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Filtering by Tag: NTSB

Final Report On 2009 New Mexico State Police Helicopter Crash Is Published

The long awaited report on the New Mexico State Police- fatal helicopter crash (June 9th, 2009) was released late last month by the NTSB.  In many ways there are no real surprises in it.  It was expected that the NTSB would find fault with the pilot's decision to take off from the remote mountain landing zone, while surrounded by inclement weather and darkness.  I don't say that to be harsh on the pilot, it was just obvious that they would find fault with it.  But the report goes much deeper than that, examining every aspect of the New Mexico State Police aviation program, the pilot's duties within the State Police, sleep habits, etc.  Essentially no stone was left unturned.  The aviation community and particularly the police aviation community should welcome such thorough investigations.

It seems so redundant to say that we must learn from others mistakes, because that is what we say each and every time we discuss one of these cases.  But it is emphatically true.  To not study, learn, and discuss incident's such as this would be simply unprofessional. 

Each of us make mistakes on a daily or weekly basis, whether flying or on the ground, that potentially could cost us our lives.  The annual death toll on our nations highways proves this to be true.  Hence the old saying "There but for the grace of God go I."  It is in that vein that we look at this report.

The number of lessons that can be drawn from it are almost to numerous to mention.  One of the most glaring however is that this rescue mission into high altitude rugged terrain, in deteriorating weather conditions, in a complex aircraft, with darkness closing in, was undertaken essentially as a single pilot operation, and without the help of NVGs.  Yes there was another officer on board.  But that officer was an un-trained air crew member who had never been up in New Mexico State's police helicopter before that fateful day.  Be assured, one cannot place any blame at his feet.  The vast majority of patrol officers on any agency would have gladly stepped up and accepted the same mission.

As an un-trained air crew member this officer likely had no idea that he was an integral part of the air crew, who has equal authority to decline a mission or decline that take off from that mountain top landing zone in inclement weather.  Even if he had understood this, he did not have any air crew experience on which to base a decision. 

True the FAA gives final authority to the pilot in command.  But as a member of an air crew, with your life as much on the line, the TFO has absolutely as much say so as the pilot.  The saying "two to go, one to say no" means that both crew members have to agree before they can launch on a mission, but it only takes one crew member to say "no" they are not comfortable with the mission.  This rule can of course be invoked at any time, during any air mission.  Just because the TFO has not yet mastered the controls of a helicopter, or passed a check ride, does not mean that his or her concerns on the safe operation of the helicopter are any less valid. 

The NTSB seemed to find plenty of fault within the New Mexico State Police air unit and command.  To include; an attitude among some of the command that was not compatible with aviation safety, staffing issues within the air unit, specifically the lack of trained TFOs, the pilot in command having split duties as public information officer, and the complete lack of any type of risk assessment. 

I will not re-hash the entire report here.  Instead I would encourage anyone who flies, whether you are a member of an air crew or not, to read the report and take your own lessons from it. 

The entire 77 page report can be read here

R.I.P Sgt. Andrew F Tingwall, and Megumi Yamamoto (student from Tokyo)

NTSB Updates Factual Report On Fatal CHP Air Crash

 CHP Officer Dan Benivides Pictured with his Cessna T206.

On February 23, 2011 the NTSB updated it's Factual Report on the fatal crash of a CHP Fixed Wing Cessna aircraft that crashed on May the 7th 2010 while on patrol in the area of Borrego Springs California.  

The pilot and sole occupant, CHP Officer Dan Benivides (39), stopped communicating with dispatch after working a speed detail with ground units.  A report of smoke eventually led searchers to the crash site on the side of a mountain in the area of Borrego Springs, in the north eastern portion of San Diego County.  Officer Benivides was fatally injured in the crash.

According to the NTSB's February 23rd update, Officer Benivides likely suffered a "cardiac event" prior to the crash, according to the San Diego County Coronor's Office.  The NTSB's factual report reads in part;

"In the medical examiner's opinion section of the report it states ".. it is possible that a cardiac event due to fibrosis and/or ischemia due to his longstanding coronary arthrosclerosis could have precipitated the crash." Updated on Feb 23 2011 2:00PM"

The following excerpt from the NTSB report talks about the final 4 minutes or so of the airplane's radar track just prior to the accident. 

"At 0940:43, the track turns southwest on a steady course of 225 degrees magnetic at 1,200 feet msl. This route was away from the highway and towards the rising mountainous terrain. The final radar return was at 0943:55, 1.7 miles northeast of the accident location. The accident location is located directly on the extended course line of 225 degrees from the last radar return, at the 1,070-foot elevation level. The highest terrain elevation in the vicinity of the accident site is 1,500 feet msl." 

The aircraft was also equipped with an auto pilot and according to CHP Officials the pilots are encouraged to use the auto pilot to lessen workload. 

The radar data coupled with the information from the San Diego County Coroner's Officer certainly leads one to conclude that the crash was most likely the result of a medical incapacitation of the pilot.  While this in no way lessens the tragedy of the loss of Officer Benivides, his family and co-workers can know that the crash was probably not pilot error, and that Officer Benivides was a professional and capable pilot and CHP Officer.

The following excerpt is from the Police Helicopter News Page and was written by me in the days following the crash:

"Officer Danny Benavides attended the 2005 CHP Air Crew course in San Diego with this writer.  Officer Benavides is the second law enforcement officer from the class of 2005 to lose his life in an air crash, the first being Deputy Kevin Patrick Blount of the Sacramento Sheriff's Office killed in the crash of his Eurocopter EC-120 helicopter on July 13th 2005.  The cause of that crash was determined to be a fuel control valve that was installed backwards at the factory.  Since 2005 Officer Benavidez had stopped into ASTREA base in his CHP fixed wing on several occassions all of which involved great conversation, swapping of airborne law enforcement stories, and a many laughs.  On at least one occassion I had taken over a vehicle pursuit from Officer Benavidez south bound on the I-15.  His voice was one that I could always recognize when it came up on the air.  It will be missed.  Police Helicopter Pilot.com sends it's condolences to the Benavides family."

djk

NTSB Releases Preliminary Report On Pima County Sheriff Helicopter Crash

While I know it is best to wait for the full report and all of the facts.  It is still human nature to ask what went wrong.  I am asking myself if this was a tail rotor strike.......

NTSB Identification: WPR11GA115
14 CFR Public Use
Accident occurred Monday, January 31, 2011 in Marana, AZ
Aircraft: MCDONNELL DOUGLAS HELI CO 369FF, registration: N530RL
Injuries: 1 Fatal, 2 Serious, 1 Minor.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed.

On January 31, 2011, about 1115 mountain standard time, a McDonnell-Douglas 369FF helicopter, N530RL, was substantially damaged during an attempted pinnacle landing on Waterman Peak near Marana, Arizona. The pilot received fatal injuries, two passengers received serious injuries, and one passenger received minor injuries. The public-use flight was operated by the Pima County Sheriff's Department (PCSD) in support of the Pima County Wireless Integrated Network (PCWIN) communications development project. Visual meteorological conditions prevailed, and no flight plan was filed for the flight.

The purpose of the flight was to enable PCWIN personnel to conduct a site survey for the planned installation of a communications-repeater tower. The helicopter departed Tucson International Airport (TUS), Tucson, Arizona, about 1050, with the PCSD pilot/deputy in the left front seat, two Pima County employees in the right front and rear seats, and a private contractor in the left rear seat. Initially, the flight was in communication with, and being tracked by, TUS local and TRACON air traffic control (ATC) facilities as it headed for the peak, located about 30 miles west-northwest of TUS.

The 1053 TUS recorded weather observation included winds from 300 degrees at 9 knots with gusts to 16 knots; visibility 10 miles; and a broken cloud layer at 7,000 feet.

The passengers reported that during the landing attempt, the helicopter either bounced or the pilot lifted off again, the nose pitched down, and then the helicopter began to spin to the right.

The helicopter tumbled and slid about 120 feet down the northeast face of the peak before it was halted by rocks and scrub vegetation.

A ground-based witness located about 1,000 feet west of and below the peak stated that the helicopter completed about four or five rotations before it disappeared from his view.

Federal Aviation Administration (FAA) records indicated that the pilot held a commercial pilot certificate with rotorcraft-helicopter and instrument-helicopter ratings, and a private pilot certificate with airplane single and multiengine land ratings. According to the pilot's personal flight log, he had approximately 11,500 total hours of flight experience, most of which was in helicopters. His first recorded flight in the accident helicopter make and model was in August 2008, and he had logged about 186 total hours in that equipment. In January 2011, excluding the accident flight, the pilot logged 6 flights, for a total of 7.5 hours, in the accident helicopter make and model. His most recent FAA second-class medical certificate was issued in February 2010. According to PCSD information, the pilot joined PCSD in November 2008, and had about 30 years experience flying helicopters for the Arizona Department of Public Safety and the Maricopa County Sheriff's Department.

The helicopter was manufactured in 1998, and was registered to Pima County in 2008. The helicopter's most recent annual inspection was completed in April 2010, and it had accumulated about 115 hours in service between that inspection and the accident. The helicopter was equipped with an Allison (Rolls-Royce) 250-C30 series turbine engine.

During the follow-up investigation, the engine was removed and prepared for a test-run. During the test run, the engine developed rated power, and engine performance exceeded minimum values for overhauled engines, and no anomalies were noted.

"Got the wires?" "Got em" High Tension Wires Continue To Be Helicopter Killers!

As a young deputy I was getting my first opportunity to go for a flight in one of our ASTREA patrol helicopters.  The purpose of the flight was to get some aerial photos of a crime scene.  The pilot had landed in an open field near our semi-rural patrol station.  As the helicopter skids left the ground, the pilot started talking to me in a way that I thought was kind of strange.  It went something like "Ok a little left pedal, a little left cyclic, and we're going to go up and over those wires right there."  At the time I wasn't quite sure why he was telling me this, but I thought "OK".

If you were to climb in the back seat of one of our patrol helicopters today, and go on a patrol flight with us, you would here similar talk between the two crew members.  While we don't necessarily verbalize every control input, there are certain things that we do verbalize every time.  Flying over or in the area of high tension wires is one of those times.  When approaching wires, one member of the crew will call them out and the other member will acknowledge them.  It goes something like  this, "coming up on the wires", "got the wires".   You might also here "crossing on the pole", or like one of our pilots likes to say "adding a couple hundred extra feet for the wife & kids." 

What we are practicing here is basic CRM, "Cockpit Resource Management" or "Crew Resource Management" whichever term you prefer.  All pilots are familiar with the concept. 

For us, verbally calling out every set of high tension wires, every time we fly over or near them is part of a disciplined approach to identifying hazards to flight.  In addition it continuously reminds us where every set of high tension wires in the county are located, particularly along some of our standard flight paths.   

No one likes to talk about the mistakes of dead pilots.  But talk about them we must in order to learn and hopefully prevent ourselves from ever making the same fatal mistake(s).  The fiery crash of a Bell 206 helicopter with 4 souls on board, near Auberry Ca. earlier this month is a sad reminder of the dangers of high tension wires.  But there is a little more to this crash than simply flying along and not seeing the wires, or not knowing they were there.  One must read the NTSB preliminary report carefully to see what I am referring to.

wikimedia.org photoIn this case, "crossing on the pole" would almost assuredly have saved the lives of the pilot and the 3 Fish & Game wildlife biologist who were passengers on the helicopter.  If you can envision two towers with a span of high tension wires between them, you would see that the high tension wires have at least some droop to them.  The greater the span, the greater the droop.  But in this case there is a smaller lighter wire running from the top of each tower to the opposite tower.   These wires are often much harder to see, and do not have the same droop as the heavier wires.  In this case the Bell 206 came down a canyon in straight and level flight over the top of the drooped high tension wires, but apparently did not see the smaller ground wire running between the tops of the two towers.  There is little doubt as to what occurred as the crash was witnessed by two USFS law enforcement officers who were in the area. 

Every year in America you can count on one or two low flying helicopters, following freeways during bad weather and often at night, crashing into high tension power lines.  The result is always the same, a fiery crash onto the freeway. 

Whether you are an LE pilot, civilial pilot, future pilot, or even a passenger in a helicopter calling out wires, knowing their locations along your flight path, and even knowing a little bit about them may very well save your life one day. 

Remember, altitude is your friend & "got the wires."

NTSB Post It's Preliminary Accident Report in New Mexico State Police Helicopter Crash

The NTSB has published the preliminary accident report involving the New Mexico State Police Rescue Helicopter which crashed on the 12,000' level of Mount Santa Fe Baldy earlier this month. The report confirms earlier news reports that the helicopter likely entered inadvertent IMC (Instrument Meteorological Conditions) shortly after lifting off and subsequently suffered a tail rotor strike as a result.

The report also confirmed that the helicopter involved in the crash was the Agusta Spa A-109E helicopter, N606SP.  The entire NTSB preliminary report is available on the NTSB website.

During the same time that the NTSB published their initial report, New Mexico State Police released the recordings of radio transmissions between the pilot and the New Mexico State Dispatch Center.  The pilot's wife was not only on duty at the communications center, but actually the dispatcher on the other end of the radio transmissions.  The pilot, Sgt. Tingwall, called her by name and advised he had hit the mountain, and that he was "going down."  The helicopter continued to fly for just under a minute before impacting the side of the mountain and rolling 800' to it's final resting place below. 

In addition to all of the events leading up to the tail rotor strike, the accident investigation will likely also focus on why Sgt. Tingwall and the hiker, Ms. Yamamoto were ejected from the aircraft, resulting in their deaths.  The medical examiner determined that Sgt. Tingwall died of hypothermia complicated by injuries suffered during the crash.

File photo of Agusta 109 helicopter, Juergen Lehle photo Wikimedia Commons. The Agusta Westland A-109E Power Helicopter is an 8 passenger (1- pilot 7- passenger) twin engine helicopter with a top speed of 168  knots (VNE) a service ceiling of 19,600', and an "in ground effect" hover ceiling of 16,600'. 

What we have not learned from the NTSB's report is if Sgt. Tingwall was an IFR rated pilot and if the crew were operating on night vision goggles, (NVG's do not provide any measure of safety when flying in the clouds, however they may help prevent inadvertent flight into clouds.)

This remains a sad day in police aviation.