NTSB Slams NM State Police Over 2009 Helo Crash — (AINonline)

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Aviation News   AINonline

By Mark Huber

June 29, 2011

The NTSB’s final report on the fatal 2009 accident that killed a New Mexico State Police (NMSP) helicopter pilot and the hiker he had just rescued is sharply critical of the department’s flight policies and the pilot’s decision-making. On June 9, 2009, the police helicopter, an Agusta A109E light twin, crashed in mountainous terrain at 9:35 p.m. near Santa Fe while taking off after picking up the lost hiker. The police spotter, the only other person aboard, sustained serious injuries.

The NTSB faulted the NMSP for a management style “that is not consistent with a safety-focused organizational culture.” Specifically, the Board criticized the NMSP for management decisions that “emphasized the acceptance and completion of all missions, regardless of conditions.” This manifested itself in “the lack of a requirement for a risk assessment at any point during a mission, inadequate staffing levels to safely provide search and rescue coverage” around the clock; “the lack of an effective fatigue management program for pilots and the lack of procedures and equipment to ensure effective communication between airborne and ground personnel during search-and-rescue missions.”

The Board criticized the pilot for flying in IMC without a helicopter instrument rating. It also noted that he prepared inadequately for the mission by failing to mitigate risks by bringing readily available equipment such as cold-weather survival gear and night-vision goggles. “The pilot exhibited poor decision-making when he chose to take off from a relatively secure landing site at night and attempt a visual flight rules flight in adverse weather conditions,” the NTSB said, adding, “Because the accident pilot did not have a helicopter instrument rating, experience in helicopter instrument operations or training specific to inadvertent helicopter IMC encounters, he was not prepared to react appropriately to the loss of visual references that he encountered shortly after takeoff.”

 

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Report raises questions about pilot’s experience, police procedures in fatal helicopter crash

Thursday, December 9, 2010 12:00 am

Anne Constable The New Mexican

A National Transportation Safety Board report on a helicopter crash near Santa Fe that killed a state police pilot and a passenger raises disquieting questions about the pilot’s qualifications to fly the mission and decisions made during the fatal attempt to rescue a hiker.

 While a final determination of the probable cause of the June 2009 accident is still pending, a “Factual Report” filed Nov. 24 by investigators paints a picture of a well-meaning, even heroic pilot, who, in a culture that encouraged risk-taking, made some dubious — and in the end — deadly judgment calls.

New Mexico State Police Chief Faron Segotta on Thursday disputed that picture, characterizing the report as the “opinion of people interviewed,” including a “disgruntled former employee” and defended the pilot, Andy Tingwall, whom he recommended for the aviation division in 2002.

“He was meticulous, well-traveled, well-qualified. That was his character. He wanted to excel,” Segotta said. “I believe he had the skills to fly that helicopter.”

In addition to Tingwall, Megumi Yamamoto, a 26-year-old Japanese national who had gotten separated from her companion in the mountains near the Lake Katherine and Hidden Lake area north of Santa Fe Baldy, died in the rescue. State police Officer Wesley Cox, who was serving as “spotter” on the mission, was seriously injured after the helicopter lifted off in bad weather, hit a ridge at about 12,000 feet elevation and tumbled down a mountainside.

The communications breakdown that contributed to the crash was cited earlier this year in a report by the New Mexico Search and Rescue Review Board and led to some improvements in dispatch procedures, additional training time and the adoption of a mission risk management worksheet, among other things.

But the federal accident report identifies additional issues that might have affected the outcome.

According to the NTSB review, chief pilot Tingwall had been prescribed Prozac (or fluoxetine) in 2002 to treat dysthymia (chronic depression) and samples of his blood taken after the crash tested positive for the drug.

But Tingwall, honored for his valiant effort to save a stranded hiker from a cold night in the mountains, did not reveal that he was taking any medication in his Nov. 13, 2008, aviation medical exam seven months before the accident.

If a pilot requires medication, it must be approved and the pilot certified fit for flight by a Federal Aviation Administration-designated medical examiner or flight surgeon. Under Department of Public Safety regulations, no pilot deemed impaired is allowed to fly a department aircraft.

The report states that the chief pilot’s personal physician had noted that Tingwall experienced no adverse reactions to fluoxetine and his mood and functioning had improved under the drug. And there is no specific evidence in the NTSB review that it affected his judgment that evening.

The 70-page NTSB report describes Tingwall as a “motivated, hard working, disciplined officer” and a “very heroic type person” who was “willing to put himself at risk to save others.” Colleagues said he had turned down past missions, either because of poor weather or fatigue, but according to the report, they held “varying opinions about his assertiveness when it came to safety.”

A pilot of fixed-wing aircraft said Tingwall tended to “act right away before thinking things out.”

In this case, the record shows that he initially declined the mission because he had already worked an eight-hour shift and because of deteriorating weather in the mountains. He relented after determining that the full-time helicopter pilot was not available.

The part-time helicopter pilot with the aviation division said he believed Tingwall accepted the mission “out of concern that the hiker would die if he did not help her.”

The report points out that Tingwall took off without night-vision goggles, possibly because it was still light and he didn’t expect the operation to last long. He also asked Cox to remove his uniform shirt and bulletproof vest because they were “too bulky” for the flight, leaving the two men ultimately unprepared for the deteriorating weather.

When the chief pilot landed the helicopter and went in search of the hiker, he gave the spotter a cigarette lighter and told him to build a fire if it got really cold.

While Tingwall was searching for Yamamoto in the sleet, the incident commander told the state police radio dispatcher (Tingwall’s wife) that ground teams were at the Winsor trailhead and could reach the hiker in a couple of hours. Search-and-rescue volunteers, who declined to speak publicly for this story, note that Yamamoto had already told her rescuers that while she was cold and hungry, she was not in danger of dying. They believe the more prudent response would have been for ground teams to rescue her.

The area commander, meanwhile, notified the spotter that if the weather deteriorated, they should “hang tight” in the helicopter and use its engines for heat until help arrived, the report says. An acting lieutenant involved with the rescue attempt, in a conversation with the dispatcher, said, “Well, they’re gonna have to just shore it up for tonight and fly out tomorrow.”

But after Tingwall returned to the helicopter, out of breath from carrying the hiker up a hill, he took off, heading toward the Santa Fe Municipal Airport.

Segotta said he expects the NTSB report to cite pilot error as a contributing factor in the crash.

While Tingwall was considered a “very skilled manipulator of the controls,” he was a relatively inexperienced pilot, according to the report.

He was authorized to operate the aircraft involved in the crash, but not at night, not in bad weather and not above 9,000 feet or in mountainous terrain without a more experienced pilot aboard, the report says.

The state police chief and the secretary of public safety both said they believed that the 9,000-foot restriction had been removed after Tingwall completed recent training, but there were no documents in the chief pilot’s training folder confirming that, the federal investigators found.

Tingwall didn’t have a helicopter instrument rating, although that was not required for pilots in the aviation section of the New Mexico State Police, in part because of cost restraints. The former chief pilot is quoted as saying, “We were primarily search and rescue, and if you can’t see the ground you can’t see the person or the marijuana farm.”

Several current and former police pilots, asked what they would have done in a situation like the one on June 9, 2009, said that if they ran into IMC (inclement meteorological conditions) they would do a 180-degree turn and leave.

The spotter, a friend of Tingwall, was not a pilot and had received no training for aircraft missions.

The report also includes testimony regarding the culture of risk-taking in the department. A letter from former chief pilot Michael Dowd, who retired in 2006, describes the pressure to accept and complete missions. He said decisions not to send pilots out on operations considered too dangerous brought him “continuous conflict” with state police managers and, according to the report, “when he turned down missions, he would receive complaints from the secretary (John Denko), sometimes relayed through the chain of command.”

Segotta denied on Thursday that there was any pressure from his office to fly if conditions were not safe. When the state police decided against a mission, there was an inquiry, he admitted, but, “I would never say, ‘you should have.’ I’m not a pilot. I don’t have the skill or knowledge to apply pressure to anyone to fly.”

Because he is often in the air with state police pilots, Segotta pointed out, “I don’t want them doing anything unsafe.” He added, “I don’t know where they’re getting that from.”

The federal report also reviewed the process by which the mission was initiated.

In this case, the dispatcher — again, Tingwall’s wife — said a state police sergeant who was the acting lieutenant for District 1 at the time directed her to call the chief pilot and have him initiate an aerial search for the lost hiker.

The state police managers who normally approved aircraft missions were out of town, so the job fell to the major who was the officer on call. This was the first time he had approved an aircraft mission, and he later called the chief of police for clarification of procedures and was told that managers allowed the pilots to decide whether to accept missions — and managers were not supposed to question them.

He then e-mailed the chief, two deputy chiefs and the chief pilot’s supervisor to notify them that the helicopter was on a search-and-rescue mission.

Segotta, who is preparing to retire from the force after nearly 29 years, said Thursday that search-and-rescue volunteers are under the impression that the field commanders control whether the pilot flies. “No, they don’t,” he said. “That responsibility is on the pilot. The field commander can say, ‘We need a helicopter.’ But it’s under the control of the Department of Public Safety.”

Contact Anne Constable at 986-3022 or aconstable@sfnewmexican.com.

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NTSB Aircraft Accident Report AAR-11/04

Crash After Encounter with Instrument Meteorological Conditions During Takeoff from Remote Landing Site New Mexico State Police Agusta S.p.A. A-109E, N606SP Near Santa Fe, New Mexico June 9, 2009

Abstract:

This accident report discusses the June 9, 2009, accident involving an Agusta S.p.A. A-109E helicopter, N606SP, which impacted terrain following visual flight rules flight into instrument meteorological conditions near Santa Fe, New Mexico. The commercial pilot and one passenger were fatally injured; a highway patrol officer who was acting as a spotter during the accident flight was seriously injured. The entire aircraft was substantially damaged. The helicopter was registered to the New Mexico Department of Public Safety and operated by the New Mexico State Police (NMSP) on a public search and rescue mission under the provisions of 14 Code of Federal Regulations Part 91 without a flight plan. The safety issues discussed in this report include the pilot’s decision-making, flight and duty times and rest periods, NMSP staffing, safety management system programs and risk assessments, communications between the NMSP pilots and volunteer search and rescue organization personnel, instrument flying, and flight-following equipment.

1.13 Medical and Pathological Information

The pilot and the hiker were ejected from the helicopter during the accident sequence and did not survive. The University of New Mexico, Health Sciences Center, Office of the Medical miner autopsy report listed the pilot’s primary cause of death as “environmental cold exposure” NTSB Aircraft Accident Report 24 exposure,” adding, “[o]ther significant contributing conditions included multiple blunt force injuries” that “would have been incapacitating, but not necessarily rapidly fatal.” The autopsy ries. Several studies have shown minimal or no effect of the drug fluoxetine at normal doses rformance of depressed patients on various task 58 nosis, to report the use and diagnosis within 6 m report listed the hiker’s cause of death as multiple blunt force injuries.  The spotter was not ejected during the accident sequence and survived the accident with serious injuries. His injuries included a broken ankle, chipped vertebrae, separated ribs, and bumps and bruises to the head. He also suffered from hypothermia. The spotter was hospitalized for 10 days and then released.

Toxicological analyses performed on fluid and tissue specimens from the pilot by the New Mexico Department of Health, Scientific Laboratory Division and the FAA’s Civil Aeromedical Institute produced largely similar results. The specimens tested negative for carbon monoxide, cyanide, ethanol, and a wide range of illegal drugs.   However, toxicological tests did detect fluoxetine and norfluoxetine in the pilot’s fluid and tissue samples. (Norfluoxetine is a metabolite of fluoxetine.) on a variety of performance measures, whereas other studies indicate that the performance of depressed patients s improves when taking fluoxetine. In April 2010, the FAA revised its policy to permit pilots requiring fluoxetine for the treatment of depression to receive a medical certificate through the agency’s Special Issuance (waiver) process, provided that a number of diagnostic and evaluative criteria are met. The FAA also permitted pilots who had been using the drug for depression, but not reporting the use or diagnosis, to report the use and diagnosis within 6 months following the policy change without any civil enforcement action for previous falsification.

1.5.1.2 Pilot Personal Background and Medical History

According to post accident interviews with the pilot’s family and friends and a review al and FAA medical records, the pilot was in good health at the time of the accident and engaged in some form of physical activity every day. The pilot’s wife stated that the pilot did not have a history of any medical conditions and that he did not exhibit any symptoms of illness in the days before the accident. The pilot’s wife stated that her husband did not snore and did not have any sleep disorders.36 The pilot’s wife reported that, in the year before the accident, there had been no signi ad been no significant changes in his daily habits (that is, sleeping, eating, or leisure activities).

A review of the pilot’s personal medical records indicated that the pilot had been diagnosed with dysthymia (depression) in June 2002 and was prescribed fluoxetine to treat this condition. These records indicated that the pilot continued to take fluoxetine until the time of the accident and noted that the pilot had not experienced adverse effects from his use of this medication. According to the NMSP aviation section’s “Policies and Procedures” document (see appendix B) regarding p d, it must be approved and the pilot certified fit for flight by an FAA-designated medical examiner or flight surgeon.” The pilot did not note the use of fluoxetine on any FAA airman medical certificate application in the 7 years during which he took the medication. (For additional information, see section 1.13.)