The National Transportation Safety Board (NTSB) on Oct. 27 ruled that the probable cause of the fatal crash of a Maryland State Police (MSP) helicopter emergency medical services flight ("Trooper 2") 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 non-precision approach.

On September 27, 2008, a Eurocopter SA365NI (N92MD) registered to and operated by the MSP as a public medical evacuation (medevac) flight, impacted terrain in District Heights, MD while on approach to Andrews AFB (ADW).

The pilot, one flight paramedic, a volunteer emergency medical technician (EMT), 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 Emergency Medical Services helicopter (HEMS) was called in to transport two teenagers with low-level injuries from a car accident site in Waldorf, MD to a local hospital in Prince Georges County with a shock trauma operation. However, Trooper 2 encountered instrument meteorological conditions (IMC) en route to the hospital, and the chopper could not land on the hospital's helipad and rerouted to its home base at ADW.

The Safety Board determined that the pilot failed to adhere to instrument approach procedures when he did not prevent the helicopter's descent. 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 Safety Board 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.

RECOMMENDATIONS

New Recommendations

To the Federal Aviation Administration:

Seek specific legislative authority to regulate Helicopter Emergency Medical Services (HEMS) operations conducted using government-owned aircraft to achieve safety oversight commensurate with that provided to civil HEMS operations.

To all public Helicopter Emergency Medical Services operators:

Develop and implement flight risk evaluation programs that include training for all employees involved in the operation and procedures that support the systematic evaluation of flight risks and the consultation with others trained in Helicopter Emergency Medical Services flight operations if the risks reach a predefined level.

Require emergency medical services operators to use formalized dispatch and flight-following procedures that include up-to-date weather information and assistance in flight risk assessment decisions.

Install terrain awareness warning systems on your aircraft and provide adequate training to ensure that flight crews are capable of using the systems to safely conduct Helicopter Emergency Medical Services operations.

To the Maryland State Police:

Implement a program to screen--and, if necessary treat--your pilots for obstructive sleep apnea.

Revise your policy regarding incident commanders to specify that, in any event involving a missing or overdue aircraft, an Aviation Command trooper will serve as the incident commander.

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.

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.

To the National Association of Air Medical Communications Specialists, the Association of Public-Safety Communications Officials International, the National Emergency Number Association, the International Association of Police Chiefs, the National Sheriffs' Association, and the International Association of Fire Chiefs:

Inform your members through your websites, newsletters, and conferences of the lessons learned from the emergency response to this accident, particularly emphasizing that search and rescue personnel need to understand how to interpret and use both global positioning system coordinates and the results of cell phone 'pinging'.

Previously Issued Recommendations Reiterated in this Report

To the Federal Aviation Administration:

Require all emergency medical services (EMS) operators to develop and implement flight risk evaluation programs that include training all employees involved in the operation, procedures that support the systematic evaluation of flight risks, and consultation with others trained in EMS flight operations if the risks reach a predefined level.

Require all rotorcraft operating under 14 Code of Federal Regulations Parts 91 and 135 with a transport-category certification to be equipped with a cockpit voice recorder (CVR) and a flight data recorder (FDR). For those transport-category rotorcraft manufactured before October 11, 1991, require a CVR and an FDR or an onboard cockpit image recorder with the capability of recording cockpit audio, crew communications, and aircraft parametric data.

Require all EMS operators to install TAWS on their aircraft and provide adequate training to ensure that flight crews are capable of using the systems to safety conduct EMS operations.

Maryland State Police Aviation Command officials, including Major A.J. McAndrew, attended the NTSB meeting.

The Maryland State Police Aviation Command has cooperated fully with the NTSB during their investigation of this crash. Prior to the meeting, the Board made several safety recommendations. The Aviation Command has already implemented many of the Board's recommendations and is in the process of implementing the remaining recommendations.

MSP is launching a flight risk evaluation program. The Aviation Command has developed and utilizes a computer based flight risk evaluation program that includes procedures that support the systematic evaluation of flight risks, and consultation with others trained in EMS flight operations if the risks reach a predefined level.

The state of Maryland has earmarked $52.5 million to begin replacing the Aviation Command's aging fleet of helicopters and allocated over $600,000 to purchase additional safety equipment for the current fleet. The Aviation Command is currently participating in a procurement process to purchase up to 12 new helicopters.

Requirement specifications for the new helicopters mandate that they must be equipped with terrain awareness and warning systems. In the interim, until the existing fleet is fully replaced, the Aviation Command has purchased new terrain awareness and warning systems to outfit each of its helicopters.

MSP is now conducting scenario-based training, including the use of simulators and flight training devices, for HEMS pilots, to include inadvertent flight into instrument meteorological conditions and hazards unique to HEMS operations, and conduct this training frequently enough to ensure proficiency. And MSP is implementing a safety management system program that includes sound risk management practices.

While the Aviation Command concurred with the Board's safety recommendations, the Maryland State Police disagreed with any statements impugning the training and proficiency of the pilot of Trooper 2. "The NTSB has stated he was certificated and qualified. There was no evidence shown that he was not proficient in performing non-precision approaches," MSP said in a written statement.

It said the pilot exceeded all of the FAA's training, qualification, and recency of experience requirements when he lifted off on September 27, 2008. The pilot met all of the FAA's pilot certification criteria for Part 135 operations.

"Maryland State Police records prove he was a highly experienced helicopter pilot who was approved by federal aviation authorities as an instrument flight instructor," the Aviation Command emphasized.

Officials said he exceeded every requirement for training and proficiency and had, within five months of the crash, targeted training in simulated instrument meteorological and night conditions. He was continuously employed by the Aviation Command as a helicopter pilot from 1981 through the date of the crash. He was a pilot with more than 5,000 hours of helicopter experience and more than 2,770 hours of that was in the model aircraft he was flying the night of the crash.

The pilot completed an Instrument Proficiency Check in May 2008 and conducted instrument landing system and tactical air navigation approaches to Andrews AFB and a global positioning system approach to St. Mary's County Airport. He completed and passed all testing and maneuvers in accordance with federal regulations.

"The Maryland State Police strongly believes that the pilot did receive adequate training for the type of circumstances he encountered, that he was very proficient in performing non-precision approaches, and that he had received recent and targeted instrument training in simulated IMC/night/poor weather conditions. The vast amount of skill, experience, training, and proficiency possessed by the pilot should not be discounted for the sake of this tragic accident" the state police stated.

And MSP defended its overall aviation safety record, saying "despite the tragic crash of Trooper 2, the Command possesses an excellent safety record. A recent study reported that the average Helicopter EMS accident rate between 1998 and 2008 was 3.8 accidents per 100,000 flight hours. Prior to the crash of Trooper 2, the Aviation Command had flown over 100,000 accident free flight hours and had not suffered a fatal crash in over 22-years. Although the Command considers one accident to be one too many, this equates to 2.8 accidents less than the average rate. The Aviation Command continually strives to improve the safety of its operations and build upon its outstanding record of service. "