NTSB: Controllers Contributed To Pilot's Poor Decisions
The NTSB this week found the pilot at fault in a fatal medevac flight in Maryland in September 2008, but cited a lack of help from air traffic controllers as a contributing factor. The Aerospatiale helicopter, operated by the Maryland State Police, descended too quickly while on a nonprecision instrument approach in fog, and hit the ground. The pilot, a paramedic, a volunteer, and one of the two teenage car-crash victims on board were killed. The safety board said inadequate handling by controllers at the Potomac Tracon and the Reagan National Airport tower contributed to an increased workload on the pilot. The flight had originated at night in VMC, but on the way to the hospital the pilot encountered IMC and diverted to Andrews Air Force Base. The board said the pilot likely became preoccupied with looking for the ground while on final approach, after failing to intercept the ILS glideslope. The pilot's limited recent instrument flight experience and a lack of adherence to effective risk management procedures of the Maryland State Police contributed to the crash, the NTSB said.
The board said "poor ATC services" caused an increased workload and distraction for the pilot. Another contributing factor was the pilot's initial inadequate assessment of the weather, which led to his decision to accept the flight. After the diversion to Andrews, the pilot was given a five-hour-old weather report for his destination. The pilot had logged just 1.9 hours of actual instrument time in the two years prior to the accident, according to the NTSB. Fatigue may have also been a factor. It was almost midnight and the pilot, who suffered from sleep apnea, had been awake for 16 hours at the time of the accident. An NTSB animation of the flight path is posted online. Click here for the full text of the NTSB synopsis.