A National Transportation Safety Board report on the crash of an Alaska State Trooper helicopter that left three dead in March of last year paints a chilling picture of a state agency that ignored safety in the desire for quick and easy search-and-rescue results.
"NTSB Slams NM State Police Over 2009 Helo Crash," said an Aviation International News headline when the final accident report came out.
The magazine went on to outline how the NTSB faulted New Mexico authorities "for a management style 'that is not consistent with a safety-focused organizational culture.' Specifically, the Board criticized the NMSP for management decisions that 'emphasized the acceptance and completion of all missions, regardless of conditions ... the lack of a requirement for a risk assessment at any point during a mission, inadequate staffing levels to safely provide search-and-rescue coverage ... the lack of an effective fatigue management program for pilots and the lack of procedures and equipment to ensure effective communication between airborne and ground personnel during search-and-rescue missions.'"
Many of those same problems pop up in the "Factual Report" found in the now-public docket of the preliminary investigation into last year's Alaska crash. They are problems that the NTSB already said should be fixed -- in 2011, two years after the New Mexico accident and two years before the crash in Alaska, the NTSB issued safety recommendations to the Airborne Law Enforcement Association, the International Association of Chiefs of Police, and the National Association of State Aviation Officials.
Somehow, those safety recommendations never reached the Alaska Department of Public Safety, although Sherry Hassell, the aircraft section supervisor from 2009 to 2013 and who retired just prior to the fatal crash, told investigators she was an Airborne Law Enforcement Association member and "received a monthly safety newsletter from ALEA, which she emailed to all the pilots because it had information in it applicable to the kinds of flying the trooper pilots were doing."
Despite this, the report on the 2013 Alaska crash said, "the recently retired aircraft supervisor (Hassell) and the aircraft section commander (trooper Lt. Tory Oleck) both said that they were not aware of the 2009 New Mexico State Police accident until after this accident.
"(Oleck) said that he learned about the accident at a Medallion Foundation (safety) meeting, and he then read the NTSB report. He said the NMSP accident was 'nearly identical' to this accident. (Hassell) said that she learned about the NMSP accident from the former relief pilot and that she then read the NTSB report. She said that she wished she had read the report before she retired and that she thought the recommendations made by the NTSB were applicable to the Alaska Department of Public Safety."
When the New Mexico report was released, NTSB Chairman Deborah Hersman warned that "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."
The motivation to fly
The high price paid in Alaska was the deaths of Helo-1 pilot Mel Nading, 55; Trooper Tage Toll, 40, and 56-year-old Carl Ober, who had called for rescue after crashing his snowmachine along the Anchorage-Fairbanks electric intertie about 12 miles outside of Talkeetna.
"The snowmobiler told the dispatcher that he had bruised his ribs," the report said, "but he did not seem concerned about this injury; rather, he expressed concern that he would develop hypothermia if he was not rescued soon."
A local trooper tried to get Talkeetna residents to organize a volunteer rescue using snowmachines, but when that didn't come together quickly, he fell back on what had become a common trooper practice in the area in and near Anchorage. He called for for Nading and Helo-1 to make the pickup.
Nading, according to the NTSB report, had a powerful incentive to do as many of these rescues as possible.
"The pilot was not salaried," the NTSB report says. "He was paid for his work on an hourly basis and he was expected to work at least 40 hours per week. He received additional compensation (premium pay) for additional hours worked (overtime), for working in the evenings or at night (swing shift or graveyard shift pay differentials), for working on a holiday, and for being on call outside of normal work hours (standby pay). DPS records indicated that his pay for calendar year 2012 consisted of $66,820 in regular pay and $38,885 in premium pay."
Nading's base salary was such that he vigorously opposed taking time off or bringing in a relief pilot because "he did not want to miss out on any flying or overtime," the report said.
Nading's bosses told investigators the pilot "was dedicated to his job and that there was also an element of financial motivation due to the premium pay. The pilot told the section commander more than once that the premium pay he earned was important because it allowed him to support his family ... The section commander said that any time he talked to the pilot about adjusting his schedule or bringing in another pilot to share the standby duty, the pilot would complain that this was going to take away from his overtime pay."
Who makes the call to fly?
Compounding the problem of a pay system that encouraged Nading to fly overtime, the NTSB report notes that the Alaska State Trooper Aircraft Operations Manual gave pilots alone the go/no-go authority on rescue flights, deciding whether or not to attempt a mission based on all the factors surrounding the flight.
Granting pilots total control over flying search-and-rescue missions has been something long frowned upon in the best search organizations because of the natural instinct to play hero, something Oleck alluded to in the NTSB report.
"He said that he believed the 'trooper pilots ... feel compelled to go, almost no matter what' and that he had told the pilots during seminars and other discussions, 'If you don't feel like going, for whatever your reasons, maybe it's below minimums for weather, or other conditions ... then don't go on the flight,'" he said.
What troopers supervisors said, however, and what other messages the state sent appear not always to align.
Nading's file, the NTSB report said, shows that he "had been commended numerous times by state officials including the governor" for his daring rescues and a "review of the pilot's DPS personnel file revealed that he had received ratings of 'outstanding' or 'high acceptable' on his yearly performance evaluations since joining the agency. The file contained numerous letters and emails of appreciation written by persons whom the pilot had rescued."
The only one of those letters the report cites in detail is one that involves some risky flying. The NTSB report recounted it, as it related to a September 2012 rescue:
"...Two Piper PA-18 Super Cubs had landed on a gravel bar on the Talkeetna River and gotten stranded by rising water. The three occupants of the Super Cubs had called on a satellite phone requesting rescue. A 210th Air National Guard Rescue Squadron crew attempted to reach the location in a Sikorsky HH-60 Pave Hawk helicopter but had to turn back when they were unable to cross a mountain pass due to poor weather conditions. The pilot stayed up all night and continued to check the weather until he saw a 'weather window on the radar' that he thought would allow him to reach the location. About 0300, the pilot launched in Helo-1, and by using a different route that avoided the mountain pass where the Air National Guard crew was forced to turn back, he reached the location and rescued the three people. The section commander said that this mission demonstrated how 'motivated and driven' the pilot was to perform rescues."
Motivated and driven pilots, the NTSB warned after the 2009 New Mexico crash, are the pilots who most need to be protected from themselves so that their lifesaving desire to rescue others doesn't put them in harm's way.
The NTSB report on the Alaska crash makes it sound like such controls were hard, if not impossible, to implement within the trooper hierarchy. According to the report, the troopers' SAR coordinator said that there was "absolutely no pressure whatsoever" for a pilot to fly if they weren't comfortable with the conditions. However, Hassell reported at least one instance where that didn't hold true. From the report:
"(Hassell) said that she could recall only one occasion when an aircraft section pilot (not the accident pilot) was pressured to fly. Shortly after she started work for the section, this pilot was asked to fly a Cessna 208 to Kodiak Island and pick up some people. After checking the weather, he informed her that the weather was not good and he did not want to go. When she informed the colonel (Commander of AWT), the response was that the pilot needed to 'get in the plane and go.' The supervisor said that she was shocked and felt that this direct pressure was 'very inappropriate.' When she informed the pilot of the colonel's response, the pilot went ahead with the mission, which was accomplished without incident."
Hassell, according to the report, "explained that she was listed as the pilot's supervisor, but 'in reality' he was supervised by the Alaska State Troopers search-and-rescue coordinator, and she 'wasn't even involved in any of (Nading's) flights.' The SAR coordinator contacted the pilot directly regarding SAR missions.
The report continued:
"(Hassell) said that she was aware when she was hired in 2009 that she was the fifth person to hold the position in five years, and when she asked why there had been so much turnover, she was told that it was 'because of the money. The position doesn't pay enough.'
"However, she found out over time that this was not the reason why people left; it was because the position 'doesn't have any authority.' The supervisor explained that, in the section's Aircraft Operating Manual (AOM), 'it says in many places that the aircraft supervisor does this, or the aircraft supervisor does that; 'however, that's not true. Actually, headquarters directs or makes a decision on those things even though it says in the manual that the supervisor does.'
"She said that if she made decisions the aircraft section staff did not like, they would just go around her to headquarters, and that 'a lot of times' decisions were made that she was not involved in and would inadvertently find out about. She described a frustrating event that occurred shortly after she was hired. The organization chart showed that she supervised a pilot located in Bethel, Alaska, and she contacted the detachment commander and said that she needed the pilot to come to Anchorage for training. The detachment commander replied that the pilot could not come and told the section supervisor that the pilot 'belonged' to the detachment and that he was the one who supervised the pilot.
"The supervisor said that she had decided to leave the section because she did not feel there was ever going to be any change in the way they were operating. A couple of weeks before she gave notice that she was leaving, a trooper pilot nosed over a Piper PA-18 Super Cub at a remote site; he and his supervisor, neither of whom was an airframe and power plant mechanic, changed the propeller; and the trooper pilot then flew the airplane back to his base. She said that this was an example of the fact that certain pilots could just do what they wanted and did not have to follow policies and that it was this specific instance that prompted her to give notice."
The NTSB report reveals 18 accidents involving Alaska State Trooper aircraft since July 1, 1999, including a previous accident in which Nading wrecked a helicopter in 2006 while trying to take off from a lake north of Cook Inlet. Neither Nading nor his two passengers were injured in that accident, but the helicopter "sustained substantial damage."
The accident happened at night with snow swirling, conditions similar to those in the Talkeetna area on the night of the fatal crash. The report also raises questions about the training trooper pilots get in the use of night-vision goggles and instrument flying.
Still no certainty about what caused the crash
The exact cause of the Talkeetna crash has not been determined, and many of these issues are expected to be explored in further detail as the investigation continues. But the report released Monday clearly suggests problems within the structure of the troopers aircraft section -- especially on issues of employee safety -- regardless of the final outcome of the investigation.
Nading was issued a "Memorandum of Warning" after a trooper investigation of the 2006 crash, the NTSB report said. And it indicates the warning left Nading fearful about hanging onto his job. As a result, he appears to have been less than forthright about a couple of potential safety-related incidents with the helicopter in the years that followed.
Alaska Mountain Rescue Group volunteer Scott Horacek, who regularly flew with Nading, told the NTSB that "the pilot was 'always worried' about losing his job." The pilot told him after the 2006 Helo-1 accident that he thought he was going to be fired and that after another minor incident in 2009 "he was being blamed for damaging the helicopter again."
Taken in their entirety, the NTSB report's observations on how Nading was paid, how he was supervised, how flight decisions were made, and how he feared for his job paint a picture of a systemic problem within the trooper organization.
Nading was under pressure in a variety of ways to get the job done, and then it was left in his hands -- and his hands alone -- to decide whether it was truly safe to fly.
Search and rescue experts interviewed by Alaska Dispatch in the weeks after the deadly crash and in the months since have called that a recipe for disaster. And trooper protocols do appear to have changed since the accident. When the agency was called upon to to rescue two women missing in a snowstorm in the Talkeetna Mountains on a November night just months ago, the state helicopter stayed on the ground awaiting better weather.
"Due to the weather conditions at the time of the report and the fact that Hatcher Pass had received in excess of 4 feet of snow," a trooper report said at the time, "it was determined that attempts to locate the hikers was not possible." A helicopter was not launched until midmorning the next day when conditions had improved.
Troopers on Monday sent a press release to Alaska media reporting the agency has "examined its aviation practices (since the Talkeetna crash) to help ensure that families will never have to go through this again. After the crash, the department has worked with the National Transportation Safety Board to determine a cause, which has yet to be determined."
The press release makes no mention of the NTSB documents released Monday and addresses none of the specifics of the many issues raised in the NTSB report. The investigation is being conducted by NTSB investigators based in Washington, D.C. after the Anchorage investigative team recused themselves due to an existing relationship with Nading.
The troopers press release ends with the declaration that "because the department realizes that aviation safety is an integral part of the service it provides to the citizens of Alaska, we continue to be committed to having a robust safety culture."
The NTSB report, however, would indicate that at least a part of the reason for the Talkeetna crash is that a "robust safety culture" was previously lacking.
Contact Craig Medred at craig(at)alaskadispatch.com