Helicopter Accident Reveals That ‘Safe’ Operation Was Shot Full of Holes

Fri, Nov 6, 2009 — David Evans

Accident Insights

“Caution, Terrain” would have sounded in the cockpit fully seven seconds before the helicopter struck trees and ploughed into the ground, killing four persons aboard and adding injuries to the surviving of two patients being evacuated for medical treatment.


But the Maryland State Police (MSP) medical evacuation helicopter was not equipped with TAWS (Terrain Awareness Warning System), which would have sounded three alerts, in increasingly forceful language for the pilot to take action.

The absence of TAWS on this helicopter, while three other MPS helicopters were so equipped, was one of many safety deficiencies surrounding the flight. Numerous corrective actions have been taken since the 27 September 2008 disaster, raising the obvious question: why must these initiatives always seem to be implemented after, not before, lives are lost? The answer is quite direct: a mixture of ignorance and complacency.

Of the two factors, complacency is the greatest threat to aviation safety. If one is complacent, knowledge of the availability of TAWS for helicopters is uncertain. Other practices, thought to be prudent, do not seem so in the hard-eyed scrutiny following a fatal accident.

The National Transportation Safety Board (NTSB) recently completed its investigation into the nighttime crash on bad weather of the MPS helicopter, known as “Trooper 2,” which was lost just a few miles from its intended landing at Andrews AFB after the pilot decided that landing at Prince George’s Hospital (PGH) was not prudent due to deteriorating weather.

The pilot, Stephen Bunker, age 59 and an experienced helicopter pilot, had the following radio exchanges (abbreviated):

1:49:12 a.m. local time Trooper 2 Potomac approach, Trooper 2, we tried to make a medevac up at PG hospital and we’re about 7 miles northwest of Andrews, like to climb to 2,000 feet and shoot an approach to runway 1L at Andrews.
1:49:36 Potomac Approach Control (PCT) All right, Trooper 2, present position 200 degrees is approved, the altimeter 2,991 Washington tower 120.75
1:49:44 Trooper 2 No sir, I want to shoot the approach at Andrews.
1:50:16 PCT 360 heading vectors to the ILS 19R just one approach into Andrews or you coming back out for another?
1:50:28 Trooper 2 No sir, I’ve got patients on board, I’m trying to get them down.
1:53:50 PCT Trooper 2, mile and a half from the final approach fix turn right heading 1 uh 70 maintain 2000 until you’re established on the localizer cleared ILS runway 1R approach into Andrews.
1:55:30 Andrews (ADW) Trooper 2, roger runway 19 (unintelligible) cleared for the option wind 090 at 5.
1:55:35 Trooper 2 Trooper 2, roger, we’ll be landing at the base of the tower.
1:55:38 ADW OK you can break it off your discretion for the ramp. Just use caution for the closure of (taxiway) whiskey just abeam the tower (unintelligible) rows it looks like 2 and 3.
1:56:44 Trooper 2 Andrews tower, Trooper 2, I’m not picking up the glideslope.
1:56:50 ADW Trooper 2, roger, it’s showing green on the panel but you’re the only aircraft we’ve had in a long time so I don’t really know if it’s working or not.
1:56:59 Trooper 2 OK could I get an ASR (airport surveillance radar) approach in?
1:57:4 ADW There isn’t anybody to do that, I’m not current on that, I can’t do it.

Investigators believe Bunker’s request for an ASR approach was for someone to talk him down. An ASR approach is an obsolescent technology, and the Andrews’ controller’s lack of currency is not surprising.

Even though Bunker was on the glide slope, the worsening visibility (low clouds, fog), threatened to push him from VFR (visual flight rules) into IFR (instrument flight rules) conditions. He had had only about 1.9 hours of actual instrument time in the previous two years, and the Federal Aviation Administration (FAA) has no definition of instrument night proficiency. The FAA does not specify the number of instrument approaches required for proficiency. Thus, even though Bunker was an IMC (instrument meteorological conditions) qualified flight instructor, he was not getting support from air traffic controllers.

He descended below the glide slope, in an apparent effort to get under the clouds (a practice known as “scud running”). The helicopter hit treetops less than 3 miles from the runway threshold.

The aircraft was not equipped with TAWS, which would have alerted Bunker to the deviation from glideslope and the rising ground beneath.

MSP had equipped three of their helicopters operating in hilly terrain in Cumberland and Frederick, with TAWS; what they did not pursue was the fact that most controlled flight into terrain (CFIT) accidents occur over flat ground, usually on approach to landing. They tried to save money while leaving most of the helicopters vulnerable to the primary CFIT threat.

At NTSB request, Honeywell engineers were called in. Honeywell is a primary avionics manufacturer of TAWS technology. The Honeywell model for helicopters is known as EGPWS (enhanced ground proximity warning system) Mark 22. Honeywell engineers performed a simulation of the accident flight. The simulation was based on the assumptions of a 50-foot look-ahead function and that the aircraft was not auto-rotating down.

The Honeywell engineers arrived at the following conclusions:

— Their equipment, if on the accident helicopter, would have alerted the pilot fully 24 seconds before impact that he had deviated from the glideslope.

— Seven seconds before impact, the system would have sounded “Caution, Terrain.”

— Four seconds before impact, “Warning, Terrain” would have sounded.

— Two seconds before impact, “Pull Up” would have been annunciated.

TAWS would have provided more than adequate warning of impending disaster, if the accident helicopter had been equipped with it.

According to Honeywell, “Whether or not the pilot could have responded to the alerts or the machine allowed a recovery in time to prevent hitting the trees is unknown.”

To be sure, we cannot say for certain that TAWS would have prevented the crash. But given that this tragedy involved a single pilot, out in darkness and fog, and “required to compensate for poor ATC services” (according to the NTSB’s resident ATC expert), TAWS would have provided plenty of warnings in the cockpit that the helicopter was too low.

Although in line with the runway, and just a few miles away, it took searchers to hours to find the down helicopter. They were attracted by the screams of the sole survivor, patient Jordan Wells, hurled from the wreck and soaked in fuel. Now 20, Wells has undergone 20 surgeries to repair damage from the combined effects of the automobile collision and the helicopter crash.

Impact less than 3 miles from the runway threshold, but the poorly coordinated search effort took some 2 hours to finally locate the crash site.

It was later determined that transport by helicopter – vice ground ambulance – would have saved less than 5 minutes. Bunker had not conducted anything in the way of a formal or structured risk assessment prior to the flight. Chairman Deborah Hersman said this is simply “mind boggling” in the dynamic operating environment encountered. A written risk assessment that can be used and archived should have been employed, she maintained.

Since the accident, the MSP helicopters conduct 40% fewer medical evacuations. “A trauma center doctor now evaluates the condition of each patient being considered for helicopter evacuation,” she recounted.

The mother of patient Ashley Younger, 17, who died in the crash, approached Hersman after the hearing, asking why safety features were not mandated. Hersman explained that the Safety Board makes recommendations and that it is up to Congress or the FAA to make rules.

Mrs. Younger began to cry.

Hersman reached into her purse for a tissue, hugged Younger and said, “I am so sorry.”

The NTSB issued nine recommendations and reiterated three others issued previously, including one to require TAWS on medical helicopters (for particulars, see

Rather than go through each of the detailed recommendations, it may be more useful to recount the general situation at MSP before and after the accident, as documented in the voluminous interview summaries produced by the NTSB. These summaries reveal an operation headed for an accident, if not this one near Andrews, at some other time and place. As is seen so often, corrective action follows, not precedes, tragedy:

Major Andrew McAndrew, Commander, MSP Aviation Command:

Major McAndrew was asked what changes have been made since the accident. He described the following changes:

1. Increased weather minimums to 1,000/3 for night operations [1,000 vertical/3 miles horizontal visibility]; 800/3 for day operations (pre-accident was 800/3 night; 600/2 day).

2. He requested a template for Part 135 operations from the private (Part 135) operators, to decide if MSP operations should be restructured to become more aligned with Part 135 [the accident flight was operating under the less demanding Part 91 rules].

3. Stricter MEL [minimum equipment list] operations (especially for autopilot or instrumentation deficiencies).

4. Grounded all helicopters in the fleet until the instrumentation could be checked (particularly glideslope functions).

5. All pilots were grounded after the accident until they performed an instrument checkride.

Major McAndrew was asked about Terrain Awareness and Warning Systems (TAWS) and night vision goggles (NVGs) in MSP helicopters. He responded that 3 of the 12 helicopters have TAWS … All new helicopers that are purchased by MSP will have TAWS … Currently, MSP helicopters are not compatible with NVGs.

Mike Gartland, Chief Pilot MSP:

Mr. Gartland was asked to describe the recent (November 2007) change in instrument training. He stated that pilots used to perform 6 approaches in 6 months to maintain currency. Because there is typically only one pilot at a base at one time (single-pilot operation), the only time they could practice with another pilot was during a shift change. Mr. Gartland thought pilots were not conducting “quality training” while practicing with other pilots, so he decided to change the training program to now require two IPCs [instrument proficiency checks] every six months …

Mr. Gartland was asked how pilot pay was at MSP. He reported it was “pretty sad,” and the reason pilots stayed was due to their dedication to the mission … (the) quality of new hires had deteriorated because of pay issues. Pilots could not afford to live in the area.

Michael DeRuggiero, MSP safety officer:

Currently, pilots do not complete a formal risk assessment (paperwork), as the Command does not believe it is the best method for evaluating risk. However, they are working to create a beneficial tool now. At the time of the accident, there was an assessment tool in the SOP, however, it was not used by pilots.

Lt. Walter Kerr, MSP flight operations and maintenance:

Lt. Kerr was asked about the quality of maintenance at MSP. He responded that he has “no reservation about flying in any aircraft.” He did not mention it was difficult to produce paperwork for every issue, and MSP is working to become better at that. Despite lacking paperwork, maintenance is always performed completely.

Robert Corolla, MSP instructor pilot:

As of November 2007, pilots would maintain their instrument currency by completing IPCs every 6 months with an instructor pilot. The rationale behind this change was to “save flight time” plus it got an instructor in the cockpit …

Mr. Corolla was asked if he thought two IPCs a year was enough training for pilots to maintain proficiency. He thought it was not, and that pilots needed to practice more than that. Before the November 2007 training change, pilots could practice approaches more often, “reinforcing learning.” According to Mr. Corolla, “proficiency” means “you can do it with your eyes closed,” and “currency” means “you comply with FAA requirements.”

According to Mr. Corolla, the MSP turnover rate was “horrendous.” After 2000, the MSP has had a “terrible time retaining pilots” … (and) maintenance had problems with turnover.

Sgt. R. F. “Bob” Adams, NCOIC System Communication Center (SYSCOM

Prior to this accident, SYSCOM did not require information on patient category. Virtually any request or distress call led to launching a helicopter and there was no quality control imposed by SYSCOM. Since this accident … SYSCOM now asks for category and stability information … Category “C” and “D” patients, who are more stable, now need authorization by a physician to receive helicopter transport. This new procedure should cut down on inappropriate launches of patients who do not need either helicopter transport or trauma centers and, perhaps, speed up necessary treatment at a local medical center. If the patient is stable (Category “C” or “D”), the new procedure specifies that they check in with a physician or trauma surgeon before requesting a helicopter …

In the next few weeks, SYSCOM will revise its procedures to allow the Duty Officer to decline missions without consulting a flight crew … Sgt. Adams suggested that as many as 60% of the patients did not meet the need for a helicopter transport, but “by flying everybody, we get all the sick ones.”

Dr. Douglas Floccare, MD, Maryland Aeromedical Director:

PG County Hospital was a 48-minute drive time, and more than a 30-minute drive justified the use of helicopter transport. Thirty minutes is considered a decent time for a patient to no longer compensate for internal injury and show a drop in vital signs.

Marvin Holt, retired MSP pilot:

Mr. Holt described safety at MSP as “excellent” 10 years ago. He stated the Director of Maintenance was qualified and knowledgeable. Since then, the organization is more concerned with not embarrassing the Command Staff than safety …

Mr. Holt was asked why he retired from MSP last year and he responded that he was targeted for investigation and threatened with disciplinary action. He received a surprise visit at work by his lieutenant and was not allowed union representation during a two-hour questioning. Mr. Holt left the MSP because he felt that “someone would ride a helo down and it wouldn’t be him.”

In reference to how Mr. Holt felt about the MSP equipment, he reported it was “not as maintained as he would have liked.” The MSP had 12 helicopters; however, usually they only had 8 in service at one time. His section was often closed for the lack of equipment. Mr. Holt stated the maintenance was “questionable,” and the subscription they had for IFR charts had expired and was not renewed …

With regard to federal oversight, Mr. Holt thought the FAA was supposed to oversee the medevac part of the MSP operation (those missions flown as Part 91 flights). The law enforcement missions were conducted as “public use” flights, and Mr. Holt thought there was no FAA oversight for those missions. Mr. Holt never saw the FAA at the MSP bases.

Peter Peterson, MSP pilot:

(He) was called to work directly for the Commander about developing a program to achieve Commission on Accreditation of Air Medical Systems (CAAMS) certification. He discovered problem and this led to a major falling out …

He believed that his concerns may have helped launch an audit by the State Legislature. He attended the audit hearing, and could see all the holes in the organization. He felt that the Commander and the Director of Maintenance were evasive …

The mechanics were eager but short on experience. He did not have faith in them. They were swamped and the experience level was down. Immediate maintenance was often not done if problems were subject to MEL. The ILS could be inoperative and they would fly VFR only. Troopers wanted control but the maintenance people signed for the work. A senior mechanic said that the FAA should take away the Part 145 [repair station] certificate. The mechanics were overwhelmed …

When he started with MSP, he received an instrument proficiency check and a BFR checkride in model. He did the BFR every year. He flew approaches with another pilot for proficiency and got 1 hour per month of actual instrument practice … More recently, following a memo in fall 2007, the program reduced to an IPC every six months. He was an instrument instructor in the Navy. To him, this new policy led to a reduction in proficiency. You need to bury your head in the cockpit …

The MSP program valued loyalty over truth. Many people bared their souls for the audit report but their criticisms never appeared.

The Safety Office program was gutless. It became a shell after … 2006 … The number of ASR’s [aviation safety reports] declined. The Safety Office settled the routine, mundane issues of the ASR reports but real safety concerns (were) not broached because of fears of recriminations.

John Astle, Maryland State Senator (and a veteran Navy helicopter pilot):

He believed that the MSP program had shaky maintenance practices. It left pilot writeups unaddressed until scheduled maintenance checks, so pilots routinely flew aircraft with writeups into the grace period on the checks. There was no process in place for tool control. The Director of the Maintenance Department was a trooper paramedic without a maintenance background. The FAA maintenance manual was not current. Wiring diagrams were worked from manufacturer preliminary, rather than final, diagrams. These deficiencies are important because, as a pilot, you need assurances that maintenance is good.

He believed that the MSP program had shaky operations practices. The pilot pool was heavy in police or retired police with lower initial flight time requirements than those applied to civilian pilots. The unit was managed by a road trooper with no knowledge of aviation and was run as a para-military organization. In the actual military, an aviation unit would always be overseen by an aviator …

He believed the overall program was shaky. It promoted itself as the “best in the world” by hiding shortcomings. For example, they experienced an event in which a helicopter was damaged on the roof of a hospital and this was not reported to the NTSB or FAA. Sen. Astle questioned whether the program complied with the law, because the level of damage appeared to require reporting. They experienced two additional events that were not reported, involving an engine shutdown in flight and a fuel leak that exposed passengers to hazardous material. The program hid these problems …

He believed the program needed upgraded oversight for safety. It should be operated to Part 135 standards, with FAA oversight and appropriate safety procedures. The program carried passengers for hire and Maryland drivers paid its support …

He believed that the State Police should not run this program. Police need aviation. Street officers loved this program. But the program could not conduct medevac, homeland security, and search and rescue efforts without suffering.

EMS [Emergency Medical Service] aviation was 35 times more dangerous than coal mines. It was challenging, particularly at night, in weather, with maintenance issues. Sen. Astle felt that Maryland benefitted by having a socialized medevac program, but believed that it needed Part 135 certification and proper oversight and needed to be run by a commercial company whose core business was aviation …

As a policymaker, Sen. Astle wanted a system that was safe. The General Assembly would soon have a debate about the future of this program, and the NTSB report would be a foundation of the discussion.

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