the loss discussed in this month's column. There are lessons in this story for all operators.
On June 9, 2009, a hiker found herself separated from her boyfriend and lost in the mountains northeast of Santa Fe, near Lake Katherine. She was frightened, cold and knew she could be in serious trouble with night coming. Fortunately, her cell phone could pick up a tower and she was able to dial 911 and reach an NMSP dispatcher. The time was 1646. The hiker was Japanese and had difficulty making herself understood but ultimately was able to describe her plight during a series of calls.
That day an acting lieutenant was commanding the local NMSP district office. He assigned a state police patrol officer to initiate a search and rescue (SAR) effort. The patrol officer, who ultimately rode along as a spotter on the accident flight, was not a pilot nor had he received special training for aircraft missions. Meanwhile, the dispatcher notified the New Mexico Search and Rescue Command. It was 1715 and all SAR gears were turning.
The NMSP acting commander then directed the dispatcher to call the aviation section chief pilot and have him initiate an aerial search for the hiker using the state police Agusta A109E twin-turbine helicopter. (The chief pilot also served as the NMSP public information officer and was the dispatcher's husband.) The aviation section had a full-time helicopter pilot and a part-timer as well, but neither was available for this mission.
The dispatcher told the acting lieutenant that the chief pilot was resting at home after working a full duty day and flying two missions. She suggested that, in accordance with state police policy, they allow the New Mexico Search and Rescue Command to organize a search effort and wait for that organization to request aircraft support. The acting lieutenant insisted that she call the chief pilot right away, because the chief pilot could “go up there and find [the lost hiker] real quick.”
The dispatcher called her husband as requested, and put him on the phone with the shift supervisor at 1756. The shift supervisor asked the chief pilot if he “[felt] like going up again” to search for the hiker. The chief pilot told the supervisor that it was too windy to fly in the high mountains at that time, but he offered to fly the mission the next morning at first light, or during the night using night-vision goggles, if necessary. The shift supervisor said OK, and he explained that there were no roads into the search area. The chief pilot said he understood the situation, but repeated it was too windy to fly the mission. The shift supervisor did not object to the chief pilot's decision, and the two men said goodbye.
At 1800, the chief pilot called the dispatcher back and stated to his wife, “So I take it SAR isn't even asking for me yet.” She told the pilot that the acting lieutenant had asked for aircraft support right away, without receiving a request from a SAR commander. The chief pilot's voice was recorded saying, “Well . . . I checked the wind and . . . I could probably go up and take a look. . . .” The chief pilot then made an unsuccessful call to see if the full-time helicopter pilot was available.
At 1803, the chief pilot called the dispatcher, who asked her husband whether she should just say it was too windy for him to fly the mission. The pilot responded, “Well, no,” and then said he would ask a relative to watch the children so that he could take the mission.
It was agreed that the patrol officer who had the case would ride along as spotter during the mission. At 1809, the chief pilot called the state police Major responsible for the western region of New Mexico and asked him to authorize two missions — one for the hiker search (“a quick in-and-out”) and a second mission that had been scheduled by another pilot later that evening. The Major authorized both missions.
A short time later, the spotter and chief pilot met at Santa Fe Airport (SAF) where the spotter shed his vest and other bulky gear and the pair walked out to the aircraft. The chief pilot performed a preflight and gave the spotter a safety briefing. He warned the spotter that it could be windy in the mountains and provided him a sack to use if he experienced airsickness. The chief pilot did not bother to include the department's night-vision goggles in the mission equipment. The weather was hot and sunny and not very windy at SAF when they took off but cold and windy in the mountains. At this point, the ground SAR effort was beginning.
The chief pilot radioed the dispatcher at 1851 that he was en route to the search area. The weather was good with few clouds and little turbulence. The chief pilot asked the dispatcher to provide more information about the search area and was reminded by the dispatcher that the spotter was carrying a map of the search area. The chief pilot said, “I'm sorry, I didn't even know that,” and added, “I didn't even bother to ask him.”
Between 1902 and 1927, the dispatcher had several cell phone conversations with the hiker attempting to pin down her position and relay information to the helicopter. The chief pilot began his search pattern and told dispatch he would have to burn off some fuel before he could “even think about setting down.”
During this period, the hiker reported hearing the helicopter. Informed of that, the pilot told dispatch, “OK . . . We'll poke around up here. We'll find her if she can already hear me.” He added, “I'm just getting bounced around right now.”
At 1920, the chief pilot told the dispatcher that he was circling at high altitude because he was “not going to be able to get close down in there until we burn off some gas.” Five minutes later he added, “We're dealing with a lot of wind up here . . . and not to worry because we're going to hang out until we get eyes on [the hiker] and go from there.” The dispatcher continued to relay messages between the chief pilot and the hiker.
At 1944, the hiker told the dispatcher that the helicopter was flying directly over her. The dispatcher informed the chief pilot who, in turn, radioed the lat/long coordinates to the dispatcher. The hiker told the dispatcher she was in a 10-meter wide clearing surrounded by trees. At 2010, the chief pilot reported he had visual contact with the hiker.
Two minutes later, the chief pilot asked the dispatcher if the hiker was ambulatory and the dispatcher said that she was. The chief pilot said, “OK . . . The closest place I can set down is on the top [of a hill], and that's . . . a good half mile [from the hiker's location].” The hiker reported (on the cell phone) that she did not think she could walk to the landing site because she was very cold.
The dispatcher asked the chief pilot if he could land on top of the hill and send the spotter down on foot to retrieve the hiker. The chief pilot responded, “That's about the only thing we're going to be able to do.” The spotter did not recall having any discussions with the chief pilot about whether they should land on the mountain. The chief pilot had simply said, “All right. We'll try to land and pick her up.” The chief pilot made at least three passes over a large clearing on top of a ridge above the hiker. The ride was very bumpy below 200 ft. AGL.
At 2015, the chief pilot told the dispatcher, “[I'm] trying to find out if I got out of ground effect up here, so give me a second. It'll take me a minute to figure it out . . . and also ask [the hiker] if she can see where we're hovering.” (The dual-engine service ceiling for N606SP was 19,600 ft. and the hovering ceiling was 11,800 ft. The one engine inoperative service ceiling was 13,100 ft.) The hiker said she could not see the helicopter and the dispatcher relayed this informaion back to the chief pilot who commented: “OK, I'll probably need to get the basket up here.”
At 2018, the chief pilot maneuvered above the hiker and flew toward the landing area. He told the dispatcher to tell the hiker to walk in the direction the helicopter was flying. The hiker again said she could not see very well. The shift supervisor encouraged the hiker to walk up the hill but said an officer would also walk down the hill to find her. By 2019, the sun had set in the Santa Fe area, and lighting conditions had officially transitioned to dusk.
At about 2022, the chief pilot landed the helicopter in a large clearing on top of a ridge and shut down the engines. The spotter opened his door and felt a blast of cold westerly wind that was strong enough to “blow him over.” He estimated the wind speed was 30 mph. It was beginning to sleet. He called the dispatcher at 2030 and told her the helicopter had landed. The dispatcher tried to connect him with the hiker's cell phone, but she could not get through to the hiker. The dispatcher asked if the spotter knew where the hiker was located. The spotter said yes, and he asked the dispatcher if the hiker was walking up the hill. The dispatcher said, “No . . . She does not want to move.” The spotter said he would confer with the chief pilot about what to do and call the dispatcher back.
At 2033, the chief pilot called the dispatcher and said, “Hey, I don't know what this lady wants us to do . . . I'm going to walk down the hill here a little bit. It's going to start snowing up here and if it does that, I've got to get the hell out of here.”
The dispatcher told the chief pilot that the ground SAR incident commander was on the other line and was asking for his coordinates. The chief pilot replied, “Well, you can tell him I'll get it to him as soon as I can . . . I'm going to walk down this hill a little way. I'm going to leave [the spotter] with the helicopter. If you talk to [the hiker], tell her to start blowing her whistle and [to] listen for me yelling, OK?” He said he knew the hiker's general location, and he added, “I'm not going to spend a lot of time or we're going to have two search and rescues. Just tell her to start blowing her [expletive] whistle and I'll try to find her, OK? Because it's right off this hill here, I think.” This call ended at 2035.
The chief pilot told the spotter to stay with the helicopter; he was going to “go down and yell for [the hiker] a little bit” and return to the helicopter if he got no response. He gave the spotter a cigarette lighter and told him to build a fire if he got really cold, and then the chief pilot walked toward a tree line located about 100 yd. away from the helicopter and disappeared down a slope. The spotter noted it was “sleeting like crazy” and the wind was “insane.” He was shivering with cold inside the helicopter.
At 2038, the SAR incident commander contacted the dispatcher and told her that SAR ground teams could “go up and get [the hiker] just as well.” He added that it would “take a little longer,” but he did not want the chief pilot to “get in trouble.”
At 2045, the dispatcher reached the hiker on her cell phone. She encouraged the hiker to blow a whistle or yell and look for the chief pilot. At 2053, the dispatcher could hear the pilot and the hiker yelling to each other. The cell call ended.
At 2113, the area commander called the dispatcher and said that he was concerned about the helicopter because SAR commanders had received no direct communications from the chief pilot and weather conditions were deteriorating in the mountains. The dispatcher connected the area commander with the spotter's cell phone. The spotter said the wind was blowing, the clouds were moving in, it was cold, and he was concerned because the chief pilot had left the helicopter without his flashlight and it was getting dark outside.
The area commander told the spotter that if the weather deteriorated to the point where they could not take off, ground teams would try to assist them. In that event, they should “hang tight” in the helicopter and use its engines to generate heat until help arrived. At 2122, the dispatcher told the acting lieutenant she had not heard from the chief pilot since he left the helicopter and that bad weather had since moved into the search area. The acting lieutenant said, “What do we do?” The dispatcher said she did not know. The acting lieutenant asked if SAR teams were on the way to the area. The dispatcher said yes. The acting lieutenant said, “Well, they're going to have to just shore it up for tonight and fly out tomorrow.” The acting lieutenant said he would call the spotter directly, but did not do so.
About this time, the chief pilot and the hiker were approaching the helicopter. The spotter heard them in the darkness, so he grabbed the flashlight, exited the helicopter, and found them 35 or 40 yd. away from the helicopter. At 2124, the spotter contacted the shift supervisor and reported that the chief pilot and the hiker had arrived at the helicopter. The shift supervisor asked what they were going to do. The spotter said, “I don't know, let me talk to [the chief pilot]. He's getting some heat on right now. He's a little out of breath. He was [carrying the hiker up the hill].”
It was still sleeting or snowing “a little bit” when the chief pilot and the hiker arrived, but snow was not sticking to the ground. It seemed to the spotter that the chief pilot wanted to get strapped in and get going right away. Later the spotter could not recall either of them raising the possibility of staying on the mountain overnight. He told investigators he would have expected the chief pilot to bring that up if taking off was going to be problematic. The spotter moved to the back of the helicopter, sat next to the hiker, and helped her adjust her seat belt.
At 2127, the spotter called the dispatcher and said, “OK, so we're on our way back to Santa Fe.” He asked the dispatcher to have ground teams to retrieve the hiker's companion from Lake Katherine and then concluded the call by saying, “That'll be it.” The helicopter's engines could be heard starting up in the background as the call ended at 2128.
The spotter recalled being in the left rear seat next to the hiker. The helicopter was on the ground and pointing south. No city lights were visible. Before taking off, the chief pilot pointed out the window to his right, as if to indicate that they would be flying in that direction. During an initial post-accident interview, the spotter said that there was a break in the clouds, or “a little cloud-free tunnel,” located in that direction, but during a subsequent interview he stated that he had only assumed there was a break in the clouds. When the chief pilot took off, the helicopter turned in the direction that the chief pilot had pointed. Immediately after takeoff, the helicopter was in the clouds with zero visibility and the flight was very turbulent, like “a roller coaster.” The helicopter appeared on radar at 2132:48.
Moments after takeoff the spotter felt an abrupt pull up and the helicopter began to make a grinding noise. “The ride got wild.” The spotter assumed that the helicopter's tail had hit something. The helicopter was going back and forth in a “jerky” fashion, like there was “obviously something wrong,” but he could not tell how the helicopter was maneuvering because he could not see anything outside. (Investigators referred to this incident as the “first strike.”)
At 2134:10, the chief pilot radioed dispatch, “Hey [dispatcher's name], can you hear me?” The dispatcher responded, “Affirmative.” The chief pilot said, “All right, I struck a mountainside. [I'm] going down.” The dispatcher asked, “Are you [OK]?” and the chief pilot replied, “Negative.” The chief pilot continued to key his microphone and could be heard breathing rapidly for the next 30 sec. The dispatcher inquired, “Santa Fe 606?” The chief pilot then said, “Hang on [unintelligible].” The chief pilot's transmission ended immediately after this statement at 2135:04.
The helicopter crashed into a steep, boulder-strewn slope — the “second strike” — and then rolled down the slope for over 600 vertical feet leaving parts behind as it went. After the main wreckage came to rest, the spotter crawled out of the crushed fuselage. It was snowing, dark and hazy, and visibility was poor, but he was able to distinguish nearby objects and he could tell that there was a lot of snow on the ground. He had a broken ankle and other injuries.
The spotter yelled for the chief pilot and heard the chief pilot yell back to him from above. The spotter saw the hiker's body lying nearby. He moved to her, checked her vital signs and determined she was dead. (She had died of multiple blunt force trauma.) He removed her jacket and put it on to stay warm.
The spotter yelled for the chief pilot again and the pilot replied, but much quieter this time. The spotter continued to call for the chief pilot for about 30 min., but he heard no more replies and he was unable to determine where the chief pilot was located. (The pilot had suffered multiple injuries that might have been survivable, but he probably succumbed to hypothermia, according to the medical examiner.)
The spotter took shelter inside the main wreckage for the night. The next morning, he started to hike downhill in search of help. A ground SAR team located him at 1155.
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.”
The chief pilot's colleagues described him as a motivated, hard-working, disciplined officer who was outgoing and personable. They said he had turned down past missions, either because of poor weather or because he was fatigued from performing other work-related duties, but they held varying opinions about his assertiveness when it came to safety. The full-time helicopter pilot, who flew frequently with the chief pilot and considered him a “very good friend,” said that the chief pilot was capable of being assertive and that the chief pilot had told the other pilots that if they felt something was unsafe they should tell him and he would take care of it.
Colleagues offered varying assessments of the chief pilot's mission-related decision-making style.
The full-time helicopter pilot said that the chief pilot had a “problem-solving mentality,” and made conscientious decisions. He said the chief pilot tended to examine all aspects of a mission and select an intelligent strategy. He did not think the chief pilot was the kind of person who would act impulsively or knowingly exceed his own limitations. He said that, because of this, he found some aspects of the chief pilot's decision making during the accident mission puzzling and out of character. He wondered what the chief pilot knew and did not know — when the weather deteriorated in the search area, why the chief pilot did not bring night-vision goggles, and why he did not stay on the mountain overnight. He wondered why he took off in possible icing conditions when he knew that the helicopter had no systems to defend against icing.
The full-time helicopter pilot said that he would have been concerned about landing on the mountain if he were flying the accident mission. He would have preferred to mark the hiker's location and seek other means for rescuing her, such as requesting helicopter support from the National Guard. He also said that he would not have tried to take off from the remote landing site at night and in poor weather conditions, and that he thought it was “insane” for the chief pilot to do so without night-vision goggles. He said he would have spent the night on the mountain rather than take off in those conditions, and he would not have expected anyone to reprimand him for doing so. He was surprised by the chief pilot's decision to take off.
Asked what would have concerned him most about the accident mission, based on the weather forecast information and his knowledge of the search area, he said: weather, mountain operations and flying single pilot. He said he “might have recommended that we re-evaluate it in the morning since we had already flown all day.” He added, “It wasn't going to be quick. It was a search.” He said if the chief pilot had asked his opinion, he would have recommended that he wait until morning or try to mitigate the risks by bringing a second pilot and a set of night-vision goggles.
The fixed-wing pilot said that the chief pilot tended to “act right away before thinking things out.”
A retired NMSP chief pilot said he believed the chief pilot did not understand the limitations associated with his inexperience, and that he would only have been able to understand his limitations after flying several thousand more hours. He said he would never fly the helicopter at night without night-vision goggles and it made him “very upset” that the chief pilot did not bring goggles on the accident mission.
The part-time helicopter pilot said he thought the chief pilot lacked “temperance” due to his youth and inexperience. The Major in charge of the special operations said the chief pilot was a “very aggressive, high-speed type of individual” that he had to “double check,” because he was “high-spirited” and “enthusiastic.” He said that the chief pilot would “go 100 mi. an hour all the time” if he were allowed.
The public safety secretary said he believed that the chief pilot, “wanted to get [the hiker] out, he thought he could do it safely and that's just not the way it happened.” He said that if the chief pilot had known he was going to enter IMC, he would have “bundled up the best [he] could for the night.”
The dispatcher was asked if she suspected the chief pilot had initially turned down the mission for a reason other than high winds — fatigue, for example. She said no; he would have told her if he was too tired to fly the mission. Why did he accept the mission? Probably because he was concerned about the hiker's safety and because a police supervisor had asked him to fly the mission, she said, adding that she did not know whether the chief pilot realized the weather was going to deteriorate, nor did she know if he felt pressured to accept the mission.
The chief pilot's colleagues said he was the kind of person who was willing to put himself at risk to save others.
Thedetermined the probable cause of this accident was the pilot's decision to take off from a remote, mountainous landing site on a dark (moonless) night, in windy, instrument meteorological conditions. Contributing to the accident was an organizational culture that prioritized mission execution over aviation safety, along with the pilot's fatigue and self-induced pressure to conduct the flight, and situational stress. Also contributing to the accident were deficiencies in the NMSP aviation section's safety-related policies, including lack of a requirement for a risk assessment at any point during the mission; inadequate pilot staffing; lack of an effective fatigue management program for pilots; and inadequate procedures and equipment to ensure effective communication between airborne and ground personnel during search and rescue missions.
Since the accident, the aviation section has been reorganized and added experienced safety-oriented personnel who have instituted extensive safety management, training and operational procedures.