Wednesday, November 12, 2014

Craig Medred: Are lessons unlearned after National Transportation Safety Board report of Helo 1 crash?


Something needs to be made bluntly clear in the wake of this week's conclusion by the National Transportation Safety Board about the causes of the crash of Alaska State Troopers Helo 1 near Talkeetna in March 2013 because some people just don't seem to understand what the board said.

The NTSB did not say trooper management contributed to the crash that killed helicopter pilot Mel Nading, trooper Tage Toll and snowmachiner Carl Ober. The safety board did not say trooper management played a "role" as has been reported elsewhere. The facts are the safety board went way beyond that.

The safety board said trooper management tipped the first domino in a string of dominoes that didn't stop falling until a state helicopter hit the ground and three people died.

What the board said, specifically, was that the actions of trooper managers were "causal." The Merriam-Webster dictionary defines causal this way: "making something happen."

Here, in case anyone is still unclear, is the full text of the probable cause statement on the crash:

"The probable cause of this accident was the pilot's decision to continue flight under visual flight rules into deteriorating weather conditions, which resulted in the pilot's spatial disorientation and loss of control. Also causal was the Alaska Department of Public Safety's punitive culture and inadequate safety management which prevented the organization from identifying and correcting latent deficiencies in risk management and pilot training. Contributing to the accident was the pilot's exceptionally high motivation to complete search and rescue missions, which increased his risk tolerance and adversely affected his decision making." (Emphasis added)

If you want, you can watch the hearing yourself at an online archive.

If you watch, you will see the NTSB staff recommended the board cite troopers' "punitive safety culture" as one of the causes of the crash, but the board amended that recommendation. Board members didn't want a safety culture thought of in any way as "punitive." The board made it clear it wanted a safety culture thought of as a good thing -- not in any possible way a bad thing.

As board chairman Christopher Hart pointed out, every aviation organization has a safety culture. The real question is whether it is a good one or a bad one.

The safety culture of troopers as it has existed in the past can be summed up by one fact -- 18 accidents in the last 12 years. That's an average of one and a half per year. Would you fly with an airline with that sort of safety record?

Privately, some in the Alaska aviation describe the trooper safety culture as "cowboy."

Ever since the crash, the press has danced around this issue. I confess to being among the dancers. The list of people who said the crash of Helo 1 was "inevitable," given the risks pilot Mel Nading had been encouraged to take, is long. No one, of course, wanted to say this on the record, and I lacked the guts to run with those opinions in a column at the time.

Since then, some things have happened, in addition to the NTSB's finding of probable cause, that require someone say something. One of those things is a letter from the NTSB general counsel to the state revealing troopers tried to tamper with the NTSB investigation into the Helo 1 crash.

The letter was included in a final packet of information released by the NTSB as the investigation was coming to a close.

"It is our understanding that following the accident the pilot's office, vehicle and locker were searched by unknown persons within AST," wrote general counsel David Tochen. "NTSB investigators have asked who participated in those searches, who directed the searches, when the searches took place, what the searchers were looking for, and whether anything was found that has not been provided to our investigators."

The letter has the troubling date of May 24, 2013 -- more than a month after the crash investigation began and long after troopers were supposed to start working with the NTSB.

The other document is a letter to the NTSB from trooper commander Col. James Cockrell that begins with an email that says this:

"It's unfortunate that in your agencies (sic) investigative process, you are obligated to release personal information about the involved pilots, as in our case. It certainly places the family in a difficult position trying to defend the actions of a now deceased victim, whether it was or was not related to the actual accident."

Attached to that note is a letter which ends with this: "During the NTSB investigation, many things were said about our involved pilot and unfortunately he cannot defend himself. It should be noted that he was a very dedicated DPS employee who was responsible for saving more lives than anyone in the history of the DPS."

Mel Nading was indeed a dedicated -- no, make that heroic – Department of Public Safety employee, someone who lived to save lives. He was exactly the sort of person who when involved in search and rescue needs to be protected against his own life-saving instincts because the consequences of an accident in the SAR business are so high, and because we all make mistakes.

We all make mistakes.

If mistakes in news reporting cost people their lives, there wouldn't be a journalist standing today -- most assuredly myself included. Sadly, unlike journalists who can walk away from mistakes unharmed, Mel Nading was in a business where mistakes can kill you. It is exactly why the people in charge needed to take steps to minimize the risks he took, and exactly why in the wake of a fatal accident the NTSB goes about its business in the cold, analytical, public way it does.

It's hard to say which is worse about Cockrell's comments -- his subtle effort to point a finger of blame at Nading instead of accepting the dangerous situation his agency created, his attempt to make this horrible accident into some sort of family issue that can't be discussed for fear of upsetting others, or his reiteration of a trooper belief that many things are best discussed only in a smoke-filled room somewhere.

That some sort of "defense" of Nading is necessary is quite simply a crock. NTSB investigations aren't about blaming anyone. They are about getting to the facts of what happened. They are about finding out what mistakes were made -- if any -- and determining what can be done to prevent them the next time. They are about making U.S. aviation safer, and they have done that. Air travel in America is now the safest form of travel in the world.

Mel Nading made a mistake and paid with his life. It is horribly sad. He was a good guy. So, too, was Toll.

But what of the bosses the NTSB said played a role in causing these deaths? When do they stand up and take responsibility? And, far more importantly, what will they do to make sure this doesn't happen again?

Until I read Cockrell's letter -- which was written almost a year after the Helo 1 crash -- it was possible to believe troopers were beginning to get the idea that 18 aircraft crashes in the last 12 years is unacceptable. Their visibly conservative management of helicopter operations since the replacement of Helo 1 was encouraging.

But now one can only wonder if anything really changed, or if it has only changed temporarily because the issue of trooper aircraft safety is in the public eye. One can only wonder what happens when things go back to the out-of-sight world in which troopers like to operate. One can only wonder if troopers get it.

After the NTSB report, the agency issued a statement calling the crash “a monumental loss,” and saying the department has always fostered aviation safety. The problem with the latter claim is that the record indicates otherwise. Just repeating over and over that you're safety conscious doesn't make you safety conscious.

It's that culture thing as the NTSB tried to point out. The old safety culture of troopers is written in a long list of crashes. The issue the agency faces now is whether it really wants to create a new and safer culture.

- Source:

NTSB Identification: ANC13GA036
14 CFR Public Use
Accident occurred Saturday, March 30, 2013 in Talkeetna, AK
Aircraft: EUROCOPTER AS350, registration: N911AA
Injuries: 3 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. : NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this public aircraft accident report.

On March 30, 2013, at 2320 Alaska daylight time, a Eurocopter AS 350 B3 single-engine helicopter, N911AA, impacted terrain while maneuvering near Talkeetna, Alaska. The airline transport certificated pilot and two passengers sustained fatal injuries. The helicopter was destroyed by impact and post-crash fire. The helicopter was registered to and operated by the State of Alaska, Department of Public Safety (DPS), as a public aircraft operations flight under 14 Code of Federal Regulations Part 91. Instrument meteorological conditions were reported in the area at the time of the accident, and department flight following procedures were in effect. The flight originated from the passenger rescue location at 2313 and was destined for an off airport location in Talkeetna.

According to Alaska State Troopers personnel and dispatch records, at 1935, a distressed individual requested assistance in an area near Talkeetna, and a search and rescue (SAR) mission with the helicopter was initiated. The pilot departed the DPS facility at Anchorage International Airport, Anchorage, Alaska, at 2117. The pilot flew to Talkeetna and at 2142, picked up an Alaska State Trooper near the Talkeetna Trooper Post facility to aid in the SAR mission. The distressed individual was located, and the helicopter landed at the remote location at 2201. At 2313, the helicopter departed the remote location and was destined for an off airport location in Talkeetna to meet emergency medical ground support.

On March 31, 2013, at 0044, attempts were made by trooper dispatch personnel to contact the pilot and trooper via radio and their cellular telephones, without success. Due to weather conditions in the Talkeetna area, search efforts were delayed. At 0923, the helicopter accident site was located by search and rescue personnel.

The accident site was located approximately 5.6 miles east of Talkeetna in wooded and snow covered terrain. The main wreckage consisted of the fuselage, tailboom, engine, and skid assembly. Several sections of fragmented fuselage were located near the main wreckage. A post-crash fire consumed a majority of the fuselage. An Appareo Vision 1000 cockpit imaging and flight data monitoring device, and a Garmin 296 global positioning system (GPS) were recovered from the accident site and sent to the NTSB Vehicle Recorders Laboratory in Washington, DC, for data extraction. A comprehensive wreckage examination is pending following recovery efforts.

The closest official weather observation station was at the Talkeetna Airport (PATK). At 2114, an aviation routine weather report (METAR) reported, in part: wind calm, visibility 7 miles with decreasing snow, broken clouds at 900 and 1,300 feet, sky overcast at 2,400 feet, temperature 34 degrees F, dew point 34 degrees F, and altimeter 30.22 inHg.

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