A National Transportation Safety Board report on a helicopter crash near Santa Fe that killed a state police pilot and a passenger raises disquieting questions about the pilot's qualifications to fly the mission and decisions made during the fatal attempt to rescue a hiker.
While a final determination of the probable cause of the June 2009 accident is still pending, a "Factual Report" filed Nov. 24 by investigators paints a picture of a well-meaning, even heroic pilot, who, in a culture that encouraged risk-taking, made some dubious — and in the end — deadly judgment calls.
New Mexico State Police Chief Faron Segotta on Thursday disputed that picture, characterizing the report as the "opinion of people interviewed," including a "disgruntled former employee" and defended the pilot, Andy Tingwall, whom he recommended for the aviation division in 2002.
"He was meticulous, well-traveled, well-qualified. That was his character. He wanted to excel," Segotta said. "I believe he had the skills to fly that helicopter."
In addition to Tingwall, Megumi Yamamoto, a 26-year-old Japanese national who had gotten separated from her companion in the mountains near the Lake Katherine and Hidden Lake area north of Santa Fe Baldy, died in the rescue. State police Officer Wesley Cox, who was serving as "spotter" on the mission, was seriously injured after the helicopter lifted off in bad weather, hit a ridge at about 12,000 feet elevation and tumbled down a mountainside.
The communications breakdown that contributed to the crash was cited earlier this year in a report by the New Mexico Search and Rescue Review Board and led to some improvements in dispatch procedures, additional training time and the adoption of a mission risk management worksheet, among other things.
But the federal accident report identifies additional issues that might have affected the outcome.
According to the NTSB review, chief pilot Tingwall had been prescribed Prozac (or fluoxetine) in 2002 to treat dysthymia (chronic depression) and samples of his blood taken after the crash tested positive for the drug.
But Tingwall, honored for his valiant effort to save a stranded hiker from a cold night in the mountains, did not reveal that he was taking any medication in his Nov. 13, 2008, aviation medical exam seven months before the accident.
If a pilot requires medication, it must be approved and the pilot certified fit for flight by a Federal Aviation Administration-designated medical examiner or flight surgeon. Under Department of Public Safety regulations, no pilot deemed impaired is allowed to fly a department aircraft.
The report states that the chief pilot's personal physician had noted that Tingwall experienced no adverse reactions to fluoxetine and his mood and functioning had improved under the drug. And there is no specific evidence in the NTSB review that it affected his judgment that evening.
The 70-page NTSB report describes Tingwall as a "motivated, hard working, disciplined officer" and a "very heroic type person" who was "willing to put himself at risk to save others." Colleagues said he had turned down past missions, either because of poor weather or fatigue, but according to the report, they held "varying opinions about his assertiveness when it came to safety."
A pilot of fixed-wing aircraft said Tingwall tended to "act right away before thinking things out."
In this case, the record shows that he initially declined the mission because he had already worked an eight-hour shift and because of deteriorating weather in the mountains. He relented after determining that the full-time helicopter pilot was not available.
The part-time helicopter pilot with the aviation division said he believed Tingwall accepted the mission "out of concern that the hiker would die if he did not help her."
The report points out that Tingwall took off without night-vision goggles, possibly because it was still light and he didn't expect the operation to last long. He also asked Cox to remove his uniform shirt and bulletproof vest because they were "too bulky" for the flight, leaving the two men ultimately unprepared for the deteriorating weather.
When the chief pilot landed the helicopter and went in search of the hiker, he gave the spotter a cigarette lighter and told him to build a fire if it got really cold.
While Tingwall was searching for Yamamoto in the sleet, the incident commander told the state police radio dispatcher (Tingwall's wife) that ground teams were at the Winsor trailhead and could reach the hiker in a couple of hours. Search-and-rescue volunteers, who declined to speak publicly for this story, note that Yamamoto had already told her rescuers that while she was cold and hungry, she was not in danger of dying. They believe the more prudent response would have been for ground teams to rescue her.
The area commander, meanwhile, notified the spotter that if the weather deteriorated, they should "hang tight" in the helicopter and use its engines for heat until help arrived, the report says. An acting lieutenant involved with the rescue attempt, in a conversation with the dispatcher, said, "Well, they're gonna have to just shore it up for tonight and fly out tomorrow."
But after Tingwall returned to the helicopter, out of breath from carrying the hiker up a hill, he took off, heading toward the Santa Fe Municipal Airport.
Segotta said he expects the NTSB report to cite pilot error as a contributing factor in the crash.
While Tingwall was considered a "very skilled manipulator of the controls," he was a relatively inexperienced pilot, according to the report.
He was authorized to operate the aircraft involved in the crash, but not at night, not in bad weather and not above 9,000 feet or in mountainous terrain without a more experienced pilot aboard, the report says.
The state police chief and the secretary of public safety both said they believed that the 9,000-foot restriction had been removed after Tingwall completed recent training, but there were no documents in the chief pilot's training folder confirming that, the federal investigators found.
Tingwall didn't have a helicopter instrument rating, although that was not required for pilots in the aviation section of the New Mexico State Police, in part because of cost restraints. The former chief pilot is quoted as saying, "We were primarily search and rescue, and if you can't see the ground you can't see the person or the marijuana farm."
Several current and former police pilots, asked what they would have done in a situation like the one on June 9, 2009, said that if they ran into IMC (inclement meteorological conditions) they would do a 180-degree turn and leave.
The spotter, a friend of Tingwall, was not a pilot and had received no training for aircraft missions.
The report also includes testimony regarding the culture of risk-taking in the department. A letter from former chief pilot Michael Dowd, who retired in 2006, describes the pressure to accept and complete missions. He said decisions not to send pilots out on operations considered too dangerous brought him "continuous conflict" with state police managers and, according to the report, "when he turned down missions, he would receive complaints from the secretary (John Denko), sometimes relayed through the chain of command."
Segotta denied on Thursday that there was any pressure from his office to fly if conditions were not safe. When the state police decided against a mission, there was an inquiry, he admitted, but, "I would never say, 'you should have.' I'm not a pilot. I don't have the skill or knowledge to apply pressure to anyone to fly."
Because he is often in the air with state police pilots, Segotta pointed out, "I don't want them doing anything unsafe." He added, "I don't know where they're getting that from."
The federal report also reviewed the process by which the mission was initiated.
In this case, the dispatcher — again, Tingwall's wife — said a state police sergeant who was the acting lieutenant for District 1 at the time directed her to call the chief pilot and have him initiate an aerial search for the lost hiker.
The state police managers who normally approved aircraft missions were out of town, so the job fell to the major who was the officer on call. This was the first time he had approved an aircraft mission, and he later called the chief of police for clarification of procedures and was told that managers allowed the pilots to decide whether to accept missions — and managers were not supposed to question them.
He then e-mailed the chief, two deputy chiefs and the chief pilot's supervisor to notify them that the helicopter was on a search-and-rescue mission.
Segotta, who is preparing to retire from the force after nearly 29 years, said Thursday that search-and-rescue volunteers are under the impression that the field commanders control whether the pilot flies. "No, they don't," he said. "That responsibility is on the pilot. The field commander can say, 'We need a helicopter.' But it's under the control of the Department of Public Safety."
Contact Anne Constable at 986-3022 or firstname.lastname@example.org.
ON THE WEB
• The National Transportation Safety Board has posted 1,241 pages of documents related to its investigation of the helicopter crash at www.ntsb.gov/dockets/aviation/CEN09PA348/