Andrews A.F.B. Airport
Aircraft Accident/Incident Report

District Heights, Maryland 20747
Saturday, September 27, 2008 23:58 EDT

NTSB Narrative Summary Released at Completion of Accident

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.

NTSB Probable Cause Narrative

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.

Event Information

Type of Event Accident
Event Date 9/27/2008
Event Day of the Week Saturday
Time of Event 2358
Event Time Zone Eastern Daylight Time
Event City District Heights
Event State MARYLAND
Event Country --
Zipcode of the event site 20747
Event Date Year 2008
Event Date Month 9
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 385215N
Event Location Longitude 0765236W
Event Location Airport Andrews A.F.B.
Event Location Nearest Airport ID ADW
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles 3.46
Degrees magnetic from airport --
Airport Elevation 280
Weather Briefing Completeness --
Investigator's weather source Pilot
Time of the weather observation 11 Eastern Daylight Time
Direction of event from weather observation facility (degrees) 190
Weather Observation Facility ID ADW
Elevation of weather observation facility 280
Distance of event from weather observation facility (units?) 346
Time Zone of the weather observation EDT
Lighting Conditions Night/Dark
Lowest Ceiling Height 500
Lowest Non-Ceiling Height 200
Sky/Lowest/Cloud Conditions Scattered
Sky Condition for Lowest Ceiling Broken
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 4
Air Temperature at event time (in degrees celsius) 20
Dew Point at event time (in degress fahrenheit) 20
Wind Direction (degrees magnetic) 90
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 3
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 29.91
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal 4
Injury Total Minor --
Injury Total None --
Injury Total Serious 1
Injury Total All 5
Investigating Agency NTSB
NTSB Docket Number (internal use) 26964
NTSB Notification Source Eastern Region ROC
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Jun 28 2010 3:44PM
User who most recently changed record lema
Basic weather conditions Instrument Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N92MD
NTSB Number MIA08MA203
Missing Aircraft Indicator --
Federal Aviation Reg. Part Public Use
Type of Flight Plan filed None
Flight plan Was Activated? No
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name AEROSPATIALE
Aircraft Model SA365N-1 D
Aircraft Series Identifier N1
Aircraft Serial Number 6311
Certified Max Gross Weight 9038
Aircraft Category Helicopter
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats 1
Cabin Crew Seats 2
Passenger Seats 3
Total number of seats on the aircraft 6
Number of Engines 2
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection 100 Hour
Date of Last Inspection Sep 24 2008 12:00AM
Airframe hours since last inspection 3.2
Airframe Hours 8869.1
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type Unknown
Aircraft Owner Name MARYLAND STATE POLICE
Aircraft Owner Street Address 3023 STRAWBERRY POINT ROAD
Aircraft Owner City BALTIMORE
Aircraft Owner State MD
Aircraft Owner Country USA
Aircraft Owner Zipcode 21220
Operator is an individual? No
Operator Name Maryland State Police
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address 3023 Strawberry Point Road
Operator City Baltimore
Operator State MD
Operator Country USA
Operator Zip code 21220
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) --
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code None
Departure City Waldorf
Departure State MD
Departure Country USA
Departure Time 2337
Departure Time Zone EDT
Destination Same as Local Flt --
Destination Airport Code ADW
Destination City Andrews AFB
Destination State MD
Destination Country USA
Specific Phase of Flight --
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Dec 9 2008 9:32AM
User who most recently changed record smic
Since inspection or accident Time of Accident
Event Location Runway Number and Location 19R
Runway Length 9003
Runway Width 200
Sight Seeing flight No
Air Medical Flight Yes
Medical Flight Medical Emergency