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)