Public Service, Regulatory

NTSB: Fatigue, Organizational Pressure Factors in Crash

By By Chris Sheppard, Associate Editor | May 25, 2011
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During a public meeting on Tuesday, the U.S. National Transportation Safety Board (NTSB) released its findings in the investigation of a June 2009 New Mexico State Police (NMSP) helicopter crash, pinning much of the blame on “poor decision making.” The AgustaWestland A109E was returning from a search and rescue mission after picking up a lost hiker when it went down, killing the pilot and hiker, and injuring another state police officer. Also listed as a contributing factor was an organizational atmosphere that “prioritized mission execution over aviation safety,” the report notes.

Sgt. Andy Tingwall piloted the A109E with a spotter, Officer Wesley Cox, who did not have any flight training. Tingwall had already worked an 11-hour day prior to the SAR mission and turned it down at first, citing increasing winds and deteriorating weather concerns.

While investigators did not find direct evidence that Tingwell received pressure to accept the mission, “…there was evidence of management actions that emphasized accepting all missions, without adequate regard for conditions,” the board noted.


NTSB faulted the pilot for not bringing adequate survival gear or night vision goggles—though the latter may not have been effective due to the whiteout conditions encountered during the accident.

Another factor that led to the accident was the decision to take off from the mountain once the hiker, Megumi Yamamoto, had been found. Tingwell had to walk a half-mile down from the landing zone, as the hiker was unable to climb up. He carried Yamamoto back in the dark to the A109E, which the board stated added to his fatigue. Weather conditions had worsened, leaving Tingwell with high winds, mixed precipitation and a low flight ceiling.

Once airborne, radar showed the helicopter flying erratically. The aircraft clipped a ridge and then rolled 500 feet down, ejecting both pilot and hiker.
“One thing we learned from this accident is that if safety is not the highest organizational priority, an organization may accomplish more missions, but there can be a high price to pay for that success,” said NTSB Chairman Deborah Hersman.

Neither the state police nor the New Mexico Department of Public Safety had a risk assessment policy in place prior to the accident, according to investigators. NMSP pilots also did not have protected rest periods. Tingwell filled multiple NMSP roles, as chief pilot, line pilot and public information officer—a role he requested to be relieved of and was denied. Two nights before the accident, he was only able to get two to four hours of sleep due to fielding media calls at home and an early morning mission. The board stated that Tingwell was expected to be available for other duties when he wasn’t in the air, and he was routinely on-call on during evening and weekend hours.

"We’re seeing that there were a lot of organizational pressures may have put that pilot in a position to make a wrong decision,” said NTSB board member Robert Sumwalt.

The board pointed out that Tingwell’s predecessor had been relieved of his chief pilot duties when he turned down another mission due to adverse weather conditions.

“At the time of the accident, the organizational culture of the New Mexico State Police not only allowed, but encouraged, a single individual to conduct a high-risk mission without any semblance of a safety net in place,” said Hersman. As a result of the accident, NMSP’s standard operating procedures (SOPs) have been expanded from nine pages to over 50 pages. It now includes requirements for NVGs, survival gear and a tactical flight officer program.

The board made a total of 15 recommendations to the governor of New Mexico, the Airborne Law Enforcement Association, and the National Association of State Aviation Officials. The recommendations for New Mexico include a requirement of protected rest periods and the development of a fatigue management program.

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