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Safety Recommendation Details

Safety Recommendation A-09-135
Details
Synopsis: On September 27, 2008, about 2358 eastern daylight time, an Aerospatiale (Eurocopter) SA365N1, N92MD, call sign Trooper 2, registered to and operated by the MSP as a public medical evacuation (medevac) 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 (ILS) 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 (PGH), 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 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 (ADS-B) communications link.
Recommendation: 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.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
Mode: Aviation
Location: District Heights, MD, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: MIA08MA203
Accident Reports: Crash During Approach to Landing of Maryland State Police Aerospatiale SA365N1, N92MD
Report #: AAR-09-07
Accident Date: 9/27/2008
Issue Date: 11/13/2009
Date Closed: 12/16/2011
Addressee(s) and Addressee Status: State of Maryland, State Police, Aviation Command (Closed - Acceptable Alternate Action)
Keyword(s): Helicopter Emergency Medical Services (Public Operators), Search and Rescue

Safety Recommendation History
From: NTSB
To: State of Maryland, State Police, Aviation Command
Date: 12/16/2011
Response: We note that search and/or rescue operations are part of the MSP’s statutory responsibility to the State of Maryland and, therefore, must be conducted only by sworn members of the MSP. We also note that 94 percent of the MSP’s pilots are civilian employees—not sworn members of the MSP—who therefore cannot serve as incident commanders. However, the MSP indicated that it has revised its policies to specify that, in any event involving a missing or overdue aircraft, an MSP Aviation Command pilot is assigned to the MSP incident commander, who is responsible for conducting the search and/or rescue operation. We believe that this revision constitutes an acceptable alternate means of satisfying Safety Recommendation A-09-135. Accordingly, the recommendation is classified CLOSED—ACCEPTABLE ALTERNATE ACTION.

From: State of Maryland, State Police, Aviation Command
To: NTSB
Date: 9/6/2011
Response: CC# 201100335: - From Major Mark E. Gibbons, Commander, Aviation Command, Maryland State Police: In response to this recommendation, the Maryland State Police (MSP) revised Chapter 32, Section 7 (Search and Rescue) of its Patrol Manual with regard to conducting a “Search and Rescue” (SAR) operations for missing and/or overdue aircraft. Effective March 11, 2010, all MSP Barrack “Duty Officers” (DOs) have been directed by this revised policy to contact the “Systems Communications Center” (SYSCOM) Duty Officer on duty at the Maryland Institute of Emergency Medical Services (MIEMSS) and request the assignment of a MSPAC pilot to assist the Incident Commander (IC) charged with conducting a search and rescue (SAR) operation involving a missing and/or overdue aircraft, within their area of responsibility. Upon receiving the request, the MSPAC Duty Officer (DO) will notify the MSPAC’s “Director of Flight Operation,” or his designee, who will dispatch a MSPAC pilot to assist the MSP IC on location, in conducting the search and rescue operation, as requested by the MSP Barrack DO. MSPAC Comment: Currently, over 94% of the pilots employed by the MSPAC are civilian employees, and not sworn members of the MSP. The MSP cannot relinquish its statutory responsibility to the State of Maryland for conducting a SAR operation to locate a missing and/or overdue aircraft to a civilian employee (pilot) of the MSPAC. However, by assigning a MSPAC pilot to assist the MSP IC responsible for conducting a SAR operation involving a missing aircraft and/or overdue aircraft, the MSP meets its statutory responsibility, as well as NTSB recommendation A-09-135, by assuring that the MSP IC in charge of the SAR operation to locate a missing and/or overdue aircraft, has direct access to an aviation professional on location. Attached to this document is the revised Chapter 32, Section 7 from the MSP Patrol Manual for your review.