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Safety Recommendation Details

Safety Recommendation A-09-137
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 PRINCE GEORGE'S COUNTY, MARYLAND: Provide additional training to your dispatchers on the use of cell phone pinging and include instruction about how to integrate the data obtained from cell phone pinging into an overall search and rescue plan.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Reconsidered
Mode: Aviation
Location: District Heights, MD, United States
Is Reiterated: No
Is Hazmat: 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: 5/29/2013
Addressee(s) and Addressee Status: State of Maryland, County of Prince George's (Closed - Reconsidered)
Keyword(s): Training and Education, Search and Rescue, Dispatch, Helicopter Emergency Medical Services (Public Operators)

Safety Recommendation History
From: NTSB
To: State of Maryland, County of Prince George's
Date: 5/29/2013
Response: We are pleased to learn that, following this accident, all Prince George’s County dispatch and 911 personnel received the recommended training and instruction and that this training is included in each academy class for new dispatch and 911 personnel. Because these actions were taken before the NTSB issued Safety Recommendation A-09-137, it is classified CLOSED—RECONSIDERED.

From: State of Maryland, County of Prince George's
Date: 2/12/2013
Response: -From Rushern L. Baker, III, County Executive: I am in receipt of your letter dated January 11,2013, requesting follow-up information on a letter originally sent in November 2009. Please understand that the apparent lack of a response from my predecessor should not be construed as representative of Prince George's County's support of the National Transportation Safety Board (NTSB) and the valuable work you perform. To the contrary, within 24 hours of the tragic event the operational management of Public Safety Communications had already started an internal investigation to determine what could have been done to assist in locating the victims in a more timely and systematic manner. Although the correspondence regarding NTSB Safety Recommendation A-09-137 had not been received by personnel within Prince George's County's Public Safety Communications training efforts, technical enhancements, helicopter communication coordination and dispatch center design changes have been put into place. These changes are consistent with the NTSB recommendations. Training was provided to dispatch and 9-1-1 personnel in 2008 on the use of mapping software and the re-transmit ("pinging") feature available on phase II compliant cellular phones. At that time, additional training was also provided on mapping systems used by dispatch and 9-1-1 personnel. It was reinforced during these training classes that there was a critical need for personnel to request clarification on the format of mapping coordinates that is being provided. This training is now included in each Academy Class for new dispatch and 9-1-1 personnel. In May 2011, this administration opened a state-of-the-art 9-1-1 Public Safety Communications Center that incorporated the service level enhancements recommended through the internal reviews. As a result, the Public Safety Communications supervisors assigned to 9-1-1, Police/Sheriff dispatch, and Fire/EMS dispatch are co-located in a common supervisor area. This effort has improved communication and coordination within the agency's critical 9-1-1 and dispatch functions. It also ensures continuity in the information being provided to Police, Sheriff, Fire and Emergency Medical Services personnel. With the new facility, all mapping programs are now standardized to prevent the possibility of mistaken data entry. New mapping software has been installed on Police and Sheriff in-vehicle computers to ensure the same mapping information viewed by dispatch personnel is also available to the County's first responders. Maryland State Police Helicopters that respond to and operate within Prince George's County have been issued Prince George's County radio equipment to ensure communication coordination with Prince George's County Public Safety Communications dispatch personnel. Additionally, Prince George's County is working closely with the State of Maryland in the deployment of the State's new radio system to ensure seamless radio communication interoperability with State and local first responders. I am confident that the changes and additional training provided has had a positive impact and faced with a similar situation would result in a more favorable outcome.

From: NTSB
To: State of Maryland, County of Prince George's
Date: 1/11/2013
Response: This letter addresses Safety Recommendation A-09-137, which the NTSB issued to the Prince George’s County government as a result of our investigation of the September 27, 2008, crash during approach to land of a Maryland State Police helicopter in District Heights, Maryland. To date, the NTSB has received no information regarding any actions that Prince George’s County has taken to address Safety Recommendation A-09-137, and we would appreciate receiving a reply regarding any actions that the county has taken or planned to address this important safety issue. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. A copy of our November 13, 2009, letter issuing Safety Recommendation A-09-137 is enclosed for your convenience, and the full NTSB report of the District Heights, Maryland, accident investigation (Report Number AAR-09/07) is available on our website at