Maryland State Firemen s Association Executive Committee Meeting December 5, 2009

Maryland State Firemen s Association Executive Committee Meeting December 5, 2009 Maryland State Police Aviation Command Update Presented by: Major Andrew J. (A. J.) McAndrew

Hello, my name is Major A. J. McAndrew of the Maryland State Police Aviation Command. I would like to thank you Mr. Chairman, the members of the Executive Committee, President Powell, Vice Presidents Cox and Lewis, and the members of the Maryland State Firemen s Association for allowing me to speak this morning on topics pertaining to the Aviation Command. Trooper 2 Crash Update o Probable Cause as Determined by the NTSB: 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. o Contributing Factors as Determined by the NTSB: The pilot s limited recent instrument flight experience. The lack of adherence to effective risk management procedures by the Maryland State Police. The pilot s inadequate assessment of the weather, which led to his decision to accept the flight. 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. The increased workload on the pilot due to inadequate Federal Aviation Administration air traffic control handling by Ronald Reagan Washington National Airport Tower and PCT controllers. Recommendations made by the NTSB and MSP s Response o Require all emergency medical services operators to comply with 14 Code of Federal Regulations Part 135 operations specifications during the conduct of all flights with medical personnel onboard. (A-06-12) The Aviation Command has already applied for and is in the process of obtaining Part 135 certification. o Require all emergency medical services (EMS) operators to develop and implement flight risk evaluation programs that include training all employees involved in the operation, procedures that support the systematic evaluation of flight risks, and consultation with others trained in EMS flight operations if the risks reach a predefined level. (A-06-13) The Aviation Command has developed and utilizes a computer based flight risk evaluation program that includes procedures that support the systematic evaluation of flight risks, and consultation with others trained in EMS flight operations if the risks reach a predefined level. o Require emergency medical services operators to use formalized dispatch and flightfollowing procedures that include up-to-date weather information and assistance in flight risk assessment decisions. (A-06-14) 1

SYSCOM (Systems Communications Center) serves as the Aviation Command s formalized dispatch and flight-following center. All Maryland State Police duty officers assigned to SYSCOM have been certified as certified flight communicators. o Require emergency medical services (EMS) operators to install terrain awareness and warning systems on their aircraft and to provide adequate training to ensure that flight crews are capable of using the systems to safely conduct EMS operations. (A-06-15) During the 2009 Legislative Session, Governor O Malley and the General Assembly allocated 52.5 million dollars to begin replacing the Command s aging fleet of helicopters and allocated over $600,000 to purchase additional safety equipment for the current fleet. The Aviation Command is currently participating in a procurement process to purchase up to 12 new helicopters. Specifications for the new helicopters mandate that they be equipped with terrain awareness and warning systems. In the interim until the existing fleet is fully replaced, the Aviation Command has purchased new terrain awareness and warning systems to outfit each of its helicopters. o Conduct scenario-based training, including the use of simulators and flight training devices, for helicopter emergency medical services (HEMS) pilots, to include inadvertent flight into instrument meteorological conditions and hazards unique to HEMS operations, and conduct this training frequently enough to ensure proficiency. (A-09-97) The Aviation Command is currently in the procurement process to purchase a new flight simulator. The simulator will be used to conduct scenario-based training to include inadvertent flight into instrument meteorological conditions and hazards unique to HEMS operations. The Aviation Command has modified its pilot training program, which includes scenario based training. The Aviation Command has, both prior to and after the Trooper 2 crash, voluntarily complied with all FAA Part 135 helicopter pilot certification requirements. The Aviation Command has adopted new pilot training requirements that includes: One instrument approach flight in VFR conditions per month on return leg of a mission (every other month the approach is conducted at night). One instrument approach flight conducted at night utilizing a view limiting device in VFR conditions per month with a safety pilot. Quarterly training flight with an instructor pilot that includes two instrument training flights (one flight will be conducted at night) and two emergency procedures training flights (one flight will be conducted at night). Two instrument proficiency check flights per year with an instructor pilot. The flights will consist of one precision approach and two non-precision approaches (one flight will be conducted at night). One evaluation/standardization flight with the Chief Pilot. The flight will include, but not be limited to, a simulated MedEvac mission and an IMC recovery followed by a coupled ILS approach to the nearest airport. The Aviation Command has adopted new SYSCOM duty officer training: SYSCOM Duty Officers have been trained and certified as Certified Flight Communicators. 2

This training provided by the National Association of Air Medical Communication Specialists training is in line with an FAA advisory circular pertaining to training HEMS operational control centers. o Implement a safety management system program that includes sound risk management practices. (A-09-98) The Aviation Command has a robust safety management system that includes but is not limited to utilizing formalized dispatch and flight-following procedures, voluntarily complying with FAA Part 135 weather minimums, and utilizing a flight risk evaluation program. o Install flight data recording devices and establish a structured flight data monitoring program that incorporates routine reviews of all available sources of information to identify deviations from established norms and procedures and other potential safety issues. (A-09-99) Requirement specifications for the new helicopters mandate that they must be equipped with flight data recording devices and cockpit video recording devices. A monitoring program that incorporates routine reviews of the information from these devices will be used to identify deviations from established norms and procedures and other potential safety issues. o Install and require that pilots use night vision imaging systems for visual flight rules operations at night. (A-09-100) Requirement specifications for the new helicopters mandate that they must be equipped with night vision imaging systems. In the interim until the existing fleet is fully replaced, the Aviation Command has purchased night vision goggles that will initially be used by flight paramedics who will assist the pilots in identifying hazards. Additionally, the Aviation Command has developed specifications and is in the procurement process to purchase night vision imaging filtering systems for several existing helicopters; these systems will enable the pilots to also utilize the night vision goggles and identify hazards. o Equip helicopters that are used in emergency medical services transportation with autopilots, and train pilots to use the autopilot if a second pilot is not available. (A-09-101) All Aviation Command helicopters are equipped with autopilots and all Aviation Command pilots are trained and proficient in using the autopilot systems. Additionally, requirement specifications for the new helicopters mandate that they must be equipped with autopilots. Furthermore, the Aviation Command has testified in favor of hiring co-pilots as an added safety measure. Note: The NTSB stated that a review of the NTSB Aviation Accident Database revealed that during the 8-year period from 2000-2008, 123 HEMS accidents occurred, killing 104 people and seriously injuring 42 more. All but nine of these accidents involved operations with only one pilot. Pilot actions or omissions, of some sort, were attributed as the probable cause in 60 of the 123 accidents. Many of these 3

60 accidents might have been prevented had a second pilot and/or an autopilot been present. Witnesses at the (February 2009) NTSB hearing described the risks for helicopter pilots working in the HEMS environment, which are greater than those in other types of flight operations. The airline industry, which has an accident rate much lower than that of the HEMS industry, conducts flights with two pilots who attend training regularly and are required to be evaluated during that training. Conducting flights with two pilots allows one pilot to fly the airplane while the other communicates on the radio, programs aircraft avionics, and runs checklists. The NTSB notes that some HEMS operators currently operate with two pilots. According to hearing testimony, the Canadian HEMS industry operates its helicopters with two pilots and has flown over 230,000 hours since 1977 with no fatal accidents. In addition, the New Jersey State Police, which flies its helicopters with two pilots, has had no accidents for the last 10 years. The NTSB noted how a second pilot might have prevented the Trooper 2 crash. The NTSB stated that in the Trooper 2 crash, a second pilot could have handled radio communications with air traffic control, reducing the pilot's workload and allowing him to concentrate on flying the helicopter. Additionally, after the controller denied the pilot's request for a surveillance radar approach, a second pilot may have suggested they declare an emergency or execute a missed approach and request a different approach rather than continue to descend. A second pilot could have also monitored the helicopter's altitude while on the approach to ensure terrain clearance. o Implement a program to screen and, if necessary treat your pilots for obstructive sleep apnea. (A-09-XX) This recently released recommendation is endorsed by the Aviation Command and is currently under study. o Revise policy regarding incident commanders to specify that, in any event involving a missing or overdue aircraft, an Aviation Command trooper will serve as the incident commander. (A-09-XX) This recently released recommendation is endorsed by the Aviation Command and is currently under study. o Provide additional training to your dispatchers on the use of cell phone pinging and include instruction about how to integrate the data obtained from cell phone pinging into an overall search and rescue plan. (A-09-XX) This recently released recommendation is endorsed by the Aviation Command and is currently under study. Aviation Command s Safety Record o A recent study reports that the average Helicopter EMS accident rate between 1998 and 2008 was 3.8 accidents per 100,000 flight hours. o Prior to the crash of Trooper 2, the MSP Aviation Command had flown over 100,000 accident free flight hours and over 90,000 of those hours were in the Dauphin helicopter. 4

Although one accident is one too many, this equates to 2.8 accidents less than the average rate. o Prior to the crash of Trooper 2, the MSP Aviation Command had not had a fatal accident in 22-years. o One tragic crash DOES NOT negate the past 100,000+ accident free flight hours or the past 22-years of non-fatal accidents. o There Aviation Command will always strive to improve its safety record. o The Aviation Command s goal is zero crashes and zero incidents. Summary o It was on March 19, 1970, that the Aviation Command became the first civilian agency to transport a critically injured trauma patient by helicopter. This had never been done before in a non-military setting. The Command has since transported over 130,000 patients and has contributed to saving thousands upon thousands of lives, thus earning a worldwide reputation as a leader in pre-hospital trauma care and air medical evacuation. In addition to MedEvac, the Command s multi mission profile includes search and rescue, law enforcement, homeland security, and damage assessment. o The Aviation Command will never rest on its laurels and will always look for ways to improve the safety of its operations and improve its delivery of services to Maryland s citizens. Respectfully submitted, Major A. J. McAndrew Commander, Aviation Command 5