- Date
- September 27, 2008, 23:58 local (Sep 28, 2008, 03:58 UTC)
- Place
- District Heights, MD
- Injuries
- 4 fatal, 1 serious
- Damage
- Substantial damage
- Phase of flight
- Approach
- Aircraft
- N92MDAerospatiale SA365N-1 D
- Defining event
- Approach-IFR final approach: Controlled flight into terr/obj (CFIT)
- Weather
- Instrument (IMC) · Night/dark
- Status
- Completed · report October 27, 2009
- Report
- Board-adopted at Board Meeting
- Investigation class
- Class 1
- Parties
- FAA/AAI -100, American Eurocopter, Turbomeca USA, Maryland State Police, Terbomeca USA
- Safety recommendations
- Yes
- FAA report
- 20080927848139A
- Case key
- 69013
From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.
On this page
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.
Findings · 11
NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.
Sequence of events
The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.
Analysis
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.
Factual 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.
Aircraft
- Registration
- N92MD
- Reported as
- Aerospatiale SA365N-1 D (N1)
- Category
- Helicopter
- Serial number
- 6311
- Airframe hours
- 8,869.1
- Engines
- Arriel 1C1, 586 horsepower, turbo shaftArriel 1C1, 586 horsepower, turbo shaft
- Damage
- Substantial damage
- Flight
- Public aircraft - state · Public use
- Operator
- Maryland State Police
- Registered owner
- Maryland State Police
- Airworthiness certificate
- Standard, Utility
- Last inspection
- 100 hour · September 24, 2008 · 3.2 hours before
- Departed
- None · Waldorf, MD
- Destination
- ADW · Andrews AFB, MD
- Airport
- ADW · Andrews A.F.B., runway 19R, 9,003 × 200 ft, concrete
Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.
Flight crew
As NTSB recorded them. NTSB leaves out names.
- Role
- Pilot
- Age
- 59
- Injuries
- Fatal
- Certificates
- Flight instructor, Commercial, Private
- Airplane ratings
- Single-engine land
- Instrument ratings
- Helicopter
- Medical
- Class 2, With waivers/limitations
- Last flight review
- October 27, 2007
- Seat
- Right
- Toxicology
- Performed
- Flight hours
- 5,225 total · 2,770 in this make and model · 5,201 as pilot in command · 48 in the last 90 days · 16 in the last 30 days
Weather
- Conditions
- Instrument (IMC) · Night/dark
- Wind
- 90° at 3 knots
- Visibility
- 4 statute miles
- Lowest ceiling
- 500 ft broken
- Temperature
- 68 °F, dew point 68 °F
- Altimeter
- 29.90 inHg
- Observed at
- ADW, 346 nm away
Docket · 126
The files NTSB released with the investigation on January 14, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports.
FAA reports on this event · 1
The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.