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Fatal helicopter crash due to safety not being a priority, says NTSB (5/25)

An organizational culture that emphasized mission completion over safety contributed to a New Mexico State Police (NMSP) helicopter crash in 2009 that killed two people and seriously injured a third, according to a determination by the National Transportation Safety Board (NTSB).

The helicopter had just taken off from a remote landing site after picking up a lost hiker when it crashed in mountainous terrain near Santa Fe, New Mexico. The NMSP pilot and the rescued hiker were fatally injured. A highway patrolman who’d been acting as an onboard spotter during the search and rescue mission was hurt.

"One thing we learned from this accident is that if safety is not the highest organizational priority, an organization may accomplish more missions, but there can be a high price to pay for that success," said NTSB Chairman Deborah A.P. Hersman.

The pilot took off without conducting a thorough assessment of the weather and nighttime conditions, according to the NTSB investigation. While the NTSB found no evidence of any direct pressure on the pilot by NMSP or the New Mexico Department of Public Safety to complete this particular mission, the Board noted evidence of previous management decisions that emphasized acceptance and completion of all missions, regardless of conditions.

“This is not consistent with a safety-focused organizational culture,” noted the report.

The Board also identified a number of safety-related deficiencies in the NMSP's aviation policies. Some of these deficiencies included 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 24 hours a day, 7 days a week; 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.

As a result of the accident investigation, the NTSB issued recommendations to the Governor of New Mexico, the Airborne Law Enforcement Association, and the National Association of State Aviation Officials that addressed pilot decision-making, flight and duty times and rest periods, staffing levels, safety management system programs and risk assessments, personnel communications, instrument flying procedures, and flight- following equipment.

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