A state police helicopter pilot's decision to take off in bad weather was the probable cause of a 2009 fatal crash in an attempted rescue of a hiker lost in the mountains near Santa Fe, the National Transportation Safety Board concluded Tuesday.

However, the board said the "organizational culture" of the Department of Public Safety and state police contributed to the accident because they placed a priority on completing missions rather than safety.

The board pointed to pilot fatigue, stress of the rescue and self-imposed pilot pressure to finish the mission as other contributing factors in the crash. The agency also said the state police had inadequate safety policies for its aviation operation, not enough pilots to ensure they were properly rested and no requirement for assessing the risks of helicopter missions. There also was poor communication between the helicopter and a ground-based search and rescue operation.

The board issued its findings Tuesday in Washington, D.C.

The helicopter crashed in June 2009 shortly after picking up the hiker and taking off in clouds as a snowstorm approached. The pilot, Sgt. Andy Tingwall, and the hiker died. One crew member survived.

"Performing search and rescue — saving lives — is noble and often heroic work, but a mission completion mindset can lead to poor decisions in an effort to 'get it done' at any cost," board chairwoman Deborah Hersman said in a statement. "Sadly, as in this case, the cost of getting it done can be too high."

The state police agency is part of the Department of Public Safety. State police and department leadership changed when Republican Gov. Susana Martinez took office in January.

The board recommended the governor ensure the department has enough staff to allow for "protected rest periods" for state police pilots. The NTSB said the Airborne Law Enforcement Association should revise its standards to define the rest periods needed by pilots.

The board said its investigation found the pilot "exhibited poor decision-making" when he chose to take off at night and attempt to fly in bad weather.

The pilot "was not prepared to react appropriately to the loss of visual references that he encountered shortly after takeoff" because he lacked training in dealing with conditions that might force him to suddenly rely on instruments for flying, the board said.

There was no evidence that state police or department managers pressured the pilot to conduct the rescue mission, the board said. But management "emphasized accepting all missions, without adequate regard for conditions," which was not consistent with a safety-focused organizational culture.



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