"Pilot Failed To Arrest Descent"
The NTSB said Tuesday 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 NTSB issued
recommendations to the FAA, 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.