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Accident Report Detail

 
Crash During Approach to Landing of Maryland State Police Aerospatiale SA365N1, N92MD

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.


Probable Cause

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.


Accident Location: District Heights , MD    
Accident Date: 9/27/2008
Accident ID: MIA08MA203

Date Adopted: 10/27/2009
NTSB Number: AAR-09-07
NTIS Number: PB2009-910407