Maryland medevac lawsuit

8/8/2019 Maryland medevac lawsuit

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IN THE UNITED STATES DISTRICT COURTFOR THE DISTRICT OF MARYLANDSouthern D ivision

STATE OF MARYLAND *and *THE INSURANCE COMPANYOF THE STATE OF PENNSYLVANIA,

*

PlaintiffsV.

UNITED STATES OF AMERICA,SERVE ON: *United States Attorney GeneralDepartment of Justice *lot and Pennsylvania Avenue, NWWashington, DC 20530 *and: *Rod J. Rosenstein *United States Attorneyfor the District of Maryland36 S. Charles Street, 4th FloorBaltimore, Maryland 21201

Defendant **

Civil Action No.

*

COMPLAINTCOM ES N OW , the State of Maryland and The Insurance Company of the State of

Pennsylvania, plaintiffs herein, and for their complaint against defendant, the United States ofAm erica, state the following upon information and belief:

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Case 8:11-cv-00094-DKC Document 1 Filed 01/12/11 Page 1 of 17


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Jurisdiction and Venue

This action arises against the United States of America under the Federal TortClaims Act ("FTCA"), codified in Title 28 of the United States Code at sections 2671-2680 (28U.S.C. 2671-2680).

2. This Court is vested with jurisdiction over this matter pursuant to 28 U.S.C. 1346(b).

3. Venue in the District of Maryland is proper pursuant to 28 U.S.C. 1402(b)because the State of Maryland resides, and many of the acts or omissions complained of

occurred, in the judicial district.4. The United States of America will be served through the United States Attorney

General and the United States Attorney for the District of Maryland pursuant to Rule 4(i) of theFederal Rules of Civil Procedure.

5. Prior to initiation of this action, the State of Maryland and The InsuranceCompany of the State of Pennsylvania filed a timely administrative claim with the United StatesDepartment of Transportation, Federal Aviation Administration ("FAA"), on or about September22, 2010, as required by 28 U.S.C. 2675(a).

6. On or about December 2, 2010, by registered mail, the FAA responded to thePlaintiffs administrative claim, denied responsibility for the loss at issue, and informed the Stateof Maryland and The Insurance Company of the State of Pennsylvania of their right to file suit.

7. The State of Maryland and The Insurance Company of the State of Pennsylvania haveelected to file suit in accordance with 28 U.S.C. 2675.

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Factual Allegations8. Plaintiff State of Maryland was the own er of a 1989 Aerospatiale SA365N- 1

Dauphin helicopter, registration N92MD, now destroyed (the "Aircraft")9. Plaintiff The Insurance Company of the State of Pennsylvania insured the Aircraft

against physical injury.10. At all times relevant hereto, the Aircraft was one of a fleet of aircraft operated by

the State of Maryland through the M aryland State Police Aviation Comm and ("MSPA C"), whichoperated a public use helicopter service on behalf of the citizens of Maryland to conduct, among

other things, medical eva cuation flights.11. The F ederal Aviation Adm inistration ("FAA"), which operates the A TC system

and employs air traffic controllers who provide services within this system, is an agency of theUnited States of America.

12. The primary purpose of the ATC system is to prevent a collision between aircraftoperating in the system and to organize and expedite the flow of traffic, and to provide supportfor National Security and Homeland Defense. In addition to its primary function, however, theATC system has the capability to provide (with certain limitations) additional services. Theability to provide additional services is limited by m any factors, such as the v olume of traffic,frequency con gestion, quality of radar, controller workload, higher priority duties, and the purephysical inability to scan and detect those situations that fall in this category. It is recognizedthat these services cannot be provided in cases in which the provision of services is precluded bythe above factors. Consistent with the aforementioned conditions, controllers are required toprovide additional service procedures to the extent permitted by higher priority duties and other

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circumstanc es. The provision of add itional services is not optional on the part of the controller,but rather is required when the work situation permits.

13. On September 27, 2008, the State dispatched the Aircraft, call sign "Trooper 2,"from its base at Andrews Air Force Base ("ADW ") to the scene of a motor vehicle accident inthe area of W aldorf, Maryland, for a medical evacuation flight.

14. Arriving near the motor vehicle scene, the Aircraft picked up two motor vehicleaccident victims and a volunteer paramedic and subsequently departed for Prince GeorgesHospital ("PGH") in Cheverly, Maryland. There were five individuals onboard Trooper 2 at thetime: two motor vehicle accident victims, the pilot, a paramedic, and a volunteer paramedic.

15. En route to PGH, the pilot of the Aircraft was in communication with the RonaldReagan Washington National Airport Tower ("Washington Tower"). The pilot advised theWashington T ower that, due to deteriorating weather, the Aircraft was not able to land at PGH:"[W]e just ran into some heavy stuff - I dont think were gonna be able to make it all the way tothe hospital.... Id like to continue on about three more miles and see what happens, and if Idont get a hole Ill have to go IFR back to Andrews."

16. Anyone familiar with the aviation lexicon would have understood this transmissionto mean that Trooper 2 was encountering weather that would prevent a descent in visualmeteorological conditions and that, if the pilot did not find an opening in the. clouds, he would needto fly under instrument flight rules through instrument meteorological conditions to ADW.

17. The Washington Tower controller advised Trooper 2s pilot that he could choosean altitude at his discretion and to advise of his intentions.

18. Subsequently, Trooper 2s pilot confirmed that the weather required flight underinstrument flight rules through instrument m eteorological conditions: "[I]ts just solid up here,"

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the pilot advised; "Id like to climb to 2,000 feet and go over to radar and shoot an approachback into Andrews." The FAA air traffic controller "approved as requested" and directedTrooper 2 to "contact approach."

19. The Washington Tower controller never inquired whether the pilot was qualifiedto fly under instrument flight rules and failed to coordinate with the Potomac Terminal RadarApproach Control ("Potomac TRACON") about transitioning the Aircraft to its airspace control.

20. Coordinating Trooper 2s request would have saved Trooper 2s pilot from havingto explain his circumstances and request to the Potomac T RACO N controller and would have

increased the likelihood that the Potomac TRACON would have provided appropriate and timelyservices to Trooper 2. The failure to do so increased the pilots workload, making an alreadystressful situation more stressful.

21. At 11:48 pm, Trooper 2s pilot made contact with the Potomac T RACO N, whichthe Potomac TRACON controller acknowledged. Trooper 2s pilot then replied, "We tried tomake a medevac up at PG hospital, were about seven miles northwest of Andrews, like to climbto 2,000 feet and shoot an approach into runway one left at Andrews."

22. The Potomac TRAC ON controller should have understood this broadcast to meanthat Trooper 2 was carrying one or more patients and needed to fly an instrument approach to,and land, at Andrews. The controller, however, did not respond.

23. Despite having heard Trooper 2s initial call, the Potomac TRACON controllerwalked away from his position to address a low priority duty, assuming that Trooper 2 would bea routine call, and he did not hear all of Trooper 2s transm ission.

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24. Trooper 2s pilot waited for a minute and broadcast once again. The PotomacTRACON controller responded this time but solely with the "Trooper 2" call sign. He failed torespond to, or even acknowledge, Trooper 2s request.

25. Trooper 2s pilot stated that he was waiting for a reply and that he was headingtwo hundred degrees and climbing to two thousand feet.

26. The Potomac TRACON controller was slow to respond and, completely disregardingthe pilots request for an approach to ADW, issued instructions to contact Washington Tower.

27. The pilot, appropriately frustrated at this point, responded, "No, sir. I want toshoot the approach at Andrews."

28. The Potomac TRACON controller transmitted, "Tell you wh at go direct to theyou - you want to shoot the ILS to 19, what runway?"

29. At this point, Trooper 2s pilot asked, "Are they using 19? Uh, runway one nine right?"

30. Thus, despite what was a very light workload for the Potomac TRACONcontroller and a heavy workload under stressful conditions for the pilot, the Potomac TRACONcontroller was slow to respond, made the pilot repeat his requests, and offered no assistance.

31. Upon information and belief, one reason the P otomac TRACON controller was sounresponsive and unhelpful is that he and anothe r controller assigned to work the pa rticular shifthad agreed that each would work only half the shift while the other would take an extendedbreak. But even that does not fully explain the poor service that the Potomac TRACONcontroller provided.

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32. The Potomac TRAC ON controller then gave T rooper 2 an instrument flightclearance to Andrews and provided radar vectors to the final approach course for the ILS runw ay19R approach.

33. He was required to, and was about to, assign a discrete transponder code to Trooper 2but then chose not to do so. This prevented the controllers from receiving minimum safe altitudewarnings ("MSAW Alerts") when T rooper 2 subsequently flew too low to the ground.

34. Trooper 2s pilot explained to the Potomac TRACON controller that he hadpatients on board and was "trying to get them down."

35. The Potomac TRAC ON controller issued to Trooper 2 w hat he called the "latest"Andrews weather (seven miles visibility, an 1,800 foot cloud ceiling, and a two degree Celsiustemperature/dewpoint spread), but the weather information was almost five hours old at the time itwas issued and suggested weather far better than the weather actually was at the time or that thencurrent report would have suggested. At the time the Potomac TRACON controller issued the"latest" weather, the current wea ther report indicated that the temperature/dewpoint spread w as zero.

36. Dewpoint is the temperature to which air must be cooled in order to be saturatedwith water vapo r present in the air. Weather reports for pilots include the dewpoint as we ll asthe temperature. When the two are compared, the difference reveals to the pilot how close theair is to being 100% saturated. This difference is called the tem perature-dew po int spread.

37. Had Trooper 2s pilot been told that the temperature had reached the dewpoint, ashe should have been, he would have known that Andrews likely was enshrouded in fog.

38. The Potomac TRAC ON controller asked the pilot whether he wanted a "shortapproach." N ormally, controllers are required to provide radar vectors so that the aircraft

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intercept the final approach course three miles or more from the final approach fix. The standardthree miles provides adequate time and distance for an aircraft to intercept and establish itself onthe approach course. Approaches can be made with less distance, but doing so makes theprocess more challenging and g ives the pilot less time to take care of other duties.

39. Trooper 2s pilot opted for the short approach (perhaps because he had patients onboard and was anxious to get them on the ground), and the Potomac TRACON controllervectored accordingly.

40. The Potomac TR ACON controller, however, was not permitted to offer a shortapproach and, in so doing, made the approach more challenging for the pilot and gave him lesstime to take care of his other cockpit duties.

41. The Potomac TRACO N controllers handling of Trooper 2 as the aircraftapproached the final approach course also was deficient. He was late in issuing a turn to interceptthe final approach course, resulting in an overshoot that was corrected by the pilot rather than thecontroller. The controller issued a heading of 170 degrees, which would have allowed Trooper 2to intercept the final approach course at an angle of about 20 degrees, except that the instructionwas issued too late. Trooper 2 c rossed the localizer and had to turn to intercept the finalapproach course from the east side, requiring a heading of about 210 degrees. The pilotcorrected the poor intercept on his own, with no comment or assistance from the controller, butwas likely distracted from other duties as a result.

42. Once Trooper 2 intercepted the final approach course, the Potomac TR ACONcontroller instructed Trooper 2 to contact the Andrews Control Tower. Despite knowing that

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Trooper 2 w as carrying two patients, the Potomac T RACO N controller did nothing to coordinatewith the Andrews T ower before switching Trooper 2 over to its frequency.

43. he ILS, or instrument landing system, approach consists of the following components:

a. The localizer, which provides course guidance by transmitting a beambetween three and six degrees wide (adjusted to provide for a 700 width atthe runway threshold);

b. The glideslope, which transmits an angular beam of 1.40 from top to bottomand provides glidepath guidance; and

c. Marker beacons or, in the case of the ILS Runway 19R to Andrews, distancemeasuring equipment (DME ) fixes and marker beacons which provide rangeinformation.

44. he localizer is a ground-based transm itter that provides course guidance for thepilot. The localizer antenna is situated at the departure end (the far end) of the primary runwaythat it serves. Not infrequently, a given runway is served by an ILS approach to each end. Insome cases, these ILS approaches have the same frequency, in which case the ILS systems ateach end of the runway are not operated simultaneously. This was the case with the ILS servingRunway 19R at Andrews. The tower controller would select which ILS system is active with acontrol panel in the tower.

45. he localizer provides lateral guidance to allow an aircraft to navigate to andarrive at the approach end of the runway aligned with the runway. The glideslope providesvertical guidance.

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46. he instrument approach that Trooper 2 was cleared to execute is the ILS Runway19R approach. A copy of the chart for this approach appears in Figure One, below.

CAMP SPRINGS, MARYLAND ILS or LOC R \A/Y 19RbC -MXK PCII CR3 Ry Id9 9300111.5 190" lev AL-561 (USAFI ANDREWS APE/NAP (KADW)

V hen AL5 mop, mncease CAT ABC DE RVR to 40 and yin to 4 mile, A SF-S MISSED APPR OACH: Climb to 900,WhenALS loop license CAT AR RVR to 50 and v o I mile, CAT CD RVR - thee climbing let Irn to 2230to 80 andvis to 1. iii en, CAT E eN to 11i miles,, -j direct R,ATTA and io d.* * Circling nct autiorized V/of Rey iL-i PRA71 OTOMAC APP CON NDREWS TOWER ND Cot-I CINC DEl.113.1 251.05 19.3 335.5 118.4 349.0 21.8 275.8 27.55 285.475 ASR

WIen AbS mop, Increase CAT AR RYR to 50 egD V BALTIMOREcod vie to 1 mile, CAT CD us 10 ilL miles, CATEve to llrriles.(I F t A Mm Rolling

25 Do/ DCAR-D57 O Maxalt 25DOholding

/ 40W It 4030Mci,c holding1149 \L_ J 23OKIAS/3 \

PUFFE Misnel approach requires ATI 0-CA R-078 RADAR monitoring.I ,-.- 40WI -o J I

803 ANDREWS\ 38 113.1ADW...l /Z \\ OPR CO

IJ R-098\ WASHNGICN - / RATTA\i it.o DCA . / AO W 0ChOti 47 . , ,__/ / L

DW 2474 Ao LI1/ 0coN LOCALIZEI1 - n .s CD0 I-MXKEMERG SAFE ALT 100 NM 6300 - . - \ _- wr FROM "ADW" VORTAC Ln

- - OTTNGI-IAMELEY 280 66i90 5.iNMAfrom FA T 30 6 61S bL269, A GDC DA 0-057 200 500 AITA0 DW CAR C78 A -098

48301 0 40W ED1 f

00 BARLS ACWVORTAC VCbl angle andito (i-t not-0" . , oncidont with20001 I lhelSglide

435 I c" I slope orgle aid

CArEoRi B 0 F81 S ILS 19R * 73/18 200 (200 - 4) 73/24 00 1200-2)

fi 680/50TOZI Rwy 1L-9R L IU S-LOC 19R - 680/24 407 (400-1-3) 680/40 407 (400-i1) 4C0-ilHIRLalI Rsvp 7201 40 1 -40 1OC es to MAP (.6 NM CIRCLING , , 1 840-2 560 16Cc-S)11-MeSon 3041 ;: 50 I 1:3715-ASR 198 1780/24 213/ (2UQfl 1780/50 0/ 131J31l 507 (600 114(1CAMP SPRINGS, MARYLAND 38" L9N-76 57W ANDREWS ATE/MAE (KADV)009 08269

ILS or LOC RWY 19RFigure 1. The Insirtitnent Approach Chart for u.S Runway 191Z at Andrews.

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47. he "plan view" (or overhead view) section of the approach chart (see FigureTwo) shows that the final approach course is 190 degrees, which aligns with Runway 19R(runways are assigned numbers based on their magnetic headings with the last digit omitted; thusif the runways magnetic heading is 191 degrees, it is called Runway 19).

+ Wion ALS mop. incroao CAT AS RVR to 50cod vis o 1 ml o CAT CO n to 1i milas , CAT0 o o 1T$n,ilos,/ t A Mm holding/ ESUDE oil 2500I/ DCA R -057ADW IT Ma,, haIair.11 4000

1149D -j , max holding230 KIA

__Vt BALTIMOREt\

AI P-56S 3~ eP-56A -

685A\\O, All" 7 WASHINGTON

11.0 DCA?c 47k

EMERG SAFE ALT 100 NM 6300FROM ADW VORTACI 268

NM90 1mm FAF X6 16

86,

PIJFFF M med opp-ooci. roqoiro ArCOCA 5-078 8ADAR monitoring,ADWED I8A ANDREW S438

SRATTAADW

I / : P,/ OILOCALIZER 11 1.5

-- 140T7INGHAM

Figure 2. Chart Plait View.48. he "profile view" section of the approach chart (see Figure Three) shows that an

aircraft on the localizer and closer than 10 DM E (nautical miles) to the A ndrews VO RTAC maydescend to an altitude of 2,000 feet or above. The lightning bolt pointing from "2000" to the Maltesecross indicates that the glideslope intercept altitude is 2,000 feet MS L. The a ircraft is to stay at orabove 2,000 feet until it intercepts the glideslope, at wh ich point descent along the g lideslope (whilefollowing the localizer) is permitted. The "G S 3.00 " indicates that the glideslope cen terline is at athree degree upward angle from the transmitter. "TCH 58" means that an aircraft on the glideslopecenterline will cross the runway threshold 58 feet above the touchdown zone elevation.

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[DUDE DCA r-O57 PUFE I 2500 I RA1TAI -O98DW E tCA -07ED

2500

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better than 2,400 feet at the runway. The "407" indicates that the MSL altitude of 680 feetequates to 407 feet above the touchdown zone elevation. The numbers in parentheses are formilitary operations. In this situation, the approach becomes a "non-precision approach," anddifferent information from the profile view becomes relevant. The reason for the d ifferent namesof the minima for the full ILS or localizer-only approaches is the recognition that, if the aircraftis descending along the glideslope, it will (due to reaction time and inertia) descend below thedecision altitude even if the decision to execute the missed approach is made at that point. Witha localizer-only approach, the minimum is in fact a minimum altitude. With a non-precisionapproach, the missed approach is initiated at a missed approach point, which is determined eitherby timing from the "final approach fix" or in the case of this approach by the BAR LE fix, whichcan be determined using distance measuring equipment or estimated using time, speed, anddistance calculations. A time table is presented on the approach chart, and pilots using the tablemust approximate their groundspeed and, if necessary, interpolate between values.

52. The final approach fix is marked by the Maltese cross and is identified by 6 .1DME from the Andrews VORTAC. BARLE is identified by 1.5 DME from AndrewsVORTAC. That the missed approach point is at BARLE is indicated by the approach course linechanging from solid to dashed at that point.

53. After the Potomac TRACON controller advised Trooper 2 to contract AndrewsTower, the pilot advised Andrews Tower that Trooper 2 is "with you ah for on the localizer forrunway one nine right."

54. The Tower Controller cleared Trooper 2 for the option. Cleared for the option isan ATC authorization for an aircraft to make a touch-and-go, low approach, missed approach,stop and go, or full stop landing at the discretion of the pilot. The Tower Controller did not

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know that Trooper 2 was carrying patients or planned a full stop landing because the PotomacTRACON controller failed to coordinate with her to provide this information.

55. After being cleared for the option to land at ADW , and just before midnight onSeptember 27, 2008, Trooper 2s pilot advised the Tower Controller that he was not "picking upthe glideslope."

56. The Tower Controller replied, "its showing green on the panel but youre theonly aircraft weve had in a long time so I dont really know if its working or not."

57. Almost immediately thereafter, and at approximately three (3) minutes beforemidnight, Trooper 2s pilot requested an Airport Surveillance Radar ("ASR") approach. Arequest for an ASR approach is a request from an aircraft to air traffic controllers to provideguidance to the runway using ground-based radar.

58. The Tower Controller responded that she was not "current" on ASR approachesand could not give one. Thereafter, she neither inquired as to the pilots intentions nor did sherender, or attempt to render, any other assistance to Trooper 2.

59. Shortly after the Tower Controller declined to give Trooper 2 the ASR approach,Trooper 2 entered a steep descent that continued until the aircraft crashed in Walker Mill RegionalPark in District Heights, Maryland, approximately three-and-a-half miles short of the runway.

60. Despite not being current on ASR approaches, the ADW Tower was equippedwith a Tower Radar Display that displayed Trooper 2s position, groundspeed, and altitude. TheTower Controller was required to use the Tower Radar Display.

61. Controllers are required to issue a safety alert to an aircraft if they are aware theaircraft is in a position/altitude which, in their judgm ent, places it in unsafe proxim ity to terrain,obstructions, or other aircraft. The issuance of a safety alert is considered a first priority duty

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once the controller observes and recognizes a situation of unsafe aircraft proximity to terrain,obstacles, or other aircraft. Conditions, such as workload, traffic volume, the quality/limitationsof the radar system, and the a vailable lead time to react are factors in determining whethe r it isreasonable for the controller to observe and recognize such situations.

62. The Tower Controller did not have any higher priority duties. There was nofrequency congestion, and her w orkload was limited to one aircraft. Her inability to see outsidethe tower cab, an aircraft that had reported trouble receiving the g lideslope, and a deniedrequested for an AS R approach justified rapt attention to the radar display.

63. The Tow er Controller never advised Trooper 2 that he was descending toorapidly, was unusually low, that she "lost him on radar," or that she could not see him becausethe control tower was shrouded in fog.

64. The Tower Controller had the last clear chance to prevent this accident, but shedid not or even attemp t to do so. Indeed, the evidence suggests that despite the fact thatTrooper 2 w as the only aircraft she was in com mun ication with at the time she was n ot payingattention to Trooper 2.

65. Trooper 2 w as destroyed in the crash and fou r of its five occupants were killedand the fifth severely injured.

66. Plaintiff The Insurance Com pany of the State of Pennsylvania insured thehelicopter operated as Trooper 2 against physical injury. As a result of its destruction, TheInsurance Com pany of the State of Pennsylvania paid plaintiff State of Maryland the insuredvalue of the helicopter, $4,114,000 less a $100,000 deductible.

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NEGLIGENCE

67 . Plaintiffs incorporate herein each of the allegations contained in paragraphs onethrough 66.

68 . The FAA, through its employees, has a duty to assign air traffic controllers towork shifts so that competent personnel are available to perform the services offered by thefacilities that they staff or, if they will not do so, to issue appropriate notices to pilots.

69 . FAA employees, including each of the air traffic controllers whose involvementwith Trooper 2 has been alleged, have a duty to act with reasonable care in performing theirofficial duties.

70 . The FAA, acting through its employees within the course of their employment,and individual FAA employees, including each of the air traffic controllers whose involvementwith Trooper 2 has been alleged, each acting within the course of employment with the FAA,breached legal duties owed to the State, including, but not limited to the following particulars:

a. Failing to staff the Andrews Tower on the shift during which the accident tookplace with a controller competent to issue ASR approaches or, alternatively,issuing notices to airmen that ASRs were not available at specified times;

b. Permitting lightly staffed sectors of air traffic control facilities to be evenmore lightly staffed by condoning a practice of air traffic controllers workingonly half of their assigned shift and remaining on break for the other half,

c. providing outdated weather information;d. failing to issue a discrete transponder code (thereby precluding minimum safealtitude warnings);e. providing poor service due to distraction of each of the controllers byunimportant or lower priority matters (costing Trooper 2 valuable time and

opportunity, distracting the pilot, and unnecessarily increasing his workload inpoor weather conditions);

f. failing to coordinate with subsequent controllers;g. improperly radar vectoring;

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h. failing to provide assistance;i. failing to issue safety alerts;

failing to closely monitor Trooper 2;k. failing to advise loss of radar contact; and1. failing to advise of rapidly deteriorating weather.

71. The foregoing breaches of duty, individually and collectively, were a substantialcause of the crash and the loss of Trooper 2.

72. The State of Maryland and The Insurance Company of the State of Pennsylvaniawere damaged thereby in the amount of $4,114,000.00.

WH ERE FOR E, Plaintiffs respectfully request that the Court grant judgment in their favoragainst the United States of America and award them damages in the sum of $4,114,000.00 pluscosts.

Dated: January 10, 2011 Respectfully submitted,STATE OF MARYLAND andTHE INSURANCE COMPANY OF THE STATEPENNSYLVANIABy Counsel

SCHNADER HA RRISON SEGAL & LEWIS LLP

BL( U2Jonhan M. Stern (Trial Bar No. W 933)[email protected] S. W oodward (Trial Bar No. 14210)gwoodwardschnader. cornMollie L. Finnan (Bar No. 17199)[email protected] Ninth Street, NW, Suite 550Washington, DC 20001Telephone: (202) 419-4202Facsimile: (202) 419-4252


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