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

[b_thom at juno.com]

National Transportation Safety Board 
Washington, DC 20594 
FOR IMMEDIATE RELEASE: October 27, 2009 
SB-09-59 
PILOT'S FAILURE TO MAINTAIN ALTITUDE CAUSED MARYLAND STATE POLICE
HELICOPTER CRASH IN MARYLAND, NTSB FINDS 
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
-30- 
Media Contact: Keith Holloway (202) 314-6100 
hollowk at ntsb.gov 
This message is delivered to you as a free service from the National
Transportation Safety Board. You may
unsubscribe at any time at
http://www.ntsb.gov/registration/registration.htm 
An archive of press releases is available at
http://www.ntsb.gov/pressrel/pressrel.htm 
Current job opportunities with the NTSB are listed at
http://www.ntsb.gov/vacancies/listing.htm 
For questions/problems, contact pubinq at ntsb.gov 
____________________________________________________________
Sell Gold for Cash Here
GMA, Today Show and CNBC all say...Sell Gold Now! A Rated BBB member.
http://thirdpartyoffers.juno.com/TGL2141/c?cp=nL6BQRHavCLMqiIOLNWaOQAAJ1DTzo1j0zK4CKewKFoZc-9IAAQAAAAFAAAAAFTjJT4AAANSAAAAAAAAAAAAAAAAAAmSJwAAAAA=