Alaska DPS crash caused by weather and ‘punitive culture’
Crash of an Alaska Department of Public Safety helicopter caused by the pilot’s decision to continue flying into deteriorating weather conditions, as well as the Department’s ‘punitive culture and inadequate safety management’, says NTSB.
In a statement issue on 5 November, the US National Transportation Safety Board (NTSB) determined that the crash of an Alaska Department of Public Safety helicopter on 30 March 2013 was caused by the pilot’s decision to continue flying into deteriorating weather conditions, as well as the Department’s ‘punitive culture and inadequate safety management’.
The NSTB described how the crash occurred on a mission to rescue a stranded snowmobiler near Talkeetna, Alaska. The pilot, another state trooper and the snowmobiler were all fatally injured. Contributing to the accident was the pilot’s ‘exceptionally high motivation to complete search and rescue missions’, which increased his risk tolerance and adversely affected his decision-making, the Board found.
Among the recommendations the NTSB made as a result of its investigation was for Alaska and other states to develop and implement a flight risk evaluation programme.
NTSB acting chairman Christopher A. Hart commented: “These brave few take great risks to save those in harm’s way. There needs to be a safety net for them as well.”
Among the Board's findings was that the Alaska Department of Public Safety lacked policies and procedures to ensure that risk was managed, such as formal weather minimums, formal training in night vision goggle operations and having a second person familiar with helicopter rescue operations involved in the go/no-go decision.
During the investigation of this accident, the Board found that the pilot had been involved in a previous accident. The Board found that the Department’s internal investigation of the earlier accident was too narrowly focused on the pilot and not enough on underlying risks that could have been better managed by the organisation.
The Board concluded that the Department had a ‘punitive culture that impeded the free flow of safety-related information and impaired the organisation’s ability to address underlying safety deficiencies relevant to this accident’.
Since 2004, the NTSB has investigated the crashes of 71 public helicopters responsible for 27 deaths and 22 serious injuries. Hart said: “Public agencies are not learning the lessons from each other’s accidents, and the tragic result is that we have seen far too many accidents in public helicopter operations.”
As a result of the investigation, the Board has issued recommendations to Alaska, 44 additional states, Puerto Rico, the District of Columbia and the Federal Aviation Administration.