Credit: NTSB Docket: ANC13GA036 http://1.usa.gov/1uH3F7i
This three-dimensional (3-D) animated reconstruction shows the March 30, 2013 accident involving a Eurocopter AS350 B3, N911AA, registered and operated by the State of Alaska, Department of Public Safety (DPS), which impacted terrain while maneuvering near Talkeetna, Alaska.
The animation depicts the final 3 minutes of the 7-minute accident flight. The animation begins at 23:16:36 Alaska daylight time and ends at 23:20:01, just before the helicopter impacts the ground. The end of the animation transitions to an overhead photograph of the crashed helicopter at the accident site.
The animation depicts a reconstruction of the sequence of events based on information extracted from the Appareo Vision 1000 Video/Data Recorder unit installed on the helicopter. Local time, altitude (above ground level) and airspeed are shown as text across the top of the animation. The left side of the animation shows a view from inside the cockpit, and the right side of the screen shows an external view of the helicopter. The animation does not depict the weather or visibility conditions at the time of the accident. The animation includes audio narration.
The instruments depicted in the cockpit view of the animation are generic and do not represent the instruments in the accident helicopter.
The attitude of the helicopter is based on data from the Appareo unit, which was not properly calibrated when installed, so the recorded data exhibits pitch and roll offsets. The animation data has been adjusted to remove these offsets. In addition, the GPS position and altitude data has been smoothed for the animation.
The attitude of the helicopter depicted in the animation becomes unreliable after time 23:18:00, which will be noted during the animation, because the helicopter starts to experience large yaw, pitch, and roll rates. Nonetheless, the motions shown after this time are likely representative of the extreme angular rates and attitudes actually achieved.
WASHINGTON – The National Transportation Safety Board today determined that the March 30, 2013 crash of an Alaska Department of Public Safety helicopter 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 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 today as a result of the investigation was for Alaska and other states to develop and implement a flight risk evaluation program.
“These brave few take great risks to save those in harm’s way,” said NTSB Acting Chairman Christopher A. Hart. “There needs to be a safety net for them as well.”
Among the Board’s findings was that the Alaska Department of Public Safety (DPS) 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 DPS’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 organization.
The Board concluded that DPS had a “punitive culture that impeded the free flow of safety-related information and impaired the organization’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.
“Public agencies are not learning the lessons from each other’s accidents,” Hart said. “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 made recommendations to Alaska, 44 additional states, Puerto Rico, the District of Columbia and the Federal Aviation Administration.
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