Pilot, weather, controller share blame for 'copter crash

Federal agency reports variety of factors caused tragedy

Friday, Oct. 30, 2009

By BETHANY RODGERS

Staff writer

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File photo by KATHERINE FREY/THE WASHINGTON POST

A Maryland state trooper walks through the wreckage of the rescue helicopter that crashed last September in the woods in Walker Mill Regional Park. Four people on board were killed, including three from Waldorf.

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A pilot's attempt to duck under thick clouds and find his runway likely led to the devastating medevac helicopter wreck that killed four people — three from Charles County — and severely injured the sole survivor last year, federal investigators determined Tuesday.

Veteran Maryland State Police helicopter pilot Stephen H. Bunker of Waldorf might have decided against flying through the murky weather at all if he'd been required to complete a written risk assessment of the Sept. 27, 2008, mission, said investigators with the National Transportation Safety Board. And once the helicopter picked up two teens from a Waldorf car crash, a host of additional factors, including ineffective air traffic control and an outdated weather report, resulted in the aircraft's plunge into the trees of Walker Mill Regional Park in District Heights.

Bunker, 59, died in the wreck, as did state police flight medic Mickey Lippy, 34, of Westminster, emergency medical technician Tonya Mallard, 39, and patient Ashley Younger, 17, both of Waldorf.

The second patient, Jordan Wells, now 19, survived, although she spent weeks in the hospital and still hasn't undergone all her surgeries.

The crash, which happened in the midst of the deadliest year on record for helicopter medical emergency services — HEMS — spotlighted Maryland's medevac program. Before the wreck, "we looked at the Maryland State Police as a gold standard operator," said NTSB member Robert Sumwalt during the meeting.

"Not only was the safety board disappointed, but the taxpayers of Maryland should be disappointed. … And I hope that this accident will serve as a wakeup call not only for the Maryland State Police, but for other agencies as well," Sumwalt said.

At Tuesday's meeting discussing the Trooper 2 crash, the board repeated many recommendations they have issued before. For one thing, the board advised that state police require their pilots to complete written flight risk evaluations, a step they said might have stopped Bunker from setting out on Sept. 27.

"I cannot fathom why any HEMS operator does not perform a written risk assessment. It's just almost mind-boggling," said Deborah Hersman, NTSB chairman.

The board's report criticized air traffic controllers at a Ronald Reagan Washington National Airport tower and a Mount Vernon, Va.-area tower for poor work that upped the pressure on Bunker during an already stressful flight. For more than a minute, the Mount Vernon controller failed to respond to Bunker's initial contact and then gave him hours-old weather information that might have convinced the pilot he could fly below the cloud ceiling on the approach to Andrews Air Force Base in Camp Springs, about 3.5 miles from the crash site.

When Trooper 2 neared the base, Bunker's request to the Andrews tower for a rarely-used landing signaled his growing distress, NTSB investigator said.

"To me, this is a pilot who is overwhelmed and who is asking for help," said Malcolm Brenner, a board staff member.

Investigators didn't find any evidence of mechanical failure, although Bunker said before the wreck that he wasn't receiving his glide slope, or the angle of his approach to the base runway. Bunker, concerned about the glide slope, might have tried to fly by sight and in searching for the ground he possibly didn't notice his instruments showed the aircraft was rapidly losing altitude; the helicopter's descent accelerated from 500 to more than 2,000 feet per minute.

A terrain awareness system, which wasn't installed on the helicopter, would probably have alerted Bunker that the aircraft was dipping dangerously close to the ground, according to investigators.

"This was a string of events where the chain was not broken, and it resulted in an accident," Hersman said to reporters after the meeting.

The day after the meeting, the Maryland State Police issued a press release contesting the board's determination that Bunker was qualified but not proficient at landing in conditions like those on the night of the accident. The state agency said Bunker had "exceeded every requirement for training and proficiency and had, within five months of the crash, targeted training in simulated instrument meteorological and night conditions."

The state police have already implemented many of the recommendations the NTSB made Tuesday, including using a computerized flight risk assessment program, and the board investigators praised them for responsiveness and transparency.

Wells, of Waldorf, said she doesn't blame anyone for the crash, especially not Bunker, an expert pilot who faced multiple setbacks during the flight.

"I can't be mad at any one thing because there were so many things that went wrong that night," she said.

Wells said she came to the NTSB hearing hoping for answers to questions she still has about the accident, including why she lived while her friend, Younger, and the three other people in the aircraft didn't survive. But she wanted to turn attention from herself and asked for thoughts and prayers for the other accident victims and their families.

"I'll always carry them in my heart," she said.

brodgers@somdnews.com

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