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NTSB: 'Inadequate safety management' contributed to fatal trooper helicopter crash

  • Author: Craig Medred
  • Updated: September 28, 2016
  • Published November 5, 2014

The deadly crash of Alaska State Trooper Helo 1 near Talkeetna in 2013 was tied to state Department of Public Safety policies that encouraged pilot Mel Nading to take dangerous risks, the National Transportation Safety Board has concluded.

The state agency says it has since moved to tighten its policies.

Nading, 55, died in the March 30, 2013 crash along with 40-year-old Trooper Tage Toll and 56-year-old Carl Ober, a snowmachine rider Nading and Toll had set out to rescue after he crashed in a remote area along a powerline intertie.

Shortly after picking up Ober, Nading launched the state's lone turbine-powered helicopter into deteriorating weather. NSTB investigators believe that within minutes of takeoff he was blinded by snow, became disoriented, and lost control of the aircraft. It spiraled into the ground, exploded and burned.

At a Wednesday morning hearing in Washington, D.C., the NTSB watched an animated depiction of what happened on that flight. The re-creation was based on the video from an in-cockpit recorder above Nading's shoulder. The staff warned some in the audience they might not want to watch.

The animation gave a pilot's eye view as the fatal flight took off from a frozen lake near Talkeetna and then came to a near stop in midair about four minutes later. Investigators believe that is when Nading flew into the heavy snow falling in the area at the time. He began to climb to make sure he was above the spruce-birch forest and low, rolling hills.

As the helicopter climbed rapidly, it began a left turn. At one point, it spun more than 180 degrees, then yawed left, rolled right and pitched up. At that point, investigators said, Nading's hand was seen "caging" an attitude indicator that depicts level flight.

They believe the pitch of the helicopter was so severe the indicator might have gone beyond its 25-degree limit up and down, and had become stuck. They think Nading was trying to level it, but by so doing when the helicopter was itself pitched over, he eliminated his main indicator of level flight.

From that point on, the animation indicated the helicopter was basically spinning out of control until it crashed. Nading was at the time flying in conditions that required instrument flight training. He been trained to fly instruments in the past, but his rating was not current.

He also lacked any training in how to handle what the NTSB called "inadvertent instrument flight conditions," which was exactly the situation he encountered on the night of the deadly crash.

"The safest course of action at this point was to perform a precautionary landing," said senior air safety investigator Georgia Struhsaker.

Why Nading failed to do that will never be known. It might be he couldn't identify a place to land, she said. It might be that his past experience in completing risky flights provided a false sense of security.

Those previous successes on risky missions were part of a pattern the NTSB identified as a partial cause of the deadly crash. The federal agency said the state should have put an end to such flights long before Nading died.

"As a result of inadequate, high-level management support, the Alaska Department of Public Safety lacked a safety program capable of highlighting the deficiencies uncovered in this accident, including training and risk management," the final NTSB report said.

When the state did act -- Nading was written up after several minor accidents -- it did so in the worst way, the report added.

"The Alaska Department of Public Safety had a punitive safety culture that impeded a free flow of safety related information and impaired the organization's ability to address underlying safety deficiencies relevant to this accident," the report said.

At the end of a four-hour hearing, the board ruled the direct cause of the accident "was the pilot's decision to continue flight under visual flight rules into deteriorating weather" but added that "also causal was the punitive culture and inadequate safety management" of public safety supervisors.

William Bramble, the NTSB's senior human performance investigator, said Nading was asked to complete a "high-risk mission" absent the sort of risk assessment procedures that "would have encouraged the pilot to decline the mission."

"It does not appear the pilot was subjected to any direct management pressure to accept search and rescue missions," Struhsaker added, but there was plenty of indirect pressure.

"The pilot was highly motivated to accept these missions by several factors, including his desire to help others, the public recognition and reward he had received for past rescues, and a pay structure that included significant income from on-call and overtime work."

Trooper policies for assigning search and rescue missions were also questionable, Bramble said.

Given the inclement weather in the Talkeetna area at the time, he said, "another strategy would have been to delegate the mission to another organization with an IFR certified helicopter and crew, such as the Alaska Air National Guard."

The five-seat, turbine-powered, A-Star helicopter Nading was flying was not certified for IFR flight.

The guard's 210th Rescue Squadron, based at Joint Base Elmendorf-Richardson just outside of Anchorage, is considered one of the world's premier search and rescue operations. But troopers are the agency responsible for SAR, as it is commonly called in the 49th state, and the 210th is a couple rungs down on the pecking order of assets regularly summoned for such operations.

After the Talkeetna crash, however, this did change somewhat. The guard helped fill in while the state replaced its A-Star 350, and the guard has remained more engaged because of a state decision to suspend night-vision goggle flights, even though the state has purchased two, $3.2 million A-Star helicopters -- one for Anchorage and one for Fairbanks -- to replace the crashed Helo 1.

The guard was called in for a difficult evening rescue in Lake Clark National Park and Preserve across Cook Inlet from Anchorage at the end of August because of the new trooper flight constraints. Alaska Wildlife Trooper Capt. Bernard Chastain told Alaska Dispatch News the agency concluded that it lacked the capabilities to successfully complete that mission.

Chastain said the state agency now follows a risk-assessment matrix that vetoes flights that are too dangerous, and it will not fly flights requiring night-vision goggles.

"We have discussed it and plan on implementing (an NVG) program in the future when we have examined all aspects of our current program and make sure that we can provide this service in accordance with federal regulations and our own self-imposed staffing minimums," Chastain said.

Federal regulations for NVG flight call for considerably more training than trooper pilots have received in the past, but as the NTSB noted on Wednesday, state helicopter agencies are not governed by federal regulations.

If they were, Struhsaker said, the Federal Aviation Administration would certainly have raised red flags about the 18 aircraft accidents over the course of a dozen years involving Alaska trooper aircraft.

"That seems like a high number of accidents," said the board member Earl Weener.

Struhsaker agreed, but said the responsibility to deal with it rests solely with the state of Alaska. She added that the state does appear to be making progress and has now joined a nationally recognized safety program. But the state was making progress once before, "and that program sort of fell apart," she said.

Safety improvements recommended by a retiring SAR commander were ignored, and the state's aircraft safety officer quit. Struhsaker indicated the NTSB is hoping for better this time.

There are clear indications the state is taking a more cautions approach to SAR. Some missions of the type that the agency might have flown in the past have been turned over to the guard or LifeMed, an Alaska-based commercial operation that has two A-Star helicopters outfitted as flying ambulances.

The hearing also revealed that a full audit of AST's helicopter maintenance, pilot training, and safety operations is underway.

NTSB staff recommended the board cite the "punitive safety culture" of trooper commanders overseeing aircraft operations as part of the cause for the 2013 crash, but the board voted unanimously to remove the word "safety" and finger simply a "punitive culture."

Not unlike many other organizations, the NTSB report said, troopers tend to manage by punishing employees who make mistakes. The result was that Nading avoided telling supervisors he'd made flight errors and pushed himself to show that he could handle tough and risky assignments so as to avoid trouble.

Despite night-vision goggle training limited to that taught by a fellow state employee in 2003, NTSB staff said, Nading went along with state standards for NVG flights that were more liberal than the standards for pilots assigned to the 210th, which trains to fly combat missions.

Those pilots are instrument-rated, fly Pave Hawk helicopters equipped to be flown under instrument flight rules and train constantly, yet they draw the line at night missions with cloud cover less than 700 feet above the ground and visibility of less than 2 miles. These are what pilots call ceiling and visibility limits.

The state of Alaska set its minimums for search and rescue at a 500-foot ceiling and 2 miles visibility. Nading wrote in an email to a colleague this his personal limit was an even riskier 200 feet with 5 miles visibility.

The NTSB did not explain how the state's chief helicopter pilot could have a flight standard so different from the state standard. Board member Robert Sumwalt did observe that Nading was operating under minimums far different from those the Federal Aviation Administration has for air-ambulance operators such as LifeMed. They are required to have a ceiling of at least 800 feet with 2 miles of visibility in non-mountainous terrain or 1,000 feet and 5 miles in mountainous terrain such as that around Talkeetna.

"Even the Alaska Air National Guard that has IFR proficient pilots and helicopters, even their minimums were seven and two," Sumwalt observed to NTSB staff. "(Nading's) minimums were much less conservative than those. Any comments on that?"

Struhsaker said she could only agree with Sumwalt's observations.

"Maybe some formal NVG training from an outside organization, which (troopers) had considered but not done, would have been beneficial and helped them identify that (problem) and set more appropriate minimums," she added.

Board chairman Christopher Hart said he was troubled to find the board gathered to examine the third deadly crash involving a law enforcement helicopter operated by a state agency in a little more than four years.

"Four people were lost in the 2008 crash of the Maryland State Police helicopter," he said. "Two lost their lives in a crash of a New Mexico State Police helicopter ... Today we are recording once again a fatal public helicopter accident."

State agencies flying helicopters need to take note, he said.

The NTSB offered those agencies seven safety recommendations and sent another three to the FAA. State agencies were told, among other things, to develop broader flight-risk evaluation programs. Many private helicopter operators work under rules that allow anyone involved with a flight to cancel it if they have weather concerns.

All pilots, the NTSB added, should be required to undergo annual training, including training in what to do if they encounter inadvertent instrument meteorological conditions. Struhsaker suggested such training might have saved Nading's life.

Nading made a mistake when he slowed the helicopter almost to a stop, she said. The accepted protocol, she said, is to maintain forward airspeed while climbing to keep the tail boom on the helicopter working as sort of a weather vane.

"It makes it easier to fly," she said.

Along with better training for pilots, the board stressed that state agencies also need to "develop and implement a comprehensive safety management system for aircraft operations that ... holds senior state personnel accountable for state aircraft operations."

Among the recommendations to the FAA was a note a that it needs to inform pilots and amend pilot handbooks to reflect that attitude indicators have limits, and that if pitch is too severe they may get stuck in the wrong position.

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