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Safety Board Blames Overworked Pilot in MSP Chopper Crash



Associated Press Writer

WASHINGTON - Last year's deadly medevac helicopter crash in Maryland was caused by a combination of factors including a pilot who was not proficient in instrument landing approaches, and air traffic controllers who provided outdated weather information, federal investigators said Tuesday.

The National Transportation Safety Board concluded at a hearing Tuesday that concerns with the pilot, air traffic control services at various sites and other issues likely caused the September 2008 crash in a wooded park in District Heights, Md., killing four people.

Read the NTSB Reports

NTSB Report Synopsis 10-27-09

NTSB Interim Factual Summary

NTSB Chairman Deborah A.P. Hersman, Vice Chairman Christopher A. Hart and board member Robert L. Sumwalt questioned a team of investigators on their findings before approving the conclusions and recommendations for the emergency medical helicopter industry.

Hersman said a number of things could have been done to prevent the accident.

"I think the challenge in this probable cause is it wasn't just one thing," Hersman said after the hearing. "As we see in so many different accidents, this was a string of events where the chain was not broken and it resulted in an accident."

Two young women had been in a car accident and state protocol called for them to be flown for treatment.

The helicopter crash killed one of the car accident victims, 17-year-old Ashley Younger, along with the pilot Stephen Bunker, 59; flight paramedic Mickey Lippy, 34; and emergency medical technician Tanya Mallard, 39. The other car accident victim, 19-year-old Jordan Wells, survived the helicopter crash.

Investigators said Bunker was fully certified and qualified to fly by Maryland State Police standards. They also said that although the helicopter was part of an aging fleet, it had no maintenance issues.

Bunker inadequately assessed the weather, leading him to go forward with the flight, investigators said. As the weather worsened on the way to a Prince George's County hospital, he diverted the flight to Andrews Air Force Base and had to rely on the craft's instruments to fly.

Investigators said the pilot started a rapid descent, hoping to find conditions that would allow him to see. But he did not stop the descent at the minimum altitude allowed, which the board said is the probable cause of the accident.

The helicopter did not have terrain warning equipment that would have likely alerted Bunker that the craft was too low.

Among other contributing factors, the NTSB cited the pilot's limited recent experience with using instruments for flying; the failure of air traffic controllers to give him updated weather details; and the pilot's increased workload and possible fatigue due to air traffic controllers' handling of the situation.

During the hearing, Hersman said it's unacceptable that in this crash along many others there were no written evaluations of potential flight risks, which could have kept the helicopters grounded.

"It's just almost mind-boggling," Hersman said.

Several issues also hampered search and rescue efforts, causing a long delay in locating the crash site.

The board called on the Federal Aviation Administration to seek legislative authority to regulate medevac operations that use government-owned aircraft, as it does with civil helicopter EMS operations.

The board also recommended that all public medevac operators develop flight risk evaluations and install terrain awareness warning systems.

Diane Spitaliere, an FAA spokeswoman, said the agency looks at recommendations carefully and has 90 days to respond. Earlier this year, the agency outlined steps it has taken in emergency medical helicopter safety and oversight.

Maryland State Police said in a statement that they have already implemented many of the board's recommendations and continue to do so.

But state police officials said they "adamantly" disagree with statements about the pilot's skills.

"He exceeded every requirement for training and proficiency," the agency said in a statement. Within the five months leading up to the crash, the pilot had undergone training in simulated flying by instruments, at night and in bad weather, the statement said.

The NTSB said though many agencies are taking steps to improve, it wants the federal government to mandate changes for the entire medevac industry. The board has no regulatory authority.

Wells, the survivor of the accident from Waldorf, Md., attended the hearing and introduced herself to investigators. She told reporters later that she has been through more than 20 surgeries since the crash, and hopes the board's findings will fix problems.

"There has been a lot of pain for everyone," said Wells, who clutched a black cane in one hand, and wore bracelets with the crash victims' names on her other wrist. "The greatest pain is emotional pain; all the physical pain I've gone through doesn't compare to the emotion of losing Ashley and being the sole survivor."


Associated Press Writer Brian Witte in Annapolis, Md. contributed to this report.


On the Net:

NTSB: http://www.ntsb.gov/events/Boardmeeting.htm

FAA: http://tinyurl.com/c2tf49


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