District Heights, Maryland
September 27, 2008
NTSB Number: AAR-09-07
NTIS Number: PB2009-910407
Adopted October 27, 2009
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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.
The National Transportation Safety Board determined that the probable cause of this accident was the 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 MSP, (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 ADW weather observation to the pilot, and (5) the increased workload on the pilot due to inadequate FAA air traffic control handling by the Ronald Reagan National Airport Tower and PCT controllers.
The safety issues discussed in this report involve risk assessments, pilot performance and training, terrain awareness and warning systems, air traffic control deficiencies, SYSCOM duty officer performance, and emergency response. Also discussed are patient transport decisions, flight recorder requirements, and FAA oversight. Safety recommendations concerning these issues are addressed to the FAA, the MSP, Prince George's County, all public helicopter emergency medical services operators, and six other organizations whose members are involved in search and rescue activities.
As a result of this investigation, the National Transportation Safety Board makes the following safety recommendations:
To 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. (A-09-130)
To All Public Helicopter Emergency Medical Services Operators:
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. (A-09-131)
Use formalized dispatch and flight-following procedures that include up-to-date weather information and assistance in flight risk assessment decisions. (A-09-132)
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. (A-09-133)
To the Maryland State Police:
Implement a program to screen and-if necessary-treat your pilots for obstructive sleep apnea. (A-09-134)
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. (A-09-135)
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. (A-09-136)
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. (A-09-137)
To the National Association of Air Medical Communications Specialists, the Association of Public-Safety Communications Officials International, the National Emergency Number Association, the International Association of Police Chiefs, the National Sheriffs' Association, and the International Association of Fire Chiefs:
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." (A-09-138)
The National Transportation Safety Board reiterates the following safety recommendations to the Federal Aviation Administration:
Require all emergency medical services (EMS) operators to develop and implement flight risk evaluation programs that include training all employees involved in the operation, procedures that support the systematic evaluation of flight risks, and consultation with others trained in EMS flight operations if the risks reach a predefined level. (A-06-13)
Require all rotorcraft operating under 14 Code of Federal Regulations Parts 91 and 135 with a transport-category certification to be equipped with a cockpit voice recorder (CVR) and a flight data recorder (FDR). For those transport-category rotorcraft manufactured before October 11, 1991, require a CVR and an FDR or an onboard cockpit image recorder with the capability of recording cockpit audio, crew communications, and aircraft parametric data. (A-06-17)
Require all emergency medical services (EMS) operators to install terrain awareness and warning systems on their aircraft and to provide adequate training to ensure that flight crews are capable of using the systems to safety conduct EMS operations. (A-06-15)
