Pilot's Failure To Hold MDA On Approach Caused Crash
By Daniel Guevarra
October 29, 2009 -
An Aerospatiale (Eurocopter), call sign Trooper 2 (N92MD), registered to
and operated by the MSP as a public medical evacuation (medevac) flight,
crashed on September 27, 2008, 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.
Transportation Safety Board has determined 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.
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
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.
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 Federal Aviation Administration, the MSP,
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