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NTSB Report
June 10, 2009 · Agusta Spa A109E · N606SP
Santa Fe, NM
Overview
Report Status
Final with probable cause
Event Type
Accident
Date
June 10, 2009
Injury Outcomes
3 injuries (2 fatalities, 1 serious injury)
Location
Santa Fe, NM
Aircraft
Agusta Spa A109E
Tail Number
N606SP
Operator
New Mexico State Police
Injuries
Fatal
Aircraft Damage
Destroyed
NTSB Number
CEN09PA348
The Safety Board’s full report is available at http://www.ntsb.gov/publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-11/04. On June 9, 2009, about 2135 mountain daylight time, an Agusta S.p.A. A-109E 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 under the provisions of 14 Code of Federal Regulations Part 91 without a flight plan. The helicopter departed its home base at Santa Fe Municipal Airport, Santa Fe, New Mexico, about 1850 in visual meteorological conditions; instrument meteorological conditions prevailed when the helicopter departed the remote landing site about 2132.
NTSB Probable Cause
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-imposed 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 effective communication between airborne and ground personnel during search and rescue missions.
Full Narrative
The Safety Board’s full report is available at http://www.ntsb.gov/publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-11/04. On June 9, 2009, about 2135 mountain daylight time, an Agusta S.p.A. A-109E 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 under the provisions of 14 Code of Federal Regulations Part 91 without a flight plan. The helicopter departed its home base at Santa Fe Municipal Airport, Santa Fe, New Mexico, about 1850 in visual meteorological conditions; instrument meteorological conditions prevailed when the helicopter departed the remote landing site about 2132.
Flight
Event TypeAccident
Event Time21:35 MDT
Nearest AirportSanta Fe Municipal Airport (21nm)
Flight Plan FiledUnknown
Flight Plan ActivatedUnknown
Aircraft FireNo
Aircraft ExplosionNo
Aircraft
AircraftAgusta Spa A109E
Tail NumberN606SP
Aircraft CategoryHeli
DamageDestroyed
OperatorNew Mexico State Police
Engines2
Engine TypeTurboshaft
Engine DetailsP&W Canada · PW206C · Turboshaft · 561 | P&W Canada · PW206C · Turboshaft · 561
Seats8
People & Injuries
Injury Summary3 injuries (2 fatalities, 1 serious injury)
Fatal2
Serious1
Minor0
Uninjured0
Total3
Crew 1Fatal
Conditions
ConditionsIMC
LightDark Night
Wind10° @ 16 kt, gusting 21 kt
Visibility10 sm
CeilingBroken clouds 11000 ft
Temperature / Dew Point55 / 46
Altimeter29.88 inHg
Observation Time03:53
Weather SourceWFAC