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ASN Wikibase Occurrence # 34330
Last updated: 7 August 2020
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Date:27-SEP-2008
Time:23:58
Type:Silhouette image of generic AS65 model; specific model in this crash may look slightly different
Aérospatiale SA 365N1 Dauphin 2
Owner/operator:Maryland State Police
Registration: N92MD
C/n / msn: 6311
Fatalities:Fatalities: 4 / Occupants: 5
Aircraft damage: Substantial
Category:Accident
Location:Walker Mill Regional Park, District Heights, MD -   United States of America
Phase: Approach
Nature:Unknown
Departure airport:Waldorf, MD (None)
Destination airport:Andrews AFB, MD (ADW)
Investigating agency: 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.
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.

Sources:

NTSB: https://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20081001X14522&key=1

Safety recommendations:

Safety recommendation A-09-130 issued 13 November 2009 by NTSB to FAA
Safety recommendation A-09-131 issued 13 November 2009 by NTSB to FOLLOWING ORGANIZATIONS
Safety recommendation A-09-132 issued 13 November 2009 by NTSB to FOLLOWING ORGANIZATIONS
Safety recommendation A-09-133 issued 13 November 2009 by NTSB to FOLLOWING ORGANIZATIONS
Safety recommendation A-09-134 issued 13 November 2009 by NTSB to MARYLAND STATE POLICE
Safety recommendation A-09-135 issued 13 November 2009 by NTSB to MARYLAND STATE POLICE
Safety recommendation A-09-136 issued 13 November 2009 by NTSB to MARYLAND STATE POLICE
Safety recommendation A-09-137 issued 13 November 2009 by NTSB to PRINCE GEORGE'S COUNTY, MARYLAND
Safety recommendation A-09-138 issued 13 November 2009 by NTSB to FOLLOWING ORGANIZATIONS


Images:


(c) NTSB / Maryland State Police

Revision history:

Date/timeContributorUpdates
28-Sep-2008 23:24 RobertMB Added
30-Sep-2008 11:25 harro Updated
15-Jan-2009 11:11 harro Updated
30-Apr-2010 22:41 slowkid Updated [Time, Other fatalities, Location, Departure airport, Source, Narrative]
18-Dec-2012 12:01 TB Updated [Time, Aircraft type, Operator, Source]
08-Sep-2014 13:30 Aerossurance Updated [Phase, Source, Narrative]
03-Dec-2017 12:04 ASN Update Bot Updated [Time, Operator, Other fatalities, Nature, Departure airport, Destination airport, Source, Damage, Narrative]

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