Individually Owned: 150,657
Corporate Owned: 137,281
Santa Fe Municipal Airport
Aircraft Accident/Incident Report
Santa Fe, New Mexico 87501
Tuesady, June 9, 2009 21:35 MDT
NTSB Narrative Summary Released at Completion of Accident
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.
NTSB Probable Cause Narrative
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.
Event Information
| Type of Event | Accident |
| Event Date | 6/9/2009 |
| Event Day of the Week | Tuesday |
| Time of Event | 2135 |
| Event Time Zone | Mountain Daylight Time |
| Event City | Santa Fe |
| Event State | NEW MEXICO |
| Event Country | -- |
| Zipcode of the event site | 87501 |
| Event Date Year | 2009 |
| Event Date Month | 6 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | 355015n |
| Event Location Longitude | 1054426w |
| Event Location Airport | Santa Fe Municipal Airport |
| Event Location Nearest Airport ID | SAF |
| Indicates whether the acc/inc occurred off or on an airport | Off Airport/Airstrip |
| Distance from airport in statute miles | 21 |
| Degrees magnetic from airport | -- |
| Airport Elevation | 6348 |
| Weather Briefing Completeness | -- |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 2153 Mountain Daylight Time |
| Direction of event from weather observation facility (degrees) | 200 |
| Weather Observation Facility ID | SAF |
| Elevation of weather observation facility | -- |
| Distance of event from weather observation facility (units?) | 21 |
| Time Zone of the weather observation | MDT |
| Lighting Conditions | Night/Dark |
| Lowest Ceiling Height | 11000 |
| Lowest Non-Ceiling Height | 6000 |
| Sky/Lowest/Cloud Conditions | Scattered |
| Sky Condition for Lowest Ceiling | Broken |
| Visibility Runway Visual Range (Feet) | -- |
| Visibility Runway Visual Value (Statute Miles) | -- |
| Visibility (Statute Miles) | 10 |
| Air Temperature at event time (in degrees celsius) | 13 |
| Dew Point at event time (in degress fahrenheit) | 8 |
| Wind Direction (degrees magnetic) | 10 |
| Variable Wind Indicator | Wind direction could be determined |
| Wind Speed (knots) | 16 |
| Wind Velocity Indicator | -- |
| Wind Gust Indicator | Gusting |
| Wind Gust (knots) | 21 |
| Altimeter Setting at event time (in. Hg) | 29.89 |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | -- |
| METAR weather report | 6:53 PM 68.0 °F 37.9 °F 33% 29.83 in 10.0 miles |
| Event Highest Injury | Fatal |
| On Ground, Fatal Injuries | -- |
| On Ground, Minor Injuries | -- |
| On Ground, Serious Injuries | -- |
| Injury Total Fatal | 2 |
| Injury Total Minor | -- |
| Injury Total None | -- |
| Injury Total Serious | 1 |
| Injury Total All | 3 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 28448 |
| NTSB Notification Source | FAA |
| NTSB Notification Date | -- |
| NTSB Notification Time | -- |
| Fiche Number and/or location -used to find docket information | -- |
| Date of most recent change to record | Jun 2 2011 4:18PM |
| User who most recently changed record | grol |
| Basic weather conditions | Instrument Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N606SP |
| NTSB Number | CEN09PA348 |
| Missing Aircraft Indicator | -- |
| Federal Aviation Reg. Part | Public Use |
| Type of Flight Plan filed | Unknown |
| Flight plan Was Activated? | -- |
| Damage | Destroyed |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | AGUSTA SPA |
| Aircraft Model | A109E |
| Aircraft Series Identifier | -- |
| Aircraft Serial Number | 11209 |
| Certified Max Gross Weight | -- |
| Aircraft Category | Helicopter |
| Aircraft Registration Class | -- |
| Aircraft is a homebuilt? | No |
| Flight Crew Seats | -- |
| Cabin Crew Seats | -- |
| Passenger Seats | -- |
| Total number of seats on the aircraft | 8 |
| Number of Engines | 2 |
| Fixed gear or retractable gear | Retractable |
| Aircraft, Type of Last Inspection | -- |
| Date of Last Inspection | -- |
| Airframe hours since last inspection | -- |
| Airframe Hours | -- |
| ELT Installed | Unknown |
| ELT Activated | Unknown |
| ELT Aided Location of Event Site | Unknown |
| ELT Type | -- |
| Aircraft Owner Name | NEW MEXICO DEPARTMENT OF PUBLIC SAFETY |
| Aircraft Owner Street Address | PO BOX 1628 |
| Aircraft Owner City | SANTA FE |
| Aircraft Owner State | NM |
| Aircraft Owner Country | USA |
| Aircraft Owner Zipcode | 87504-1628 |
| Operator is an individual? | No |
| Operator Name | NEW MEXICO STATE POLICE |
| Operator Same as Owner? | No |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | Yes |
| Operator Street Address | PO BOX 1628 |
| Operator City | SANTA FE |
| Operator State | NM |
| Operator Country | USA |
| Operator Zip code | 87504-1628 |
| Operator Code | -- |
| Owner has at least one certificate | None |
| Other Operator of large aircraft? | No |
| Certified for Part 133 or 137 Operation | -- |
| Operator Certificate Number | -- |
| Indicates whether an air carrier operation was scheduled or not | -- |
| Indicates Domestic or International Flight | -- |
| Operator carrying Pax/Cargo/Mail | -- |
| Type of Flying (Per_Bus / Primary) | -- |
| Second Pilot on Board | No |
| Departure Point Same as Event | Yes |
| Departure Airport Code | SAF |
| Departure City | Santa Fe |
| Departure State | NM |
| Departure Country | USA |
| Departure Time | -- |
| Departure Time Zone | MDT |
| Destination Same as Local Flt | dest & departure same, accident can occur anywhere |
| Destination Airport Code | SAF |
| Destination City | Santa Fe |
| Destination State | NM |
| Destination Country | USA |
| Specific Phase of Flight | -- |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Jun 15 2009 5:46PM |
| User who most recently changed record | bakd |
| Since inspection or accident | -- |
| Event Location Runway Number and Location | N/A |
| Runway Length | -- |
| Runway Width | -- |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |