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NTSB/AAR-09/07 National PB2009-910407

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NTSB/AAR-09/07 National PB2009-910407 Crash During Approach to Landing of Maryland State Police Aerospatiale SA365N1, N92MD District Heights, Maryland September 27, 2008 Accident Report NTSB/AAR-09/07 National PB2009-910407 Transportation Safety Board This page intentionally left blank. ERRATA THE CORRECTION BELOW IS INCLUDED IN THIS REVISED VERSION OF THE DOCUMENT AIRCRAFT ACCIDENT REPORT NTSB/AAR-09/07 (PB2009-910407) CRASH DURING APPROACH TO LANDING OF MARYLAND STATE POLICE AEROSPATIALE SA365N1, N92MD, DISTRICT HEIGHTS, MARYLAND, SEPTEMBER 27, 2008 Pages 21 and 62 have been changed to indicate that the coordinates were in the form of degrees, decimal degrees. The report originally stated that the coordinates were in the form of degrees, decimal minutes. NTSB/AAR-09/07 PB2009-910407 Notation 8067A Adopted October 27, 2009 Aircraft Accident Report Crash During Approach to Landing of Maryland State Police Aerospatiale SA365N1, N92MD District Heights, Maryland September 27, 2008 National Transportation Safety Board 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 National Transportation Safety Board. 2009. Crash During Approach to Landing of Maryland State Police Aerospatiale SA365N1, N92MD, District Heights, Maryland, September 27, 2008. Aircraft Accident Report NTSB/AAR-09/07. Washington, DC. Abstract: This report describes the circumstances of an accident involving an Aerospatiale SA365N1 that crashed on approach to landing during an emergency medical services flight operated by the Maryland State Police (MSP). The safety issues discussed include risk assessments, pilot performance and training, terrain awareness and warning systems, air traffic control deficiencies, MSP System Communications Center duty officer performance, and emergency response. Also discussed are patient transport decisions, flight recorder requirements, and Federal Aviation Administration (FAA) oversight. Safety recommendations concerning these issues are addressed to the FAA; the MSP; Prince George’s County, Maryland; all public helicopter emergency medical services operators, and six associations whose members are involved in search and rescue operations. The National Transportation Safety Board (NTSB) is an independent federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The NTSB makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Internet at <http://www.ntsb.gov>. Other information about available publications also may be obtained from the website or by contacting: National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, SW Washington, DC 20594 (800) 877-6799 or (202) 314-6551 NTSB publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2009-910407 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000 The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of NTSB reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. NTSB Aircraft Accident Report Contents Figures .............................................................................................................................................v Tables ............................................................................................................................................ vi Abbreviations and Acronyms .................................................................................................... vii Executive Summary .......................................................................................................................x 1. Factual Information .................................................................................................................1 1.1 History of Flight .......................................................................................................................1 1.2 Injuries to Persons ....................................................................................................................7 1.3 Damage to Aircraft ...................................................................................................................7 1.4 Other Damage ...........................................................................................................................8 1.5 Personnel Information ..............................................................................................................8 1.6 Aircraft Information ...............................................................................................................10 1.7 Meteorological Information ...................................................................................................11 1.7.1 Preflight Weather Information .....................................................................................12 1.7.2 Department of Defense Weather Dissemination ..........................................................14 1.7.3 Runway Visual Range Information .............................................................................15 1.8 Aids to Navigation ..................................................................................................................15 1.9 Communications .....................................................................................................................15 1.10 Airport Information ................................................................................................................16 1.10.1 Instrument Approach Procedures .................................................................................16 1.11 Flight Recorders .....................................................................................................................17 1.12 Wreckage and Impact Information .........................................................................................17 1.13 Medical and Pathological Information ...................................................................................18 1.14 Fire ..........................................................................................................................................19 1.15 Survival Aspects .....................................................................................................................19 1.15.1 Emergency Response ...................................................................................................20 1.15.2 Additional Information on Emergency Response ........................................................23 1.16 Tests and Research .................................................................................................................24 1.16.1 Engine Examinations ...................................................................................................24 1.16.2 Avionics Examinations ................................................................................................24 1.16.3 Aircraft Performance Study .........................................................................................25 1.16.3.1 TAWS Simulation .......................................................................................25 1.17 Organizational and Management Information .......................................................................26 1.17.1 Training ........................................................................................................................27 1.17.2 Dispatch System...........................................................................................................28 1.17.3 Operational Policies .....................................................................................................29 1.17.3.1 Aviation Command Operational Policies ....................................................29 1.17.3.2 SYSCOM Operational Policies ...................................................................31 1.17.4 Previous Accidents Involving Maryland State Police .................................................32 iii NTSB Aircraft Accident Report 1.17.5 Maryland State Police Postaccident Actions ...............................................................33 1.17.6 Federal Aviation Administration Oversight .................................................................34 1.18 Additional Information ...........................................................................................................36 1.18.1 Public versus Civil Aircraft Operations .......................................................................36 1.18.2 Protocols for Medevac Helicopter Request .................................................................39 1.18.3 Previous Related Safety Recommendations ................................................................41 1.18.3.1 Safety of EMS Flights .................................................................................41
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