Maryland State Police responds to NTSB
The US National Transportation Safety Board (NTSB) has determined that the probable cause of the crash of Trooper 2, a Maryland State Police (MSP) emergency medical services helicopter, 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 (MDA) during a nonprecision approach.
The NTSB states that on 27 September 2008, Trooper 2 impacted terrain in District Heights, Maryland, while on approach to Andrews Air Force Base. 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 localiser approach. The controller responded that her ILS equipment status display was indicating no anomalies with the equipment. The NTSB said that 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 onboard the helicopter, the 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 (FAA) 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.
MSP Aviation Command (MSPAC) officials, including Major A. J. McAndrew, attended the recent NTSB meeting in which issues that may have contributed to the crash of the helicopter were discussed. The MSP released a statement after the meeting, saying it has co-operated fully with the NTSB during the investigation of the crash and understands that the hearing dealt with probable issues contributing to the crash and that a final probable cause report has not been issued. The statement continues: “Prior to today’s meeting, the Board made several safety recommendations. The Aviation Command values and concurs with the Board’s past safety recommendations. In fact and although not mandated to, the Aviation Command has already implemented many of the Board’s recommendations and is in the process of implementing the remaining recommendations.” The MSP statement then details the recommendations made by the NTSB, detailing in each case the changes that have been implemented in order to improve safety.
