Aerospatiale SA365N-1 D accident near District Heights, Maryland, September 28, 2008
On September 28, 2008 at about 3:58 am local time, a Aerospatiale SA365N-1 D (helicopter), registered N92MD, was substantially damaged in an accident during approach (IFR final approach) near District Heights, Maryland (Andrews A.F.B. airport). It was a public-use flight (state) under public-use (government) rules. 4 people were killed and 1 person was seriously injured. The weather was instrument conditions (cloud, fog or low visibility).
The NTSB's probable cause their words, unchanged
The pilot's attempt to regain visual conditions by performing a rapid descent and his failure to arrest the descent at the minimum descent altitude during a nonprecision approach. Contributing to the accident were (1) the pilot’s limited recent instrument flight experience, (2) the lack of adherence to effective risk management procedures by the Maryland State Police, (3) the pilot’s inadequate assessment of the weather, which led to his decision to accept the flight,, (4) the failure of the Potomac Consolidated Terminal Radar Approach Control (PCT) controller to provide the current Andrews Air Force Base weather observation to the pilot, and (5) the increased workload on the pilot due to inadequate Federal Aviation Administration air traffic control handling by the Ronald Reagan National Airport Tower and PCT controllers.
Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.
What the record shows
- Date
- September 28, 2008 · about 3:58 am local time
- Place
- District Heights, Maryland · Andrews A.F.B. · map
- Type
- Accident
- Injuries
- 4 people were killed and 1 person was seriously injured.
- Weather
- instrument conditions (cloud, fog or low visibility)
- Aircraft
- Aerospatiale SA365N-1 D N1
- Registration
- N92MD · no longer on the register · serial 6311
- Damage
- Substantial damage
- Flight
- Public-use flight (state) · public-use (government) rules
The NTSB's narrative final · quoted from the NTSB record
The Safety Board's full report is available at http://www.ntsb.gov/Publictn/2009/AAR0907.pdf. The Aircraft Accident Report number is NTSB/AAR-09/07 On September 27, 2008, about 2358 eastern daylight time, an Aerospatiale (Eurocopter) SA365N1, N92MD, call sign Trooper 2, registered to and operated by the Maryland State Police (MSP) as a public medical evacuation flight, impacted terrain about 3.2 miles north of the runway 19R threshold at Andrews Air Force Base (ADW), Camp Springs, Maryland, during an instrument landing system approach. The commercial pilot, one flight paramedic, one field provider, and one of two automobile accident patients being transported were killed. The other patient being transported survived with serious injuries from the helicopter accident and was taken to a local hospital. The helicopter was substantially damaged when it collided with trees and terrain in Walker Mill Regional Park, District Heights, Maryland. The flight originated from a landing zone at Wade Elementary School, Waldorf, Maryland, about 2337, destined for Prince George's Hospital Center, Cheverly, Maryland. Night visual meteorological conditions prevailed for the departure; however, Trooper 2 encountered instrument meteorological conditions en route to the hospital and diverted to ADW. No flight plan was filed with the Federal Aviation Administration (FAA), and none was required. The MSP System Communications Center (SYSCOM) was tracking the flight using global positioning system data transmitted with an experimental Automatic Dependent Surveillance-Broadcast communications link.
The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.
The factual record from the NTSB's investigation tables, in plain English
What happened, in order
- Preflight or dispatch event during prior to flight
- VFR encounter with IMC during maneuvering
- Altitude deviation during approach
- Controlled flight into terrain or object (CFIT) during approach (IFR final approach) defining event
The NTSB's findings
- factor Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip › Fog › Effect on operation
- factor Personnel issues › Experience/knowledge › Experience/qualifications › Recent instrument experience › Pilot
- cause Personnel issues › Action/decision › Action › Incorrect action selection › Pilot
- Environmental issues › Operating environment › Communication system › Datalink › Availability of related info
- cause Aircraft › Aircraft oper/perf/capability › Performance/control parameters › Descent/approach/glide path › Not attained/maintained
- Personnel issues › Task performance › Workload management › (general) › Pilot
- Personnel issues › Task performance › Use of equip/info › Use of policy/procedure › ATC personnel
- Organizational issues › Support/oversight/monitoring › Oversight › Oversight of operation › FAA/Regulator
- Organizational issues › Support/oversight/monitoring › Safety programs › (general) › Operator
- Aircraft › Aircraft systems › Navigation system › Ground proximity system › Not installed/available
- Organizational issues › Management › Policy/procedure › Adequacy of policy/proc › Operator
Pilot
- Certificate: flight instructor, commercial pilot, private
- Ratings: single-engine land; instructor: helicopter; instructor: instrument helicopter; instrument: helicopter; rotorcraft: helicopter
- Flight time: 5,225 hours in all; 2,770 in this make and model; 48 in the last 90 days; 16 in the last 30 days; 5,201 as pilot in command
- Last flight review: October 27, 2007
- Medical certificate: Class 2 (with waivers/limitations)
- Seat: rgt
- Injury: fatal
The aircraft
- Airframe total time: 8,869.1 hours
- Last inspection: 100-hour inspection, September 24, 2008; 3.2 hours since
- Maximum gross weight: 9,038 lb
- Seats: 6
- Landing gear: fixed
- Engine 1: Arriel 1C1 (turboshaft); 0 hours total
- Engine 2: Arriel 1C1 (turboshaft); 0 hours total
- Operator: Maryland State Police
The flight
- Departed from: None Waldorf MD at 3:37 am
- Destination: ADW Andrews Afb MD
- Flight plan: none
- Runway 19R, 9,003 ft by 200 ft
Weather at the time
- Light: night, dark
- Wind: from 090° at 3 knots
- Visibility: 4 statute miles
- Sky: broken clouds at 500 ft; scat at 200 ft
- Temperature: 68°F (20°C), dew point 68°F (20°C)
- Altimeter: 29.90 inHg
- Observation at 4:11 am from ADW, 346 miles away
Injuries
| Fatal | Serious | Minor | None | |
|---|---|---|---|---|
| Flight crew | 3 | |||
| Passengers | 1 | 1 |
Documents from the investigation the NTSB's docket: the evidence folder behind the report
The docket, the folder of records gathered during an investigation (maintenance records, photographs, witness statements, examinations), has not been read from the NTSB for this case yet; the list appears here once it has. Open the docket at the NTSB.
Everything on this page comes from the NTSB's public records. The narrative, probable cause and findings are the NTSB's own words; the coded tables behind the report are written out in plain English, with pilots' ages, home towns and medical details left out. The documents and photographs are the NTSB's docket, shown as the NTSB released them. This site's own text never names anyone involved. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.