- Date
- June 9, 2009, 21:35 local (Jun 10, 2009, 03:35 UTC)
- Place
- Santa Fe, NM
- Injuries
- 2 fatal, 1 serious
- Damage
- Destroyed
- Phase of flight
- Maneuvering
- Aircraft
- N606SPAgusta A109E
- Defining event
- Maneuvering-low-alt flying: VFR encounter with IMC
- Weather
- Instrument (IMC) · Night/dark
- Status
- Completed · report June 2, 2011
- Report
- Board-adopted at Board Meeting
- Investigation class
- Class 1
- NTSB office
- Central Region
- Parties
- Agusta Westland, New Mexico State Police
- Safety recommendations
- Yes
- FAA report
- 20090609009009A
- Case key
- 73997
From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.
On this page
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.
Findings · 10
NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.
Sequence of events
The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.
Analysis
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.
Factual 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.
Aircraft
- Registration
- N606SP
- Reported as
- Agusta A109E
- Category
- Helicopter
- Serial number
- 11209
- Engines
- P&W Canada PW206C, 561 horsepower, turbo shaftP&W Canada PW206C, 561 horsepower, turbo shaft
- Damage
- Destroyed
- Flight
- Public aircraft - state · Public use
- Operator
- New Mexico State Police
- Registered owner
- New Mexico Department Of Public Safety
- Airworthiness certificate
- Standard, Normal
- Departed
- SAF · Santa Fe, NM
- Destination
- SAF · Santa Fe, NM
- Flight plan
- Unknown
- Airport
- SAF · Santa Fe Municipal Airport
Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.
Flight crew
As NTSB recorded them. NTSB leaves out names.
- Role
- Pilot
- Injuries
- Fatal
- Certificate
- Commercial
- Airplane ratings
- Multi-engine land, Single-engine land
- Instrument ratings
- Airplane
- Seat
- Right
Weather
- Conditions
- Instrument (IMC) · Night/dark
- Wind
- 10° at 16 knots, gusting 21
- Visibility
- 10 statute miles
- Lowest ceiling
- 11,000 ft broken
- Temperature
- 55 °F, dew point 46 °F
- Altimeter
- 29.88 inHg
- Observed at
- SAF, 21 nm away
Docket · 36
The files NTSB released with the investigation on November 29, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 108 MB in all.
FAA reports on this event · 1
The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.