The Alaska DPS safety culture, which seemed to overemphasize the culpability of the pilot in his past accident and events, appears to have had this effect. The pilot had adopted a defensive posture with respect to the organization, and he was largely setting his own operational limitations and making safety-related operational decisions in a vacuum, masking potential risks, such as the risk posed by his operation of helicopter NVG flights at night in low IFR conditions. This had a deleterious effect on the organization’s efforts to manage the overall safety of its SAR operations. The investigation found that Alaska DPS had a punitive safety 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.