ASN Wikibase Occurrence # 65505
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Date: | Tuesday 9 June 2009 |
Time: | 21:35 |
Type: | Agusta A109E Power |
Owner/operator: | New Mexico State Police |
Registration: | N606SP |
MSN: | 11209 |
Year of manufacture: | 2003 |
Engine model: | P&W Canada PW206C |
Fatalities: | Fatalities: 2 / Occupants: 3 |
Aircraft damage: | Substantial |
Category: | Accident |
Location: | near Santa Fe, NM -
United States of America
|
Phase: | Take off |
Nature: | Aerial patrol |
Departure airport: | |
Destination airport: | Santa Fe, NM (KSAF) |
Investigating agency: | NTSB |
Confidence Rating: | Accident investigation report completed and information captured |
Narrative:On June 9, 2009, about 2135 mountain daylight time, an Agusta A109E helicopter, N606SP, 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 to find a hiker who had become lost in the Pecos Wilderness Area about 20 miles northeast of Santa Fe and was feeling very cold.
The helicopter departed its home base at Santa Fe Municipal Airport, Santa Fe, New Mexico, about 18:50 in visual meteorological conditions; instrument meteorological conditions prevailed when the helicopter departed the remote landing site about 21:32.
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 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 effect
Accident investigation:
|
| |
Investigating agency: | NTSB |
Report number: | CEN09PA348 |
Status: | Investigation completed |
Duration: | |
Download report: | Final report |
|
Sources:
NTSB
http://aerossurance.com/helicopters/ntsb-going-beyond-helicopter-safety/ Location
Images:
Media:
Revision history:
Date/time | Contributor | Updates |
11-Jun-2009 06:35 |
slowkid |
Added |
11-Jun-2009 06:37 |
slowkid |
Updated |
11-Jun-2009 06:51 |
slowkid |
Updated |
11-Jun-2009 23:20 |
slowkid |
Updated |
27-Jan-2010 09:53 |
Alpine Flight |
Updated [Date, Aircraft type, Nature, Departure airport, Destination airport, Source] |
23-Dec-2011 12:43 |
Anon. |
Updated [Source, Damage] |
26-Mar-2013 09:52 |
TB |
Updated [Operator, Location, Source] |
26-Mar-2013 10:29 |
TB |
Updated [Time, Operator, Source] |
06-Sep-2014 14:29 |
Aerossurance |
Updated [Time, Phase, Nature, Departure airport, Destination airport, Source, Narrative] |
21-Dec-2016 19:25 |
ASN Update Bot |
Updated [Time, Damage, Category, Investigating agency] |
02-Dec-2017 15:38 |
ASN Update Bot |
Updated [Operator, Other fatalities, Nature, Departure airport, Destination airport, Source, Narrative] |
20-Dec-2018 17:09 |
liamdaniel98 |
Updated [Nature, Embed code] |
20-Dec-2018 17:17 |
harro |
Updated [Other fatalities, Nature, Departure airport, Destination airport, Embed code, Damage, Narrative, Photo, Accident report, ] |
13-Mar-2020 16:10 |
Aerossurance |
Updated [Source] |
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