Crash Following Encounter with Instrument Meteorological

Conditions After Departure from Remote Landing Site

Alaska Department of Public Safety

Eurocopter AS350 B3, N911AA

Talkeetna, Alaska

March 30, 2013

Accident Report

NTSB/AAR-14/03 PB2014-108877

National

Transportation

Safety Board

NTSB/AAR-14/03 PB2014-108877

Notation 8602 Adopted November 5, 2014

Aircraft Accident Report

Crash Following Encounter with Instrument Meteorological

Conditions After Departure from Remote Landing Site

Alaska Department of Public Safety

Eurocopter AS350 B3, N911AA

Talkeetna, Alaska

March 30, 2013

National

Transportation

Safety Board

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

National Transportation Safety Board. 2014. Crash Following Encounter with Instrument

Meteorological Conditions After Departure from Remote Landing Site, Alaska Department of Public

Safety, Eurocopter AS350 B3, N911AA, Talkeetna, Alaska, March 30, 2013. Aircraft Accident Report

NTSB/AAR-14/03. Washington, DC.

Abstract: This report discusses the March 30, 2013, accident involving a Eurocopter AS350 B3

helicopter, N911AA, operated by the Alaska Department of Public Safety, which impacted terrain while

maneuvering during a search and rescue flight near Talkeetna, Alaska. The airline transport pilot, an

Alaska state trooper serving as a flight observer for the pilot, and a stranded snowmobiler who had

requested rescue were killed, and the helicopter was destroyed by impact and postcrash fire. Safety issues

include inadequate pilot decision-making and risk management; lack of organizational policies and

procedures to ensure proper risk management; inadequate pilot training, particularly for night vision

goggle use and inadvertent instrument meteorological condition encounters; inadequate dispatch and

flight following; lack of a tactical flight officer program; punitive safety culture; lack of management

support for safety programs; and attitude indicator limitations. Safety recommendations are addressed to

the Federal Aviation Administration, the state of Alaska, 44 additional states, the Commonwealth of

Puerto Rico, and the District of Columbia.

The National Transportation Safety Board (NTSB) is an independent federal agency dedicated to promoting

aviation, railroad, highway, marine, and pipeline safety. Established in 1967, the agency is mandated by Congress

through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable

causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety

effectiveness of government agencies involved in transportation. The NTSB makes public its actions and decisions

through accident reports, safety studies, special investigation reports, safety recommendations, and statistical

reviews.

The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation,

“accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties … and

are not conducted for the purpose of determining the rights or liabilities of any person.” 49 C.F.R. § 831.4.

Assignment of fault or legal liability is not relevant to the NTSB’s statutory mission to improve transportation safety

by investigating accidents and incidents and issuing safety recommendations. In addition, statutory language

prohibits the admission into evidence or use of any part of an NTSB report related to an accident in a civil action for

damages resulting from a matter mentioned in the report. 49 U.S.C. § 1154(b).

For more detailed background information on this report, visit http://www.ntsb.gov/investigations/dms.html and

search for NTSB accident ID ANC13GA036. Recent publications are available in their entirety on the Internet at

http://www.ntsb.gov. Other information about available publications also may be obtained from the website or by

contacting:

National Transportation Safety Board

Records Management Division, CIO-40

490 L’Enfant Plaza, SW

Washington, DC 20594

(800) 877-6799 or (202) 314-6551

NTSB publications may be purchased from the National Technical Information Service. To purchase this

publication, order product number PB2014-108877 from:

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(800) 553-6847 or (703) 605-6000

http://www.ntis.gov/

NTSB Aircraft Accident Report

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Contents

Figures …………………………………………………………………………………………………………………………. iii

Tables ………………………………………………………………………………………………………………………….. iv

Abbreviations …………………………………………………………………………………………………………………v

Executive Summary …………………………………………………………………………………………………….. vii

1. Factual Information …………………………………………………………………………………………………….1 1.1 History of the Flight …………………………………………………………………………………………………..1

1.1.1 Mission Coordination …………………………………………………………………………………………1 1.1.2 Outbound Flight to Remote Rescue Location ………………………………………………………..2

1.1.3 Accident Flight ………………………………………………………………………………………………….4 1.2 Personnel Information ………………………………………………………………………………………………….7

1.2.1 Pilot ………………………………………………………………………………………………………………….7 1.2.1.1 Training and Performance at Alaska DPS …………………………………………………7 1.2.1.2 Work/Sleep/Wake History ………………………………………………………………………9

1.2.1.3 Previous Accident ………………………………………………………………………………..10 1.2.1.4 Schedule and Compensation ………………………………………………………………….10

1.2.1.5 Colleagues’ and Others’ Perceptions ………………………………………………………11 1.2.2 Flight Observer ………………………………………………………………………………………………..13

1.3 Helicopter Information……………………………………………………………………………………………….13

1.3.1 Maintenance …………………………………………………………………………………………………….15 1.3.2 Pilot’s Concerns about Maintenance …………………………………………………………………..16

1.4 Meteorological Information ………………………………………………………………………………………..16 1.4.1 Weather Information Available Before Departure ………………………………………………..17

1.4.2 Weather and Lighting Conditions at Accident Site and Time …………………………………18 1.5 Cockpit Image, Audio, and Data Recorder ……………………………………………………………………19 1.6 Wreckage and Impact Information ………………………………………………………………………………23

1.7 Medical and Pathological Information………………………………………………………………………….24 1.8 Organizational and Management Information ……………………………………………………………….24

1.8.1 General ……………………………………………………………………………………………………………24 1.8.2 Aircraft Section Policies and Procedures …………………………………………………………….26

1.8.2.1 Operational Control and Go/No-Go Decisions …………………………………………26 1.8.2.2 Flight and Duty Time Policies ……………………………………………………………….27

1.8.2.3 Preflight Risk Assessment and Weather Minimums …………………………………28 1.8.2.4 Safety Program…………………………………………………………………………………….28

1.8.3 Response to Pilot’s Previous Accident and Events ……………………………………………….30

1.8.3.1 Accident in 2006 ………………………………………………………………………………….30 1.8.3.2 Engine and Rotor Overspeed Event in 2009 …………………………………………….32 1.8.3.3 Overtorque Event in 2011 ……………………………………………………………………..33

1.8.4 Use of Flight Observers …………………………………………………………………………………….34 1.8.5 Use of MatCom Dispatch Services ……………………………………………………………………..35

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1.8.6 Alaska DPS Changes Since This Accident …………………………………………………………..36

1.9 Previously Issued Safety Recommendations …………………………………………………………………38 1.9.1 Airborne Law Enforcement Association Safety Policies Guidance …………………………38 1.9.2 HEMS Operations …………………………………………………………………………………………….39

1.9.2.1 Pilot Training on Inadvertent IMC Encounters ………………………………………..39 1.9.2.2 Preflight Risk Assessment …………………………………………………………………….40

1.9.3 Inconsistencies Among Weather Information Products …………………………………………42

2. Analysis …………………………………………………………………………………………………………………….45 2.1 General …………………………………………………………………………………………………………………….45

2.1.1 Pilot Qualifications and Fitness for Duty …………………………………………………………….45 2.1.2 Helicopter Maintenance and Wreckage Examinations …………………………………………..45 2.1.3 Weather Conditions ………………………………………………………………………………………….46

2.2 Accident Flight………………………………………………………………………………………………………….47 2.3 Pilot’s Risk Management Considerations ……………………………………………………………………..50

2.3.1 Decision to Accept Mission ……………………………………………………………………………….50

2.3.2 Preparations for Departure …………………………………………………………………………………51 2.3.3 Decision to Continue Mission ……………………………………………………………………………53

2.4 Organizational Issues …………………………………………………………………………………………………54 2.4.1 Risk Assessment ………………………………………………………………………………………………54 2.4.2 Pilot Training …………………………………………………………………………………………………..56

2.4.3 Use of Trained Observers ………………………………………………………………………………….58 2.4.4 Safety Management and Safety Culture ………………………………………………………………59

2.5 Similarities with Other Public Aircraft Operations Accidents …………………………………………63 2.6 Attitude Indicator Limitations……………………………………………………………………………………..64 2.7 Investigative Benefits of Onboard Recorder………………………………………………………………….66

3. Conclusions ……………………………………………………………………………………………………………….69 3.1 Findings……………………………………………………………………………………………………………………69 3.2 Probable Cause………………………………………………………………………………………………………….71

4. Recommendations ……………………………………………………………………………………………………..72

References …………………………………………………………………………………………………………………….74

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Figures

Figure 1. End of GPS flight track from Sunshine to landing site with flight track shown in

orange. …………………………………………………………………………………………………………………………… 3

Figure 2. Aerial photograph of helicopter landing site. . ……………………………………………………… 4

Figure 3. GPS-derived flight track of the accident flight (shown in orange). ………………………….. 5

Figure 4. Aerial view of the accident site with helicopter wreckage circled in red. …………………. 6

Figure 5. Preaccident photograph of the helicopter. ………………………………………………………….. 14

Figure 6. Appareo Vision 1000 unit from the accident helicopter. ………………………………………. 20

Figure 7. Accident site showing main wreckage. ……………………………………………………………… 23

Figure 8. Chain of command structure in place at the time of the accident. ………………………….. 25

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Tables

Table 1. Pilot’s estimated potential sleep. ………………………………………………………………………… 10

Table 2. Summary of select information from Appareo images ………………………………………….. 21

Table 3. Summary of Alaska DPS safety improvements since the accident………………………….. 37

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Abbreviations

AAWU

Ag

Alaska Aviation Weather Unit

agl above ground level

ALEA Airborne Law Enforcement Association

AMPA Air Medical Physicians Association

AMRG Alaska Mountain Rescue Group

ANC Ted Stevens Anchorage International Airport

ASOS automated surface observing system

AST Alaska State Troopers

AWT Alaska Wildlife Troopers

CDI course deviation indicator

CFR Code of Federal Regulations

DPS Department of Public Safety

ELT emergency locator transmitter

EMS emergency medical services

FA area forecast

FAA Federal Aviation Administration

FLI flight limit indicator

FLIR forward-looking infrared

fpm feet per minute

FSS flight service station

HEMS helicopter emergency medical services

HSI horizontal situation indicator

IFR instrument flight rules

IMC instrument meteorological conditions

in Hg inches of mercury

METAR meteorological aerodrome report

min Minutes

NTSB Aircraft Accident Report

vi

msl mean sea level

NMSP New Mexico State Police

NTSB National Transportation Safety Board

NVG night vision goggles

NWS National Weather Service

OCC operations control centers

PAQ Palmer Municipal Airport

PED portable electronic device

PIC pilot-in-command

RCC Alaska Air National Guard Rescue Coordination Center

SAR search and rescue

SFAR special federal aviation regulation

SMS safety management system

TAF terminal aerodrome forecast

TFO tactical flight officer

TKA Talkeetna Airport

TSO technical standard order

VFR visual flight rules

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Executive Summary

On March 30, 2013, at 2320 Alaska daylight time, a Eurocopter AS350 B3 helicopter,

N911AA, impacted terrain while maneuvering during a search and rescue (SAR) flight near

Talkeetna, Alaska. The airline transport pilot, an Alaska state trooper serving as a flight observer

for the pilot, and a stranded snowmobiler who had requested rescue were killed, and the

helicopter was destroyed by impact and postcrash fire. The helicopter was registered to and

operated by the Alaska Department of Public Safety (DPS) as a public aircraft operations flight

under 14 Code of Federal Regulations Part 91. Instrument meteorological conditions (IMC)

prevailed in the area at the time of the accident. The flight originated at 2313 from a frozen pond

near the snowmobiler’s rescue location and was destined for an off-airport location about 16 mi

south.

After picking up the stranded, hypothermic snowmobiler at a remote rescue location in

dark night conditions, the pilot, who was wearing night vision goggles (NVG) during the flight,

encountered IMC in snow showers within a few minutes of departure. Although the pilot was

highly experienced with SAR missions, he was flying a helicopter that was not equipped or

certified for flight under instrument flight rules (IFR). The pilot was not IFR current, had very

little helicopter IFR experience, and had no recent inadvertent IMC training. Therefore,

conducting the flight under IFR was not an option, and conducting the night flight under visual

flight rules in the vicinity of forecast IFR conditions presented high risks. After the helicopter

encountered IMC, the pilot became spatially disoriented and lost control of the helicopter.

At the time the pilot was notified of the mission and decided to accept it, sufficient

weather information was available for him to have determined that the weather and low lighting

conditions presented a high risk. The pilot was known to be highly motivated to accomplish SAR

missions and had successfully completed SAR missions in high-risk weather situations in the

past.

The investigation also identified that the Alaska DPS lacked organizational policies and

procedures to ensure that operational risk was appropriately managed both before and during the

mission. Such policies and procedures include formal pilot weather minimums, preflight risk

assessment forms, and secondary assessment by another qualified person trained in helicopter

flight operations. These risk management strategies could have encouraged the pilot to take steps

to mitigate weather-related risks, decline the mission, or stay on the ground in the helicopter after

rescuing the snowmobiler. The investigation also found that the Alaska DPS lacked support for a

tactical flight officer program, which led to the unavailability of a trained observer on the day of

the accident who could have helped mitigate risk.

Any organization that wishes to actively manage safety as part of an effective safety

management system must continuously strive to discover, understand, and mitigate the risks

involved in its operations. Doing so requires the active engagement of front-line personnel in the

reporting of operational risks and their participation in the development of effective risk

mitigation strategies. This cannot occur if a focus of the organization’s approach to dealing with

safety-related events is to punish those whose actions or inactions contributed to the event.

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Although front-line personnel may, on rare occasions, be involved in intentional misdeeds, the

majority of accidents and incidents involve unintentional errors made by well-intentioned

personnel who are doing their best to manage competing performance and safety goals. An

organizational safety culture that encourages the adoption of an overly punitive approach to

investigating safety-related events tends to discourage the open sharing of safety-related

information and to degrade the organization’s ability to adapt to operational risks.

The Alaska DPS safety culture, which seemed to overemphasize the culpability of the

pilot in his past accident and events, appears to have had this effect. The pilot had adopted a

defensive posture with respect to the organization, and he was largely setting his own operational

limitations and making safety-related operational decisions in a vacuum, masking potential risks,

such as the risk posed by his operation of helicopter NVG flights at night in low IFR conditions.

This had a deleterious effect on the organization’s efforts to manage the overall safety of its SAR

operations. The investigation found that Alaska DPS had a punitive safety culture that impeded

the free flow of safety-related information and impaired the organization’s ability to address

underlying safety deficiencies relevant to this accident.

The National Transportation Safety Board (NTSB) determines that the probable cause of

this accident was the pilot’s decision to continue flight under visual flight rules into deteriorating

weather conditions, which resulted in the pilot’s spatial disorientation and loss of control. Also

causal was the Alaska Department of Public Safety’s punitive culture and inadequate safety

management, which prevented the organization from identifying and correcting latent

deficiencies in risk management and pilot training. Contributing to the accident was the pilot’s

exceptionally high motivation to complete search and rescue missions, which increased his risk

tolerance and adversely affected his decision-making.

It is important to note that the investigation was significantly aided by information

recovered from the helicopter’s onboard image and data recorder, which provided valuable

insight about the accident flight that helped investigators identify safety issues that would not

have been otherwise detectable. Images captured by the recorder provided information about

where the pilot’s attention was directed, his interaction with the helicopter controls and systems,

and the status of cockpit instruments and system indicator lights, including those that provided

information about the helicopter’s position, engine operation, and systems. Information provided

by the onboard recorder provided critical information early in the investigation that enabled

investigators to make conclusive determinations about what happened during the accident flight

and to more precisely focus the safety investigation on the issues that need to be addressed to

prevent future accidents. For example, the available images allowed the investigation to

determine that the pilot caged the attitude indicator in flight. This discovery resulted in the

development of important safety recommendations related to attitude indicator limitations.

Although the recording device on board the accident helicopter was not required and was

not a crash-protected system, the NTSB has a long history of recommending that the Federal

Aviation Administration (FAA) require image recording devices on board certain aircraft. Some

of these safety recommendations, which were either closed or superseded after the FAA

indicated that it would not act upon them, date as far back as 1999. The NTSB notes that, had the

FAA required all turbine-powered, nonexperimental, nonrestricted-category aircraft operated

under Parts 91, 135, and 121 to be equipped with crash-protected image recording system by

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January 1, 2007 (as the NTSB had recommended in 2003), 466 aircraft involved in accidents

would have had image recording systems; in 55 of these accidents, the probable cause statements

contained some element of uncertainty, such as an undetermined cause or factor.

As a result of this investigation, the NTSB makes 3 safety recommendations to the FAA

and 7 safety recommendations to the state of Alaska, 44 additional states, the Commonwealth of

Puerto Rico, and the District of Columbia that conduct law enforcement public aircraft

operations.

NTSB Aircraft Accident Report

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1. Factual Information

1.1 History of the Flight

On March 30, 2013, at 2320 Alaska daylight time, a Eurocopter AS350 B3 helicopter, 1

N911AA, impacted terrain while maneuvering during a search and rescue (SAR) flight near

Talkeetna, Alaska. The airline transport pilot, an Alaska state trooper serving as a flight observer

for the pilot, and a stranded snowmobiler who had requested rescue were killed, and the

helicopter was destroyed by impact and postcrash fire. The helicopter was registered to and

operated by the Alaska Department of Public Safety (DPS) as a public aircraft operations 2 flight

under 14 Code of Federal Regulations (CFR) Part 91. Instrument meteorological conditions

(IMC) prevailed in the area at the time of the accident. The flight originated at 2313 from a

frozen pond near the snowmobiler’s rescue location and was destined for an off-airport location

about 16 mi south.

1.1.1 Mission Coordination

At 1935, the snowmobiler used his cell phone to call 911 to request rescue after his

snowmobile became stuck in a ditch under the Intertie (a major power transmission line) between

Larson Lake and Talkeetna. According to the MatCom 3 dispatcher who handled the call, the

snowmobiler reported that he bruised his ribs but was more concerned about developing

hypothermia if not rescued soon. After receiving notification from MatCom, the trooper on duty

at the Alaska State Troopers (AST) Talkeetna post tried to coordinate a ground rescue mission. 4

The trooper found that no local Alaska Wildlife Troopers (AWT) units were on duty and that

other local resources (residents with snowmobiles and SAR experience) did not want to

participate because of the distance involved and the deteriorating weather, which included rain

and poor snow conditions on the ground. After the trooper’s attempts to coordinate a ground

rescue were unsuccessful, at 2009, he telephoned the AST on-duty SAR coordinator, 5 and they

agreed that it would be appropriate to use the Alaska DPS’s primary SAR helicopter to retrieve

the snowmobiler.

1 Eurocopter is now known as Airbus Helicopters, a wholly owned subsidiary of the Airbus Group, which is

headquartered in France. 2 The term “public aircraft” refers to a subset of government aircraft operations that, as such, are not subject to

some of the regulatory requirements that apply to civil aircraft. Because public aircraft operators (like the Alaska

DPS) are exempted from certain aviation safety regulations, government organizations conducting public aircraft

operations supervise their own flight operations without oversight from the Federal Aviation Administration. 3 MatCom, a public safety dispatch center located in Wasilla, Alaska, is a division of the Wasilla Police

Department. 4 The Alaska DPS has two major divisions, the AST and the Alaska Wildlife Troopers (AWT). The AST is

charged with statewide law enforcement, prevention of crime, pursuit and apprehension of offenders, service of civil

and criminal process, prisoner transport, central communications, and SAR. The AWT is charged with enforcing

fish and game regulations; AWT troopers also enforce criminal laws and participate in SAR operations. 5 According to the Alaska DPS SAR protocol, the SAR coordinator handled all requests for the use of the

accident helicopter. If the SAR coordinator approved, then the coordinator would notify the pilot, who would

evaluate the weather and determine if the mission was acceptable.

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According to records from the pilot’s portable electronic device (PED), 6 at 2019, he

received an incoming call from the SAR coordinator. The SAR coordinator stated that he relayed

details of the situation to the pilot, and the pilot said he would check the weather. The pilot’s

spouse recalled that, immediately after the pilot received the call, he went upstairs to check the

weather. The pilot called the SAR coordinator soon after and said he would accept the mission. 7

The pilot’s spouse recalled that she asked her husband about the weather, and he said that it was

“good.” The pilot then drove to Ted Stevens Anchorage International Airport (ANC),

Anchorage