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CEN09PA348 · Agusta SPA A109E

9 Jun 2009 · Santa Fe, NM, United States

New Mexico State Police Agusta SPA A109E · Accident: VFR encounter with IMC while maneuvering

From Santa Fe Municipal Airport (SAF) to Santa Fe Municipal Airport (SAF)

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Narrative check · The NTSB narrative appears to contradict this record's damage. Values are shown as recorded, not corrected; compare with the narrative.

Event

NTSB case
CEN09PA348
Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
Accident
InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
Completed
API-reported fatalities
2 · all aircraft and ground
Ground fatalities
Unknown
OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
Government
WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
Instrument Meteorological Cond

Agusta SPA A109E

Aircraft type
Agusta A109
Category
Helicopter
RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
N606SP
Onboard fatalities
Unknown
Route
From Santa Fe Municipal Airport (SAF), Santa Fe, NMTo Santa Fe Municipal Airport (SAF), Santa Fe, NM
Aircraft age
Not recorded
Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
Public Aircraft
Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
Maneuvering · low-altitude flying
Defining eventThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
VFR encounter with IMC
DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
Destroyed Possible conflict

Cause areas

  • Personnel issues › Action/decision

Approximate · Coordinates as recorded by the NTSB; no uncertainty radius is established.

NTSB narrative

The Safety Board’s full report is available at http://www.ntsb.gov/publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-11/04.

On June 9, 2009, about 2135 mountain daylight time, an Agusta S.p.A. A-109E helicopter, N606SP, impacted terrain following visual flight rules flight into instrument meteorological conditions near Santa Fe, New Mexico. The commercial pilot and one passenger were fatally injured; a highway patrol officer who was acting as a spotter during the accident flight was seriously injured. The entire aircraft was substantially damaged. The helicopter was registered to the New Mexico Department of Public Safety and operated by the New Mexico State Police (NMSP) on a public search and rescue mission under the provisions of 14 Code of Federal Regulations Part 91 without a flight plan. The helicopter departed its home base at Santa Fe Municipal Airport, Santa Fe, New Mexico, about 1850 in visual meteorological conditions; instrument meteorological conditions prevailed when the helicopter departed the remote landing site about 2132.

Probable cause

The pilot's decision to take off from a remote, mountainous landing site in dark (moonless) night, windy, instrument meteorological conditions. Contributing to the accident were an organizational culture that prioritized mission execution over aviation safety and the pilot's fatigue, self-imposed pressure to conduct the flight, and situational stress. Also contributing to the accident were deficiencies in the NMSP aviation section's safety-related policies, including lack of a requirement for a risk assessment at any point during the mission; inadequate pilot staffing; lack of an effective fatigue management program for pilots; and inadequate procedures and equipment to ensure effective communication between airborne and ground personnel during search and rescue missions.

Verbatim NTSB analysis and probable cause from the NTSB dataset

Sources

NTSB record CEN09PA348
Event ID
20090610X23159
Case number
CEN09PA348
Dataset
full-current
Source SHA-256
5cf380f0061817c0331a6b2d8cc7e0ee3a79bea469a1001dc5c10e56f35f5ab3
Source notes (4)
  • Unreviewed is an editorial label, not an investigation status. API-sourced is not report-checked or human-reviewed. Explicit event totals are used without summing aircraft injury tables; onboard allocation is withheld. Unknown values remain unknown. The operation category is mapped from the NTSB-reported FAR part and has not been reviewed.
  • Filled from the NTSB case API where the bulk record had no value: local date, investigation status. Values present in the bulk record are kept.
  • The date is the local date; the NTSB stores the UTC date 2009-06-10.
  • API snapshot SHA-256: 5c4394c409eccedf2c944edb478fc048313b727985caef21265a3fbbf46b024b; retrieved 2026-09-13T20:11:18.831Z.