Flying in Alaska is different. In many locations, an airplane is the only method of contact with civilization. Further, extraordinary challenges are imposed due to the weather and the topography, particularly as to rescue missions. Consequently, what would be an unacceptable risk in the lower states is often a standard operation in the 50th state. The NTSB found that the Alaska Department of Public Safety exceeded acceptable norms and created a “punitive culture”, an anathema to safety culture.
The accident was a rescue mission in which a snowboarder was stranded near Talkeetna, Alaska. The helicopter DPS pilot, driven by the DPS rescue mission’s exigency, flew into deteriorating weather conditions. The result was a crash killing the snowboarder, a state trooper and the pilot. The same right hand seat PIC had been involved In a previous accident, but the DPS investigation did not focus on the similar bad flying conditions there.
Acting NTSB Chairman Hart said that “[t]hese brave few take great risks to save those in harm’s way. There needs to be a safety net for them as well.” In support of that conclusion, the report found that
- DPS” lacked policies and procedures to ensure that risk was managed, such as formal weather minimums,
- formal training in night vision goggle operations and
- having a second person familiar with helicopter rescue operations involved in the go/no-go decision, and
- DPS had a “punitive culture that impeded the free flow of safety-related information and impaired the organization’s ability to address underlying safety deficiencies relevant to this accident.”
Consistent with recent NTSB probable cause findings, the Board extrapolated from the specific facts and recommended that other states to develop and implement a flight risk evaluation program.
Safety culture is a fragile stasis to achieve and retain. Its continuing vigilance is best supported by Safety Management Systems in that this discipline establishes and reinforces all of the managerial and operation supports needed to strive towards higher achievement and detecting problems before they emerge.
The Alaska DPS has a major challenge. Its mission is to save those in harm’s way, but the conditions compelling rescue mission frequently correlate with bad weather and/or terrain. SMS would provide the sort of matrix which would quantify risks, rewards and remediation of the identified problems.
PRESS RELEASE: Alaska DPS Helicopter Crash Caused by Flight Into Bad Weather and Department’s “Punitive Culture