NTSB -- PILOT'S FAILURE TO MAINTAIN ALTITUDE CAUSED MARYLAND STATE POLICE HELICOPTER CRASH IN MARYLAND, NTSB FINDS

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NTSB PRESS RELEASE

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National Transportation Safety Board

Washington, DC 20594

FOR IMMEDIATE RELEASE: October 27, 2009

SB-09-59

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PILOT'S FAILURE TO MAINTAIN ALTITUDE CAUSED MARYLAND STATE

POLICE HELICOPTER CRASH IN MARYLAND, NTSB FINDS

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Washington, DC - The National Transportation Safety Board

today determined that the probable cause of the crash of a

Maryland State Police (MSP) helicopter emergency medical

services flight 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.

On September 27, 2008, an Aerospatiale (Eurocopter), call

sign Trooper 2 (N92MD), registered to and operated by the

MSP as a public medical evacuation (medevac) flight,

impacted terrain in District Heights, Maryland while on

approach to Andrews Air Force Base (ADW). The 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 Board found that the pilot failed to adhere to

instrument approach procedures when he did not prevent the

helicopter's descent at the MDA. The flight was cleared for

an instrument landing system (ILS) approach. After the

initial call to the ADW tower, the pilot reported that he

could not capture the glideslope and was on a localizer

approach. The controller responded that her ILS equipment

status display was indicating no anomalies with the

equipment. Post accident tests confirmed no anomalies with

the instrument approach equipment and testing of the

helicopter's navigation equipment did not find any

deficiencies that would have precluded the pilot from

capturing the glideslope.

Furthermore, the Board concluded that although the descent

rate and altitude information were readily available through

cockpit instruments which the pilot had access to, he likely

became preoccupied with looking for the ground, which he

could not identify before impact because of the lack of

external visual cues. Since there were no recorders on

board the accident helicopter, the Safety Board could not

determine why the pilot did not use other options available

to conduct a safe landing in instrument conditions.

Several contributing factors to the cause of the accident,

the Board noted, were the pilot's limited recent instrument

flight experience, the lack of adherence to effective risk

management procedures by the Maryland State Police, the

pilot's inadequate assessment of the weather, which led to

his decision to accept the flight, 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 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.

As a result of this accident investigation, the Safety Board

issued recommendations to the Federal Aviation

Administration, the MSP, Prince George's County, and all

public Helicopter Emergency Medical Service operators

regarding pilot performance and training, air traffic

control deficiencies, patient transport decisions, emergency

response and FAA oversight.

A summary of the findings of the Board's report will be available

on the NTSB's website at: http://www.ntsb.gov/events/Boardmeeting.htm

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Media Contact: Keith Holloway (202) 314-6100

hollowk@xxxxxxxx

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