10 Jun 2009: AGUSTA SPA A109E (N606SP) — NEW MEXICO STATE POLICE — Santa Fe, NM

2 fatalitiesSanta Fe, NM, United States

An Agusta S.p.A. A-109E helicopter crashed into terrain during a search and rescue mission in New Mexico.

What happened

On June 9, 2009, at approximately 2135 mountain daylight time, an Agusta S.p.A. A-109E helicopter, registration N606SP, struck terrain near Santa Fe, New Mexico. The aircraft was being operated by the New Mexico State Police on a public search and rescue mission under 14 CFR Part 91. The helicopter had departed Santa Fe Municipal Airport earlier that evening at approximately 1850 under visual meteorological conditions. However, when the helicopter departed a remote landing site at approximately 2132, instrument meteorological conditions were prevailing. The flight was being conducted under visual flight rules.

The accident resulted in 2 fatal injuries to the commercial pilot and one passenger, and 1 serious injury to a highway patrol officer who was serving as a spotter. The helicopter sustained substantial damage.

Probable cause

The pilot's decision to depart from a remote, mountainous landing site during a dark, windy night under instrument meteorological conditions. Contributing factors included an organizational culture prioritizing mission execution over safety, pilot fatigue, self-imposed flight pressure, and situational stress. Additionally, deficiencies in the New Mexico State Police aviation section's safety policies, such as the lack of required risk assessments, inadequate pilot staffing, lack of a fatigue management program, and insufficient communication procedures/equipment, contributed to the accident.

Contributing factors

PilotDecision related to conditionOperatorEffect on personnelEmergency locator beaconIndicating/recording systems