Ntsb: ‘inadequate Safety Management’ Contributed To Fatal Trooper Helicopter Crash

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.
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