Accident at Santa Fe, New Mexico, 9 Jun 2009 (N606SP)

Accident narrative

On June 9, 2009, about 2135 mountain daylight time, an Agusta S.p.A. A-109E helicopter operated by the New Mexico State Police (NMSP) crashed near Santa Fe, New Mexico. The helicopter, N606SP, was conducting a public search and rescue mission when it encountered instrument meteorological conditions during takeoff from a remote landing site. The commercial pilot and the rescued passenger were fatally injured, and a highway patrol officer acting as a spotter was seriously injured. The helicopter was substantially damaged.

**The flight**

The mission began after a lost hiker called 911 at 1646. She was in the Pecos Wilderness Area, about 20 miles northeast of Santa Fe. At 1756, an NMSP dispatcher contacted the accident pilot, who was the aviation section’s chief pilot. The pilot initially stated it was too windy to fly but offered to conduct the mission at first light or during the night if the winds calmed. At 1800, he called back, stating he had checked the winds and could probably fly. The pilot had already worked a full 8-hour shift that day, which included three previous flights.

A patrol officer requested to ride as a spotter. The pilot instructed the spotter to remove his bulky police gear before they departed Santa Fe Municipal Airport at about 1850 in visual meteorological conditions.

The crew searched for more than an hour, coordinating with the dispatcher who was on the telephone with the hiker. At 1927, the pilot reported dealing with "a lot of wind." They made visual contact with the hiker at about 2010. The hiker was ambulatory but very cold and unable to walk uphill. The dispatcher asked if the pilot could land on top of the hill and send the spotter down. The pilot agreed, and at about 2030, he landed the helicopter on a ridge at an elevation of about 11,600 feet.

The spotter noted strong, cold westerly winds and sleet. At 2033, the pilot, wearing an unlined summer-weight flight suit, told the dispatcher he would walk down the hill to find the hiker. He stated, "It’s going to start snowing up here and if it does that, I’ve got to get the [expletive] out of here." He left the helicopter without a flashlight.

While the pilot was retrieving the hiker, a search and rescue area commander called the dispatcher, worried about the deteriorating weather. The commander advised the spotter to "hang tight" in the helicopter and use the engines for heat if they were unable to take off.

**The accident**

The pilot returned with the hiker, and at 2127, the spotter advised the dispatcher they were flying back to Santa Fe. The spotter recalled that it was completely dark with no city lights visible. He stated that almost immediately after takeoff, the helicopter entered clouds with "zero visibility" and turbulent conditions.

Radar data showed the helicopter flying erratically, climbing to 12,500 feet, and then descending rapidly. The spotter heard the pilot curse and felt the helicopter pitch up abruptly, followed by a grinding noise. At 2134:10, the pilot radioed the dispatcher, stating, "I struck a mountainside. [I’m] going down." The dispatcher asked if he was okay, and the pilot replied, "negative." The radio transmitted rapid breathing for about 39 seconds before cutting off.

The helicopter struck the terrain and rolled down a steep, rock-covered slope. The pilot and hiker were ejected. The hiker died from multiple blunt force injuries, and the pilot died of environmental cold exposure and blunt force injuries. The spotter survived inside the main fuselage and was rescued the next day at 1155.

**What the investigation found**

The Board found no evidence of preimpact structural, engine, or system failures. The helicopter was properly certificated and maintained. The weather at the time featured a heavy overcast, strong gusty winds, and precipitation. The night was particularly dark with no moonlight.

The 36-year-old pilot held a commercial pilot certificate but did not have a helicopter instrument rating, which was not required by the NMSP. The Board concluded that because he lacked this rating and specific training for inadvertent instrument encounters, he was not prepared to react appropriately to the loss of visual references.

The Board also evaluated the pilot’s rest. He had awakened at about 0300 the day before the accident, flown missions, and experienced interrupted sleep. The Board concluded that the pilot was likely experiencing residual fatigue, which, combined with self-induced pressure to complete the mission and situational stress, distracted him from identifying alternative courses of action, such as remaining on the mountain overnight.

The investigation identified several organizational deficiencies. The NMSP aviation section did not have a safety management system or a requirement for risk assessments. The Board found evidence of an organizational culture that prioritized mission execution over aviation safety, noting that a former chief pilot had been relieved of his duties after declining a high-risk mission. Additionally, the aviation section was inadequately staffed to provide 24-hour coverage, and its flight and duty time policies did not ensure minimum contiguous rest periods for pilots.

Finally, the helicopter’s radio equipment did not allow the pilot to monitor the NMSP dispatch frequency and the search and rescue frequency simultaneously. The Board concluded that NMSP pilots did not routinely communicate directly with search and rescue commanders, which reduced the safety and effectiveness of the missions.

**Probable cause**

The National Transportation Safety Board determines that the probable cause of this accident was the pilot’s decision to take off from a remote, mountainous landing site in dark (moonless) night, windy, instrument meteorological conditions. Contributing to the accident were an organizational culture that prioritized mission execution over aviation safety and the pilot’s fatigue, self-induced pressure to conduct the flight, and situational stress. Also contributing to the accident were deficiencies in the New Mexico State Police 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.