The fixed-wing pilot said that the chief pilot tended to “act right away before thinking things out.”
A retired NMSP chief pilot said he believed the chief pilot did not understand the limitations associated with his inexperience, and that he would only have been able to understand his limitations after flying several thousand more hours. He said he would never fly the helicopter at night without night-vision goggles and it made him “very upset” that the chief pilot did not bring goggles on the accident mission.
The part-time helicopter pilot said he thought the chief pilot lacked “temperance” due to his youth and inexperience. The Major in charge of the special operations said the chief pilot was a “very aggressive, high-speed type of individual” that he had to “double check,” because he was “high-spirited” and “enthusiastic.” He said that the chief pilot would “go 100 mi. an hour all the time” if he were allowed.
The public safety secretary said he believed that the chief pilot, “wanted to get [the hiker] out, he thought he could do it safely and that's just not the way it happened.” He said that if the chief pilot had known he was going to enter IMC, he would have “bundled up the best [he] could for the night.”
The dispatcher was asked if she suspected the chief pilot had initially turned down the mission for a reason other than high winds — fatigue, for example. She said no; he would have told her if he was too tired to fly the mission. Why did he accept the mission? Probably because he was concerned about the hiker's safety and because a police supervisor had asked him to fly the mission, she said, adding that she did not know whether the chief pilot realized the weather was going to deteriorate, nor did she know if he felt pressured to accept the mission.
The chief pilot's colleagues said he was the kind of person who was willing to put himself at risk to save others.
The NTSB determined the probable cause of this accident was the pilot's decision to take off from a remote, mountainous landing site on a dark (moonless) night, in windy, instrument meteorological conditions. Contributing to the accident was an organizational culture that prioritized mission execution over aviation safety, along with the pilot's fatigue and self-induced 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.
Since the accident, the aviation section has been reorganized and added experienced safety-oriented personnel who have instituted extensive safety management, training and operational procedures.