Pilot Debrief

AEROSPATIALE SA365N-1 D near District Heights, MD — 2008-09-28

Final reportMIA08MA203
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Date
2008-09-28
Location
District Heights, MD, USA
Airport
ADW
Aircraft
AEROSPATIALE SA365N-1 D
Registration
N92MD
Category
Helicopter
Highest injury
Fatal
Fatalities
4
Phase of flight
Approach

Probable cause

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 Maryland State Police, (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 Andrews Air Force Base weather observation to the pilot, and (5) 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.

NTSB narrative

The Safety Board's full report is available at http://www.ntsb.gov/Publictn/2009/AAR0907.pdf. The Aircraft Accident Report number is NTSB/AAR-09/07 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.

Analysis

Primary failure mode
VFR into IMC
First missed decision gate
Pilot could have aborted the approach upon encountering IMC conditions.

NTSB coding

Evidence available

  • ATC audio
  • ADS-B / radar
  • Photos
  • 126 docket documents
View NTSB final reportView NTSB docket

Docket documentsshowing 50 of 126

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