After reading a recent accident report I found myself shaking my head in disbelief. Then I got upset and mumbled under my breath “why am I surprised?” In fact, why would anyone be surprised? This blood boiling piece involved the 2013 Alaska Department of Public Safety fatal helicopter accident. It is nearly impossible to recap all of the details of this tragedy in one short article, especially when the NTSB’s final report contained hundreds of pages of facts and circumstances leading to the cause of the accident. However, in general, three lives were lost when an Airbus AS350 crashed near Talkeetna, Alaska, when the helicopter inadvertently flew into instrument conditions during a search and rescue operation.
The NTSB probable cause finding was: “The National Transportation Safety Board determines that the probable cause of this accident was the pilot’s decision to continue flight under visual flight rules into deteriorating weather conditions, which resulted in the pilot’s spatial disorientation and loss of control. Also causal was the Alaska Department of Public Safety’s punitive culture and inadequate safety management, which prevented the organization from identifying and correcting latent deficiencies in risk management and pilot training. 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.”
Few pilots like to second-guess an accident situation, especially when it involves an industry colleague who was fatally injured or killed. But many of the facts regarding the Alaska Trooper accident will make you want to pull your hair out. Several of the facts surrounding this accident are worth highlighting to help prevent such an accident from happening again.
The weather at the time of the initial flight request and during the actual operation was less than ideal. The investigation revealed the pilot was likely blinded by heavy snow fall, low-hanging clouds, and near-zero visibility conditions. According to the NTSB, marginal to worsening conditions were to be expected based on forecasts and current observations. In addition, it was night and the pilot was wearing night vision goggles. Like so many other helicopter accidents we read about he was flying an aircraft not certificated nor equipped for flight in IMC. Although the NTSB’s probable cause made no mention of icing as a contributing factor, icing conditions were ideal at the time of the accident. This is just one of the many factors that would have been obvious with a proper preflight weather analysis.
Should this flight have ever occurred? Absolutely not. Did the operator have weather minimums in place? If you want to call it that. The investigation revealed the Alaska DPS had weather minimums of 500 foot ceiling and 2 miles visibility, which is crazy. What is even more alarming is that the investigation revealed the pilot had set his “own minimums” to include a 200 foot ceiling. This is absolutely ridiculous. Why was a culture like this ever allowed to exist? More on this later.
So, we know the pilot found himself flying in the aforementioned conditions and he lacked the “equipment” but did he possess the necessary skills to survive this type of encounter? No, and here’s why. The accident pilot had not flown a helicopter in IMC conditions since 1986, almost three decades before the crash. Furthermore, it was determined the pilot had no recent or proper training on how to recover from inadvertent IMC encounters.
As previously mentioned, the accident pilot was utilizing NVGs. The investigation revealed the pilot had minimal NVG training. In fact, his only recorded training involving the use of NVGs was in 2003 (10 years prior to the accident) from other pilots within the organization who themselves had questionable NVG training. So, armed with this factual information, why would anyone be surprised by the outcome of this flight?
The NTSB did more than finger-pointing at just the pilot in this case. The culture within the Alaska DPS was also put on trial. Numerous findings were made that detailed agency shortcomings, including a lack of organizational policy to ensure that operational risk is appropriately managed, a lack of mission-specific training, and a lack of adequate information about best practices for helicopter inadvertent instrument meteorological training, just to name a few.
This case could very well be a game changer within the helicopter industry. As a result of the investigation the NTSB made three safety recommendations to the FAA and seven safety recommendations not only to the State of Alaska, but also for 44 additional states, Puerto Rico, and the District of Columbia. This case may very well be the catalyst that will spark many changes much like those witnessed in the HEMS industry in recent years. Unfortunately, sometimes it takes an accident like this to blaze a new trail.
As always, I may be alone but I’m afraid not. So what say you?