An Alaska Department of Public Safety (DPS) pilot trying to transport a stranded snowmobiler to safety likely encountered heavy snow and near-zero visibility shortly before his Eurocopter AS350 B31 crashed in Talkeetna, Alaska, U.S., the U.S. National Transportation Safety Board (NTSB) says.
The March 30, 2013, crash killed the pilot, the DPS state trooper who was serving as a flight observer and the snowmobiler; the helicopter was destroyed by the crash and subsequent fire.
The NTSB identified twin probable causes: the pilot’s continuation of the flight into worsening instrument meteorological conditions, which led to his “spatial disorientation and loss of control,” and the DPS’s “punitive culture and inadequate safety management.”
Contributing factors were the pilot’s “exceptionally high motivation to complete search-and-rescue [SAR] missions, which increased his risk tolerance and adversely affected his decision making,” the NTSB said.
The accident pilot was contacted by an officer of Alaska State Troopers at 2019 local time on the night of the accident, after attempts to organize a ground rescue mission failed because no local Alaska Wildlife Troopers (AWT) were on duty and because local residents with snowmobiles and SAR experience declined to participate, citing the distances they would need to travel and the deteriorating weather conditions.
The snowmobiler had used his cell phone at 1935 to ask for help after his vehicle became stuck in a ditch. He said he was concerned that he would develop hypothermia if he could not be rescued soon.
The pilot checked the weather and then called the DPS troopers’ SAR coordinator to accept the mission. He left his home, telling his wife the weather was “good,” and drove to the helicopter’s base at Ted Stevens Anchorage International Airport (ANC).
ANC ground personnel helped tow the helicopter from its hangar about 2100 and watched as the pilot conducted a walk-around inspection and cockpit checks. Ten to 15 minutes after the helicopter was towed out, he started the engine, and soon afterward, he conducted a takeoff.
At 2117, he told the public safety dispatcher that he had left ANC, and at 2142, he said he was landing at a landing zone near the troopers’ Talkeetna post to pick up the trooper who would serve as a flight observer. At 2154, he radioed that he had located the snowmobiler and would land nearby and walk to his location.
At 2220, the pilot and the flight observer reached the snowmobiler, who was too weak to stand. The report noted that the snowmobile was found parked on a frozen pond, near tracks presumably made by the helicopter’s landing skids, indicating that the pilot and the observer had freed it from the ditch and used it to transport their passenger to the helicopter.
The seven-minute accident flight began when the helicopter took off from the frozen pond about 2313. The only radio communication came three minutes later, when the flight observer told the dispatcher that they were en route to the troopers’ Talkeetna post and asked that an ambulance meet them to pick up the snowmobiler, who was suffering from hypothermia.
At the time of the radio call, the helicopter had been heading south at 60 kt, between 900 and 1,100 ft above mean sea level — 200–300 ft above ground level (AGL). The helicopter turned right, and its speed increased slightly, then began decreasing.
About 2318, the helicopter “began to climb and turn left rapidly with little forward airspeed,” the report said. The helicopter was equipped with a video recorder that showed that, as the helicopter completed a 360-degree turn, the pilot “caged” the attitude indicator — that is, he set it to display a level flight attitude — even though caging is intended only for an aircraft that actually is in level flight.
“After this, the helicopter entered a series of erratic turns, climbs and descents,” the report said. Global positioning system (GPS) data recorded the helicopter’s final position about 3 nm (6 km) south of the takeoff point.
Emergency medical services personnel reported the helicopter missing about 90 minutes after it was due at the troopers’ landing zone in Talkeetna. There had been no flight tracking and no signals from the helicopter’s emergency locator transmitter, and the search for the aircraft was delayed by bad weather.
The wreckage was found about 200 ft (61 m) north of the GPS final position at 0930 on March 31 by the crew of an Air National Guard Sikorsky HH-60 Pave Hawk.
Hired in 2000
The 55-year-old pilot had accumulated about 10,693 flight hours, including 8,452 hours in helicopters. His approximately 247 recorded hours of simulated instrument time and 141 hours of actual instrument time were primarily in airplanes and all were logged before 2001. Of the 38 hours of instrument time that were logged in helicopters, 0.5 hour was actual instrument time; the most recent instrument flight in a helicopter was in 1986.
The pilot held a commercial pilot certificate with ratings for helicopters, single- and multi-engine land airplanes and single-engine seaplanes; instrument ratings for helicopters and airplanes; an airline transport pilot certificate for multi-engine land airplanes; and an airframe and powerplant mechanic’s certificate.
He was hired in 2000 by DPS as the primary pilot for the accident helicopter and had accumulated 3,415 flight hours working for the agency, including 1,738 hours in SAR flights. In the 30 days before the accident, he had flown eight hours. His most recent flight in the accident helicopter had been on March 17, when he conducted an SAR mission to pick up an injured hiker.
He had completed a DPS check flight on March 18 in a Robinson R-44; AS350 B3 recurrent training, which included emergency procedures but not instrument flight, was completed Nov. 20, 2012.
Records showed that the pilot had undergone night vision goggles (NVG) training with the DPS in 2003 and that he had been authorized to use the equipment; he had flown about 16 hours using NVGs in the six months before the accident, the report said. He also had used NVGs as a military pilot; and in his 2009 performance evaluation report, he had said that a goal for the following year was to update his NVG training by attending a commercial NVG course. His 2010 performance evaluation report said that attending the course was ruled out because of its cost.
The pilot’s most recent “flight authorizations/limitations” form, completed in 2003, said that he was subject to no restrictions on visual flight rules flights and that he was authorized to use NVGs as long as there was a minimum 500 ft ceiling and 2 mi (3 km) visibility.
A review of the pilot’s annual performance evaluations showed that he had received top ratings of “outstanding” or “high acceptable” every year. His colleagues praised him as a “by the book” pilot with a “high level of proficiency,” although a former relief pilot who last flew with the accident pilot in 2010 said he had average skills.
The accident pilot had numerous commendations from state officials, including a 2007 award for the life-saving rescue of a kayaker, and the DPS received notes of appreciation from those he had helped, including a 2012 email that said, “Thank you for rescuing us during the flooding. … Our situation was pretty grim. We were surrounded by rising waters with no way to get out. … Your pilot, who was only asked to do a weather check, pushed on through to get us out of that situation. … The weather wasn’t all that great when he flew in and got us back.”
The DPS aircraft section commander said that the pilot had spoken to him about weather conditions he had encountered during his SAR flights and how he compensated for them. He said he did not consider the pilot a risk-taker but rather that the pilot “knew what the risks were and felt a self-imposed obligation to conduct SAR missions in difficult conditions,” the report said.
The section commander also said that the pilot resisted efforts to get him to take time off. “He said that any time he talked to the pilot about adjusting his schedule or bringing in another pilot to share the standby duty, the pilot would complain that this was going to take away from his overtime pay,” the report said.
His schedule in 2012 showed that 37 percent of his earnings were “premium pay” — additional compensation paid for working overtime, evenings, nights or holidays, and for being on call outside of normal working hours. The pilot’s time sheet for March 16–31, 2013, listed him as on call every day.
The relief pilot told investigators that the accident pilot had told him that “he was afraid that he would be replaced if other pilots were allowed to fly more of the helicopter’s missions.” The accident pilot also had been upset after a March 28 conversation about a proposal that the relief pilot be designated as the helicopter’s primary pilot two days each week — a move intended to give the accident pilot time off.
Heavy Snow
There was no record that the pilot had obtained a weather briefing for the March 30 mission from a Flight Service Station or the Internet-based direct user access terminal service, but other DPS pilots said that they typically obtained information from the Alaska Aviation Weather Unit website, which had links to numerous weather information products.
When the pilot was first notified about the mission, the forecast for Talkeetna Airport, 4 nm (7 km) west of the accident site, included a broken ceiling at 1,000 ft AGL, visibility of more than 6 mi (10 km) and calm wind. About eight minutes before the accident, weather conditions observed at Talkeetna included a broken ceiling at 900 ft, broken skies at 1,300 ft and an overcast at 2,400 ft; and visibility of 7 mi (11 km) in light snow. Radar images showed showers in the area around the time of the accident.
One witness, who often makes “go–no go” decisions for U.S. National Park Service SAR operations, told accident investigators that, about five minutes before the accident and about 5 mi (8 km) southwest of the accident site, he drove through heavy snow. Other nearby witnesses also reported periods of heavy snow and a mix of rain and sleet.
The NTSB said available information indicated that soon after departure from the remote landing site, the helicopter probably encountered low clouds, heavy snow and near-zero visibility.
Accident in 2006
The pilot had been involved in an earlier accident in the same helicopter on April 21, 2006, as he attempted to take off while using NVGs during a whiteout in dark night conditions in Nikiski, Alaska. No one was injured. The NTSB said the probable cause was the pilot’s “failure to maintain adequate altitude/clearance from terrain” during the rejected takeoff, which ended in a collision with terrain.
After the accident, the pilot passed a commercial pilot reexamination administered by a U.S. Federal Aviation Administration (FAA) inspector and underwent training from a DPS senior pilot on takeoffs in blowing snow.
DPS conducted an internal investigation of the accident and issued the pilot a “memorandum of warning,” dated Aug. 29, 2006, that said, “The cause of the incident was due to pilot error. Specifically, your momentary distraction within the cockpit from your instruments during the departure and the inability to transition from instrument to VFR [visual flight rules] flight resulted in a momentary loss of aircraft control.”
The DPS memorandum described aircraft damage and the temporary loss of the SAR helicopter as significant, and added, “[You] are hereby warned. Any future occurrence of a similar incident may result in more severe disciplinary action.”
The memorandum also criticized the pilot for not conducting an instrument flight rules (IFR) departure — a complaint that the NTSB said was “inappropriate” because the pilot was not current for IFR flight in helicopters and the helicopter was not equipped for IFR flight.
The NTSB added, “Had the Alaska DPS’s investigation been more focused on identifying systemic safety issues, it may have identified that it had not provided the pilot with simulator training in IFR flying or inadvertent IMC [instrument meteorological conditions] encounters and had not imposed adequate weather minimums to maintain separation between the VFR-only operation and IMC. As a result, the Alaska DPS missed an opportunity to identify and correct some of the latent safety deficiencies that again presented themselves in the 2013 accident. Without improvements to pilot training and operational policies, the risk of another inadvertent IMC accident remained high.”
In 2009, an engine and rotor overspeed event occurred as the pilot was landing the accident helicopter; the report following the departmental investigation said the cause was not determined. Around the same time, while the pilot was flying a Robinson R-44, the tail rotor “may or may not” have struck the water during a water landing; the AWT director said the pilot denied that a strike occurred.
After the two events, the director suggested installing onboard monitoring equipment, and eventually, the video imaging system was installed.
The trained volunteer observer from the Alaska Mountain Rescue Group, who typically flew with the pilot but was out of town the day of the accident, said the pilot was “always worried” that he might lose his job, the report said, adding that the pilot had told the observer that he expected to be fired after the 2006 accident and that he was blamed for damage resulting from the overspeed. The lead mechanic and others told investigators that “the pilot felt that everybody in the organization was against him.”
In 2011, an overtorque condition occurred while the pilot was flying the accident helicopter in an external load operation aimed at removing a Piper PA-18 from a frozen lake.
Afterward, the pilot saw that the vehicle and engine multifunction display had recorded an “overtorque spike” of 107 percent for one second; he then “performed an inspection of the rotor head and transmission support arms, found no damage and signed off the inspection on the helicopter’s log sheet for the day.” He did not, however, tell the lead mechanic or the aircraft section supervisor what had happened. Maintenance personnel subsequently saw his signoff and notified the FAA, which reviewed the maintenance records. The pilot’s maintenance credentials meant that he was qualified to perform and sign off the inspection. However, the DPS said that, in the future, he should report similar events to the maintenance department.
‘Punitive in Nature’
The DPS internal investigations “narrowly focused” on the pilot’s actions, the NTSB said, “while disregarding the organization’s management of flight-related risks,” such as the pilot’s work schedule.
The NTSB said the investigations “appeared to be punitive in nature” and noted that, “as a result, it appears that the pilot was motivated to conceal safety-related information,” including his inspection of the helicopter after the overtorque event.
The safety board said it concluded that the DPS “had a punitive culture that impeded the free flow of safety-related information.”
The board also noted structural deficiencies in the DPS’s approach to safety, with a safety program that lacked the backing of top DPS officials and, as a result, limited pilot confidence and participation in the program.
The report included 10 safety recommendations, including provisions calling for Alaska and other states to implement flight risk-evaluation programs, formal dispatch and flight-following procedures, NVG training and comprehensive safety management systems that “[hold] senior state personnel accountable for the safety of state law enforcement aircraft operations.”
This article is based on NTSB Accident Report NTSB/AAR-14/03, “Crash Following Encounter With Instrument Meteorological Conditions After Departure From Remote Landing Site; Alaska Department of Public Safety Eurocopter AS350 B3, N911AA; Talkeetna, Alaska; March 30, 2013.” Adopted Nov. 5, 2014.
Note
- Eurocopter was rebranded as Airbus early in 2014.