Office of Aviation Safety Maryland State Police Trooper 2 District Heights, MD Jill Demko Operations...
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![Page 1: Office of Aviation Safety Maryland State Police Trooper 2 District Heights, MD Jill Demko Operations Group Chairman Malcolm Brenner, Ph.D. Human Performance.](https://reader030.fdocuments.net/reader030/viewer/2022032722/56649ce25503460f949ada41/html5/thumbnails/1.jpg)
Office of Aviation Safety
Maryland State Police Trooper 2District Heights, MD
Maryland State Police Trooper 2District Heights, MDJill DemkoOperations Group Chairman
Malcolm Brenner, Ph.D.Human Performance Group Chairman
![Page 2: Office of Aviation Safety Maryland State Police Trooper 2 District Heights, MD Jill Demko Operations Group Chairman Malcolm Brenner, Ph.D. Human Performance.](https://reader030.fdocuments.net/reader030/viewer/2022032722/56649ce25503460f949ada41/html5/thumbnails/2.jpg)
Pre-flight Weather EvaluationPre-flight Weather Evaluation
• Pilot obtained weather briefing at 1851
• VFR conditions forecast for ADW until 0100
• Weather at time of launch within MSP and FAA weather minimums
![Page 3: Office of Aviation Safety Maryland State Police Trooper 2 District Heights, MD Jill Demko Operations Group Chairman Malcolm Brenner, Ph.D. Human Performance.](https://reader030.fdocuments.net/reader030/viewer/2022032722/56649ce25503460f949ada41/html5/thumbnails/3.jpg)
VFR VFR
1,400 few;10 mi visibility1,400 few;10 mi visibility
IFR IFR800 broken;10 mi visibility800 broken;10 mi visibility
VFR VFR
1,800 broken;7 mi visibility 1,800 broken;7 mi visibility
![Page 4: Office of Aviation Safety Maryland State Police Trooper 2 District Heights, MD Jill Demko Operations Group Chairman Malcolm Brenner, Ph.D. Human Performance.](https://reader030.fdocuments.net/reader030/viewer/2022032722/56649ce25503460f949ada41/html5/thumbnails/4.jpg)
Risk AssessmentRisk Assessment
• Single-pilot operation• Risk assessment matrix existed• Not required to be used
![Page 5: Office of Aviation Safety Maryland State Police Trooper 2 District Heights, MD Jill Demko Operations Group Chairman Malcolm Brenner, Ph.D. Human Performance.](https://reader030.fdocuments.net/reader030/viewer/2022032722/56649ce25503460f949ada41/html5/thumbnails/5.jpg)
Pilot ExperiencePilot Experience
• Commercial pilot certificate– Instrument rating– Rotorcraft-helicopter rating
• Flight instructor certificate– Instrument rating– Rotorcraft-helicopter rating
• 27 years, 2,700 hours in accident helicopter
• 1.9 hours actual instrument time in previous 2 years
![Page 6: Office of Aviation Safety Maryland State Police Trooper 2 District Heights, MD Jill Demko Operations Group Chairman Malcolm Brenner, Ph.D. Human Performance.](https://reader030.fdocuments.net/reader030/viewer/2022032722/56649ce25503460f949ada41/html5/thumbnails/6.jpg)
MSP Instrument TrainingMSP Instrument Training
• Instrument training program change 10 months prior to accident
• Previously: 6 approaches every 6 months
• At time of accident: 2 instrument proficiency checks per year
• Training program change– 20 approaches prior for pilot– 4 approaches after for pilot
![Page 7: Office of Aviation Safety Maryland State Police Trooper 2 District Heights, MD Jill Demko Operations Group Chairman Malcolm Brenner, Ph.D. Human Performance.](https://reader030.fdocuments.net/reader030/viewer/2022032722/56649ce25503460f949ada41/html5/thumbnails/7.jpg)
Instrument ApproachInstrument Approach
• Helicopter aligned with glideslope despite pilot’s report of glideslope failure
• No evidence of glideslope malfunction• FAA and MSP guidance dictate ILS
becomes LOC approach after loss of glideslope
• Minimum descent altitude assures terrain clearance
• Many options available to pilot
![Page 8: Office of Aviation Safety Maryland State Police Trooper 2 District Heights, MD Jill Demko Operations Group Chairman Malcolm Brenner, Ph.D. Human Performance.](https://reader030.fdocuments.net/reader030/viewer/2022032722/56649ce25503460f949ada41/html5/thumbnails/8.jpg)
Terrain Awareness and Warning SystemTerrain Awareness and Warning System
• MSP had 3 TAWS equipped helicopters in fleet
• Accident helicopter not equipped with TAWS
• If equipped, pilot would have received 3 warnings:– 7 seconds: Caution terrain– 4 seconds: Warning terrain– 2 seconds: Pull up
![Page 9: Office of Aviation Safety Maryland State Police Trooper 2 District Heights, MD Jill Demko Operations Group Chairman Malcolm Brenner, Ph.D. Human Performance.](https://reader030.fdocuments.net/reader030/viewer/2022032722/56649ce25503460f949ada41/html5/thumbnails/9.jpg)
Public vs. Civil Aviation OperationsPublic vs. Civil Aviation Operations
• HEMS flights conducted by civil and public operators
• Civil HEMS flights under Part 135• Public HEMS flights exempt from
most FAA regulations and oversight • FAA safety oversight discrepancy
![Page 10: Office of Aviation Safety Maryland State Police Trooper 2 District Heights, MD Jill Demko Operations Group Chairman Malcolm Brenner, Ph.D. Human Performance.](https://reader030.fdocuments.net/reader030/viewer/2022032722/56649ce25503460f949ada41/html5/thumbnails/10.jpg)
Workload Issues Workload Issues
• Time pressure to deliver patients• Actual instrument conditions• Air traffic issues• Possibility of flying below cloud
cover
![Page 11: Office of Aviation Safety Maryland State Police Trooper 2 District Heights, MD Jill Demko Operations Group Chairman Malcolm Brenner, Ph.D. Human Performance.](https://reader030.fdocuments.net/reader030/viewer/2022032722/56649ce25503460f949ada41/html5/thumbnails/11.jpg)
PerformancePerformance
• No gross deficiencies in alertness or responsiveness
• Performance below his normal standards
![Page 12: Office of Aviation Safety Maryland State Police Trooper 2 District Heights, MD Jill Demko Operations Group Chairman Malcolm Brenner, Ph.D. Human Performance.](https://reader030.fdocuments.net/reader030/viewer/2022032722/56649ce25503460f949ada41/html5/thumbnails/12.jpg)
Fatigue Evaluation Fatigue Evaluation
• Late hour • Awake 16 hours• Sleep disorder risk factors• Routine sleep history• Rest facilities/coffee available• Fatigue may have contributed to
pilot’s deficient performance
![Page 13: Office of Aviation Safety Maryland State Police Trooper 2 District Heights, MD Jill Demko Operations Group Chairman Malcolm Brenner, Ph.D. Human Performance.](https://reader030.fdocuments.net/reader030/viewer/2022032722/56649ce25503460f949ada41/html5/thumbnails/13.jpg)