Aircraft Accident Report
Crash During Approach to Landing of
Maryland State Police
Aerospatiale SA365N1, N92MD
District Heights, Maryland
September 27, 2008

NTSB Number: AAR-09/07
NTIS Number: PB2009-910407

PDF Document (1.50 MB)

Executive Summary: 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.

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