Poor pilot decision making, partly exacerbated by self-induced stress and fatigue, alongside organisational failings within the New Mexico State Police, contributed to the fatal crash of an AgustaWestland A109E Power helicopter on a search and rescue mission near Santa Fe on 9 June 2009.
A synopsis of the National Transportation Safety Board report into accident said that the primary cause of the crash, in which both the pilot and a passenger were killed, was the pilot's decision to take-off from a remote landing site without a thorough assessment of the weather and night-time conditions.
Shortly after take-off at 21.35 local time, the helicopter hit terrain following visual flight rules flight into instrument meteorological conditions. The pilot and passenger were thrown from the aircraft as it rolled down the steep mountainside and sustained fatal injuries. A highway patrol officer also on board the aircraft was seriously injured.
The report said the pilot exhibited "poor decision making" to leave the "relatively secure" landing site, given the prevailing conditions, which "made an immediate return to [his base at] Santa Fe inadvisable".
This was because "his fatigue, self-induced pressure to complete the mission, and situational stress distracted him from identifying and evaluating an alternative course of action", it said.
Although the investigation found there was no direct pressure on the pilot from management in either the police department or New Mexico Department of Public Safety, to which the helicopter was registered, it said there was evidence of "management actions that emphasised accepting all missions, without adequate regard for conditions". The report said this went against current guidance on safety management.
State police policies at the time "did not ensure minimum contiguous rest periods for its pilots", it added. The report said staffing levels were also insufficient to allow round-the-clock helicopter operations "without creating an unacceptable risk of pilot fatigue", adding that there was also a culture of insufficient communication between pilots and SAR controllers during missions, it added.
The NTSB is recommending that the state police and public safety department be required to bring their aviation policies into line with industry standards.