A release of documents Monday related to the March 2013 crash of a helicopter operated by the Alaska State Troopers -- a crash that killed three people -- does not list a probable cause behind the accident, but does provide a look at the culture surrounding aviation safety within the troopers, as well as other factors that may have contributed to the crash.
The National Transportation Safety Board released the public docket for the multiple-fatality crash last spring of Helo-1, the trooper helicopter conducting a search and rescue operation when the accident occurred. The documents include an immense amount of data gathered by investigators ranging from the pilot’s flight experience to the operational structure of the troopers' aviation department and the maintenance records of the helicopter. This investigation has been conducted by a Washington, D.C.-based team as the Alaska NTSB investigators recused themselves due to personal relationships with the troopers involved.
According to the NTSB’s preliminary report on the crash, at 7:35 p.m. on March 30, 2013, troopers received a phone call from a snowmachiner in distress near Talkeetna. A search and rescue mission operating under Part 91 of the Federal Aviation Regulations was launched and trooper pilot Mel Nading departed Ted Stevens Anchorage International Airport shortly after 9 p.m. in a Eurocopter AS350, more commonly referred to as "Helo-1." After picking up trooper Tage Toll in Talkeetna, the helicopter landed at a remote location at 10 p.m. to pick up snowmachiner Carl Ober, who had called when his snowmachine became stuck. After picking Ober up, the helicopter departed at 11:13 p.m. on a return flight to Talkeetna to meet emergency ground personnel. At 12:44 a.m., multiple unsuccessful attempts were made to contact the helicopter. At 9:23 the next morning the crash site was located, 5.6 miles east of the town in wooded terrain.
The public docket released Monday by the NTSB includes extensive interviews with personnel within the troopers' aviation department, including other pilots, former pilots and supervisory personnel. The information reveals a problematic operational structure that is often at odds with the levels of safety present in comparable operations in the aviation sector.
A “culture of safety” in an aviation organization refers to various aspects of its operation, from proper maintenance and training to more nuanced aspects of dispatching and managing flight activities. The NTSB has long reported on Alaska’s compromised industry safety structure, specifically in published reports from 1980 and 1995. Within discussions of “bush pilot syndrome,” the NTSB has researched a variety of pressures on air taxi and commuter pilots as well as an attitude of excessive risk-taking that permeates the aviation environment in Alaska. From the 1995 report:
The demands for reliable air service in Alaska can easily place pressures on pilots and operators to perform. An underlying factor is risk-taking or “bush syndrome,” a response by pilots and operators to powerful demands for reliable air service in an operating environment and aviation infrastructure that are often inconsistent with those demands.
In the years since that report was issued, a multitude of changes both technological -- like published GPS approaches -- and training-related -- like development of Cockpit Resource Management techniques and increased emphasis on pilot fatigue and scheduling -- have transformed aviation nationwide. In Alaska, both commercial and general aviation pilots have enjoyed the development of more enhanced aids to navigation at many Bush destinations and weather-reporting systems in remote locations like Rainy Pass.
Search-and-rescue operations are particularly susceptible to pressure, though, both self-induced by pilots compelled to do whatever it takes to save a person in need, and externally from supervisors, medical personnel, family members or the patients themselves who perceive heroics as part of the job. In the face of several high-profile medevac crashes attributed to pilot error in recent year, the air ambulance industry, which operates under Part 135 of the Federal Aviation Regulations, has pursued stricter risk-assessment procedures among its members. These involve intensive training, specific checklists that must be followed, required discussions between pilots and dispatch personnel on topics ranging from weather reports to pilot fatigue and protecting the flight crew from all information regarding the patient’s care and condition. Military search and rescue operations, including those in Alaska, follow similar guidelines.
But public-use aircraft, which includes everything from law enforcement to forestry and the National Park Service, do not operate under Part 135 and are subject instead to Part 91 of the regulations, which governs general aviation. This requires far less oversight on the part of federal inspectors and allows these organizations to operate without the required manuals, training and operational oversight that air taxis and commuters require. It places an extreme amount of responsibility on the pilot, who must make all decisions concerning flight safety. The NTSB has long sought increased oversight of public use aircraft and in 2001 released a formal report into the excessive number of accidents that occur in this sector. The crash of Helo-1 echoes many of their previous findings. Now, the public docket lays bare all of the decisions Nading was required to make on his own and the lack of specialized aviation infrastructure to support him on the night of his final flight.
Shortly after the docket was released by the NTSB, the Alaska State Troopers released a statement emphasizing its commitment to safety while acknowledging that the crash had caused it to review its aviation practices and led it to make some changes.
"Since the crash, the department made some changes to its safety management system to include installing real-time satellite tracking devices in its aircraft and creating a new position in the aviation section for a safety officer," the statement said.