AEROSPATIALE SA365N-1 DMaryland State Police
District Heights, MD, USA · 2008-09-28·N92MD
What happened
NTSB summary, verbatimThe Safety Board's full report is available at http://www.ntsb.gov/Publictn/2009/AAR0907.pdf. The Aircraft Accident Report number is NTSB/AAR-09/07 On September 27, 2008, about 2358 eastern daylight time, an Aerospatiale (Eurocopter) SA365N1, N92MD, call sign Trooper 2, registered to and operated by the Maryland State Police (MSP) as a public medical evacuation flight, impacted terrain about 3.2 miles north of the runway 19R threshold at Andrews Air Force Base (ADW), Camp Springs, Maryland, during an instrument landing system approach. The commercial pilot, one flight paramedic, one field provider, and one of two automobile accident patients being transported were killed. The other patient being transported survived with serious injuries from the helicopter accident and was taken to a local hospital. The helicopter was substantially damaged when it collided with trees and terrain in Walker Mill Regional Park, District Heights, Maryland. The flight originated from a landing zone at Wade Elementary School, Waldorf, Maryland, about 2337, destined for Prince George's Hospital Center, Cheverly, Maryland. Night visual meteorological conditions prevailed for the departure; however, Trooper 2 encountered instrument meteorological conditions en route to the hospital and diverted to ADW. No flight plan was filed with the Federal Aviation Administration (FAA), and none was required. The MSP System Communications Center (SYSCOM) was tracking the flight using global positioning system data transmitted with an experimental Automatic Dependent Surveillance-Broadcast communications link.
Photographs
57the aircraft, and what the investigators foundPhotographs are NTSB docket attachments — works of the US government, in the public domain. Captions are the Board’s own.
Probable cause
the Board's determinationThe pilot's attempt to regain visual conditions by performing a rapid descent and his failure to arrest the descent at the minimum descent altitude during a nonprecision approach. Contributing to the accident were (1) the pilot’s limited recent instrument flight experience, (2) the lack of adherence to effective risk management procedures by the Maryland State Police, (3) the pilot’s inadequate assessment of the weather, which led to his decision to accept the flight,, (4) the failure of the Potomac Consolidated Terminal Radar Approach Control (PCT) controller to provide the current Andrews Air Force Base weather observation to the pilot, and (5) the increased workload on the pilot due to inadequate Federal Aviation Administration air traffic control handling by the Ronald Reagan National Airport Tower and PCT controllers.
Occurrence sequence
4 stepsNTSB coding · CICTT taxonomy- 1 · Prior to flightPreflight or dispatch event
- 2 · ManeuveringVFR encounter with IMC
- 3 · ApproachAltitude deviation
- 4 · Approach-IFR final approachControlled flight into terr/obj (CFIT)defining event
Findings
7 causal · 4 contributing- CAUSEEnvironmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip › Fog — Effect on operation
- CAUSEPersonnel issues › Experience/knowledge › Experience/qualifications › Recent instrument experience — Pilot
- CAUSEPersonnel issues › Action/decision › Action › Incorrect action selection — Pilot
- CAUSEEnvironmental issues › Operating environment › Communication system › Datalink — Availability of related info
- CAUSEAircraft › Aircraft oper/perf/capability › Performance/control parameters › Descent/approach/glide path — Not attained/maintained
- CAUSEPersonnel issues › Task performance › Workload management — Pilot
- CAUSEPersonnel issues › Task performance › Use of equip/info › Use of policy/procedure — ATC personnel
- FACTOROrganizational issues › Support/oversight/monitoring › Oversight › Oversight of operation — FAA/Regulator
- FACTOROrganizational issues › Support/oversight/monitoring › Safety programs — Operator
- FACTORAircraft › Aircraft systems › Navigation system › Ground proximity system — Not installed/available
- FACTOROrganizational issues › Management › Policy/procedure › Adequacy of policy/proc — Operator
Safety recommendations
9 issuedwhat changed because of this accidentTO THE FEDERAL AVIATION ADMINISTRATION: Seek specific legislative authority to regulate helicopter emergency medical services (HEMS) operations conducted using government-owned aircraft to achieve safety oversight commensurate with that provided to civil HEMS operations.
TO 40 PUBLIC OPERATORS OF EMS HELICOPTERS: Develop and implement flight risk evaluation programs that include training for all employees involved in the operation, procedures that support the systematic evaluation of flight risks, and consultation with others trained in helicopter emergency medical services flight operations if the risks reach a predefined level.
TO 40 PUBLIC OPERATORS OF EMS HELICOPTERS: Use formalized dispatch and flight-following procedures that include up-to-date weather information and assistance in flight risk assessment decisions.
TO THE FOLLOWING ORGANIZATIONS: Install terrain awareness and warning systems on your aircraft and provide adequate training to ensure that flight crews are capable of using the systems to safely conduct helicopter emergency medical services operations.
TO THE MARYLAND STATE POLICE: Implement a program to screen and if necessary treat your pilots for obstructive sleep apnea.
TO THE MARYLAND STATE POLICE: Revise your policy regarding incident commanders to specify that, in any event involving a missing or overdue aircraft, an Aviation Command trooper will serve as the incident commander.
TO THE MARYLAND STATE POLICE: Provide additional training to your dispatchers on the use of cell phone pinging and include instruction about how to integrate the data obtained from cell phone pinging into an overall search and rescue plan.
TO PRINCE GEORGE'S COUNTY, MARYLAND: Provide additional training to your dispatchers on the use of cell phone pinging and include instruction about how to integrate the data obtained from cell phone pinging into an overall search and rescue plan.
TO THE ASSOCIATION OF PUBLIC SAFETY COMMUNICATIONS OFFICIALS INTERNATIONAL, INTERNATIONAL ASSOCIATION OF CHIEFS OF POLICE, INTERNATIONAL ASSOCIATION OF FIRE CHIEFS, NATIONAL ASSOCIATION OF AIR MEDICAL COMMUNICATIONS SPECIALISTS, NATIONAL EMERGENCY NUMBER ASSOCIATION, AND THE NATIONAL SHERIFFS ASSOCIATION: Inform your members through your websites, newsletters, and conferences of the lessons learned from the emergency response to this accident, particularly emphasizing that search and rescue personnel need to understand how to interpret and use both global positioning system coordinates and the results of cell phone pinging.
NTSB analysis
from the final reportThe Safety Board's full report is available at http://www.ntsb.gov/Publictn/2009/AAR0907.pdf. The Aircraft Accident Report number is NTSB/AAR-09/07 On September 27, 2008, about 2358 eastern daylight time, an Aerospatiale (Eurocopter) SA365N1, N92MD, call sign Trooper 2, registered to and operated by the Maryland State Police (MSP) as a public medical evacuation flight, impacted terrain about 3.2 miles north of the runway 19R threshold at Andrews Air Force Base (ADW), Camp Springs, Maryland, during an instrument landing system approach. The commercial pilot, one flight paramedic, one field provider, and one of two automobile accident patients being transported were killed. The other patient being transported survived with serious injuries from the helicopter accident and was taken to a local hospital. The helicopter was substantially damaged when it collided with trees and terrain in Walker Mill Regional Park, District Heights, Maryland. The flight originated from a landing zone at Wade Elementary School, Waldorf, Maryland, about 2337, destined for Prince George's Hospital Center, Cheverly, Maryland. Night visual meteorological conditions prevailed for the departure; however, Trooper 2 encountered instrument meteorological conditions en route to the hospital and diverted to ADW. No flight plan was filed with the Federal Aviation Administration (FAA), and none was required. The MSP System Communications Center (SYSCOM) was tracking the flight using global positioning system data transmitted with an experimental Automatic Dependent Surveillance-Broadcast communications link.