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NTSB says overworked Maryland State Police pilot to blame for the crash of Trooper 2. Also faults air traffic controllers along with MSP’s response to the crash. Report says there are lessons to be learned for search crews.

NTSB Report Synopsis 10-27-09 

Previously released NTSB Interim Factual Summary’s earlier coverage of this story here, here, here, here, here and here

By Bruce Leshan,

We finally know the most-likely cause of that horrible crash of a Maryland State Police helicopter.

The pilot, two medics, and an accident victim died a year ago –and just one teenager survived.

The National Transportation Safety Board is blaming pilot Stephen Bunker, who unexpectedly flew into a dense cloud bank, and then tried desperately to get below it.

He was looking so frantically for the ground that he ignored an altimeter that might have warned him he was about to crash into it.

But the Board also says a whole series of other mistakes by air traffic controllers contributed to the crisis.

“I wear the bracelet with everyone’s name on it,” says Jordan Wells, who was the only survivor. She’ll never forget the crash that killed her friend Ashley and three other people trying to rush the teens to a hospital.

“The look on Lippy’s face, then I heard something brush against the helicopter,” says Wells. “Then I blacked out because I broke this side of my face.”

Wells came to the NTSB hearing, hoping the long investigation will help save other lives.

“You can only hope,” she says. “You can only pray that it will fix things and make them better.”

“The probable cause of this accident was the pilots attempt to regain visual conditions by performing a rapid descent,” the NTSB’s David Mayer told the board.

It was a miserable night, and the pilot briefly considered refusing the mission. But based in part on five hour old weather data, he decided to go anyway. And that bad data was just one of the “numerous procedural deficiencies” the NTSB blamed on air traffic controllers, “…including unresponsiveness, inattention, and poor radar vectoring,” said Mayer.

Bunker had almost three decades of experience, but it had been a long time since he’d practiced an instrument landing.

And when he suddenly flew into heavy fog, he failed to follow procedures.

The NTSB is recommending that all public air ambulances be regulated just like commercial aircraft. It’s also pushing for formal risk assessments on every flight, and for new technology like night vision goggles and terrain awareness warning systems.

“We want to make sure when they’re going to save a life, they don’t lose their life, or risk other lives,” says chair Deborah Hersman.

The NTSB also criticized the Maryland State Police for its performance after the crash. It took some time for the agency to even realize the chopper had gone down — and then an hour or so to find it. If not for the heroic efforts of a couple of troopers, it might have taken hours longer to discover the crash scene — even though it was right on an electronic map at Syscom, but just hard to read.

The Maryland State Police says it has already corrected many of the problems, and is working on others. And the NTSB praised the agency for its cooperation.

Below are NTSB finding that deal directly with the search for the downed helicopter:

20. Had two Maryland State Police aviation employees not pursued their own search effort, locating the accident site would likely have taken several more hours than it did.

21. The incident commander’s lack of aviation knowledge diminished the effectiveness of search and rescue activities.

22. Maryland State Police troopers and System Communications Center personnel were insufficiently equipped and trained to conduct a search involving global positioning system coordinates, and this hindered their ability to locate the site of the wreckage.

23. Neither Prince George’s County nor Maryland State Police dispatchers fully understood the importance of obtaining distance and bearing information, as well as the cell tower location, before releasing a location obtained from cell phone ‘pinging;’ this lack of understanding led dispatchers to provide the cell phone tower’s simple street address without context to all units involved in the search. This distracted and confused units already searching a more likely location.

24. The Federal Aviation Administration air traffic control’s inability to produce timely location data also hampered search and rescue efforts.

25. Knowledge of the disjointed search and rescue efforts and the techniques eventually employed to locate the accident site could provide valuable lessons to agencies, such as Helicopter Emergency Medical Services dispatch centers, 911 dispatch centers, and fire, police, and sheriff’s departments, involved in search and rescue efforts.

Comments - Add Yours

  • Sam

    Way back in 1986 a Md. State Police Helicopter crashed into trees in a city park in West Baltimore (Leakin Park) killing the pilot Corp. Gregory A. May and Trooper 1st. Class Cary S. Poetzman. They were killed while trying to get out of dense fog that had covered the area after they had cleared MIEMSS (University Hospital).Realizing they needed a more advanced type of helicopter the state purchased Dauphin’s which had FLIR (Forward Looking Infrared Radar)so that they could fly in this type weather condition if so incountered. Why was it not required for the pilot of this latest crash not to be trained/recertified in an instrument landing?

  • dave statter

    As your comment arrived I am in the process of writing about the January 19, 1986 crash of Trooper 3 for tomorrow. I covered the search in Carroll County in the fog on that Sunday morning and raced with everyone else down I-70 to Leakin Park. Another very sad day.


  • Sam

    Dave, I’d like to mention that in the 1986 incident that if it had not been for neighbors hearing what they thought was “something crashing” into the trees in this densely wooded portion of the park the troopers way not of been found for days or maybe weeks. I guess not much has changed in 23 years.

  • Sam

    Dave, should have proof read my last comment. Should have said, MAY not have been found for days or maybe weeks.If you are able to change it, please do. Thanks, Sam

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  • Mike Simpson

    This was a tragic series of events that night. I have spent 17 years working in roter wing medical and many times had this happen to us. To visualize the fog is difficult in the day and almost impossible to do at night. The standard procedure for our pilots ( who only flew VFR )was to stop forward flight and raise up to 1000 ft or higher to put them over the trees and away from obstacles and do a 180 degree turn to reverse out of the fog until clear. I pray for my fellow flight crews, one of which is my wife, to always be aware of the situations surrounding them all the time.

  • Margery Ford

    As Mother of Maryland State Trooper, Carey Suzanne Poetzman, who crashed in Jan. of 1986, I have always wondered, Why was Piolet May, given the OK to fly? Then, why didn’t someone see them go off the radar screen? Those two lives, saved someone, yet when they needed help, no one knew where they were? Why?

  • Commenter

    Maryland flies too much. Protocols for flying patients should be strictly based on evidence. Pilots should be professional pilots, not cross-trained cops. It should be easy to find some great high-hour rotor wing pilots now that we’ve been at war for more than a decade.

    • Another Comment

      There’s plenty of opening for pilots with several thousand hours…the problem is: why would anyone work for nickels when other EMS organizations pay dollars for the same work.

      In short MDSP needs to increase their salary in order to attract more skilled employees. Simple economics I’m afraid.