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STATE OF MARYLAND *
and *
SERVE ON: *
United States Attorney General
Department of Justice *
lot
and Pennsylvania Avenue, NW
Washington, DC 20530 *
and: *
Rod J. Rosenstein *
United States Attorney
for the District of Maryland *
36 S. Charles Street, 4th Floor
Baltimore, Maryland 21201 *
Defendant *
* * * * * * * * * * * * *
COMPLAINT
COMES NOW, the State of Maryland and The Insurance Company of the State of
Pennsylvania, plaintiffs herein, and for their complaint against defendant, the United States of
PHDATA 33530911
Case 8:11-cv-00094-DKC Document 1 Filed 01/12/11 Page 2 of 17
This action arises against the United States of America under the Federal Tort
Claims Act ("FTCA"), codified in Title 28 of the United States Code at sections 2671-2680 (28
U.S.C. §§ 2671-2680).
2. This Court is vested with jurisdiction over this matter pursuant to 28 U.S.C. §
1346(b).
because the State of Maryland resides, and many of the acts or omissions complained of
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 the
5. Prior to initiation of this action, the State of Maryland and The Insurance
Company of the State of Pennsylvania filed a timely administrative claim with the United States
Plaintiffs’ administrative claim, denied responsibility for the loss at issue, and informed the State
of 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 have
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Factual Allegations
9. Plaintiff The Insurance Company of the State of Pennsylvania insured the Aircraft
10. At all times relevant hereto, the Aircraft was one of a fleet of aircraft operated by
the State of Maryland through the Maryland State Police Aviation Command ("MSPAC"), which
operated a public use helicopter service on behalf of the citizens of Maryland to conduct, among
11. The Federal Aviation Administration ("FAA"), which operates the ATC system
and employs air traffic controllers who provide services within this system, is an agency of the
12. The primary purpose of the ATC system is to prevent a collision between aircraft
operating in the system and to organize and expedite the flow of traffic, and to provide support
for National Security and Homeland Defense. In addition to its primary function, however, the
ATC system has the capability to provide (with certain limitations) additional services. The
ability to provide additional services is limited by many factors, such as the volume of traffic,
frequency congestion, quality of radar, controller workload, higher priority duties, and the pure
physical inability to scan and detect those situations that fall in this category. It is recognized
that these services cannot be provided in cases in which the provision of services is precluded by
the above factors. Consistent with the aforementioned conditions, controllers are required to
provide additional service procedures to the extent permitted by higher priority duties and other
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circumstances. The provision of additional services is not optional on the part of the controller,
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 in
14. Arriving near the motor vehicle scene, the Aircraft picked up two motor vehicle
accident victims and a volunteer paramedic and subsequently departed for Prince George’s
Hospital ("PGH") in Cheverly, Maryland. There were five individuals onboard Trooper 2 at the
time: 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 Ronald
Reagan Washington National Airport Tower ("Washington Tower"). The pilot advised the
Washington Tower that, due to deteriorating weather, the Aircraft was not able to land at PGH:
"[W]e just ran into some heavy stuff - I don’t think we’re gonna be able to make it all the way to
the hospital.... I’d like to continue on about three more miles and see what happens, and if I
16. Anyone familiar with the aviation lexicon would have understood this transmission
to mean that Trooper 2 was encountering weather that would prevent a descent in visual
meteorological conditions and that, if the pilot did not find an opening in the. clouds, he would need
to fly under instrument flight rules through instrument meteorological conditions to ADW.
17. The Washington Tower controller advised Trooper 2’s pilot that he could choose
18. Subsequently, Trooper 2’s pilot confirmed that the weather required flight under
instrument flight rules through instrument meteorological conditions: "[I]t’s just solid up here,"
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the pilot advised; "I’d like to climb to 2,000 feet and go over to radar and shoot an approach
back into Andrews." The FAA air traffic controller "approved as requested" and directed
19. The Washington Tower controller never inquired whether the pilot was qualified
to fly under instrument flight rules and failed to coordinate with the Potomac Terminal Radar
Approach Control ("Potomac TRACON") about transitioning the Aircraft to its airspace control.
20. Coordinating Trooper 2’s request would have saved Trooper 2’s pilot from having
to explain his circumstances and request to the Potomac TRACON controller and would have
increased the likelihood that the Potomac TRACON would have provided appropriate and timely
services to Trooper 2. The failure to do so increased the pilot’s workload, making an already
21. At 11:48 pm, Trooper 2’s pilot made contact with the Potomac TRACON, which
the Potomac TRACON controller acknowledged. Trooper 2’s pilot then replied, "We tried to
make a medevac up at PG hospital, we’re about seven miles northwest of Andrews, like to climb
to 2,000 feet and shoot an approach into runway one left at Andrews."
22. The Potomac TRACON controller should have understood this broadcast to mean
that Trooper 2 was carrying one or more patients and needed to fly an instrument approach to,
23. Despite having heard Trooper 2’s initial call, the Potomac TRACON controller
walked away from his position to address a low priority duty, assuming that Trooper 2 would be
a routine call, and he did not hear all of Trooper 2’s transmission.
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Case 8:11-cv-00094-DKC Document 1 Filed 01/12/11 Page 6 of 17
24. Trooper 2’s pilot waited for a minute and broadcast once again. The Potomac
TRACON controller responded this time but solely with the "Trooper 2" call sign. He failed to
respond to, or even acknowledge, Trooper 2’s request.
25. Trooper 2’s pilot stated that he was waiting for a reply and that he was heading
26. The Potomac TRACON controller was slow to respond and, completely disregarding
the pilot’s 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 to
28. The Potomac TRACON controller transmitted, "Tell you what go direct to the
29. At this point, Trooper 2’s pilot asked, "Are they using 19? Uh, runway one nine right?"
30. Thus, despite what was a very light workload for the Potomac TRACON
controller and a heavy workload under stressful conditions for the pilot, the Potomac TRACON
controller was slow to respond, made the pilot repeat his requests, and offered no assistance.
31. Upon information and belief, one reason the Potomac TRACON controller was so
unresponsive and unhelpful is that he and another controller assigned to work the particular shift
had agreed that each would work only half the shift while the other would take an extended
break. But even that does not fully explain the poor service that the Potomac TRACON
controller provided.
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Case 8:11-cv-00094-DKC Document 1 Filed 01/12/11 Page 7 of 17
32. The Potomac TRACON controller then gave Trooper 2 an instrument flight
clearance to Andrews and provided radar vectors to the final approach course for the ILS runway
19R approach.
33. He was required to, and was about to, assign a discrete transponder code to Trooper 2
but then chose not to do so. This prevented the controllers from receiving minimum safe altitude
warnings ("MSAW Alerts") when Trooper 2 subsequently flew too low to the ground.
34. Trooper 2’s pilot explained to the Potomac TRACON controller that he had
35. The Potomac TRACON controller issued to Trooper 2 what he called the "latest"
Andrews weather (seven miles visibility, an 1,800 foot cloud ceiling, and a two degree Celsius
temperature/dewpoint spread), but the weather information was almost five hours old at the time it
was issued and suggested weather far better than the weather actually was at the time or that then
current report would have suggested. At the time the Potomac TRACON controller issued the
"latest" weather, the current weather report indicated that the temperature/dewpoint spread was zero.
36. Dewpoint is the temperature to which air must be cooled in order to be saturated
with water vapor present in the air. Weather reports for pilots include the dewpoint as well as
the temperature. When the two are compared, the difference reveals to the pilot how close the
air is to being 100% saturated. This difference is called the temperature-dew point spread.
37. Had Trooper 2’s pilot been told that the temperature had reached the dewpoint, as
he should have been, he would have known that Andrews likely was enshrouded in fog.
38. The Potomac TRACON controller asked the pilot whether he wanted a "short
approach." Normally, controllers are required to provide radar vectors so that the aircraft
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Case 8:11-cv-00094-DKC Document 1 Filed 01/12/11 Page 8 of 17
intercept the final approach course three miles or more from the final approach fix. The standard
three miles provides adequate time and distance for an aircraft to intercept and establish itself on
the approach course. Approaches can be made with less distance, but doing so makes the
process more challenging and gives the pilot less time to take care of other duties.
39. Trooper 2’s pilot opted for the short approach (perhaps because he had patients on
board and was anxious to get them on the ground), and the Potomac TRACON controller
vectored accordingly.
40. The Potomac TRACON controller, however, was not permitted to offer a short
approach and, in so doing, made the approach more challenging for the pilot and gave him less
approached the final approach course also was deficient. He was late in issuing a turn to intercept
the final approach course, resulting in an overshoot that was corrected by the pilot rather than the
controller. The controller issued a heading of 170 degrees, which would have allowed Trooper 2
to intercept the final approach course at an angle of about 20 degrees, except that the instruction
was issued too late. Trooper 2 crossed the localizer and had to turn to intercept the final
approach course from the east side, requiring a heading of about 210 degrees. The pilot
corrected the poor intercept on his own, with no comment or assistance from the controller, but
42. Once Trooper 2 intercepted the final approach course, the Potomac TRACON
controller instructed Trooper 2 to contact the Andrews Control Tower. Despite knowing that
PHDATA 3353091_1
Case 8:11-cv-00094-DKC Document 1 Filed 01/12/11 Page 9 of 17
Trooper 2 was carrying two patients, the Potomac TRACON controller did nothing to coordinate
with the Andrews Tower before switching Trooper 2 over to its frequency.
43. The ILS, or instrument landing system, approach consists of the following components:
between three and six degrees wide (adjusted to provide for a 700’ width at
b. The glideslope, which transmits an angular beam of 1.40 from top to bottom
c. Marker beacons or, in the case of the ILS Runway 19R to Andrews, distance
measuring equipment (DME) fixes and marker beacons which provide range
information.
44. The localizer is a ground-based transmitter that provides course guidance for the
pilot. The localizer antenna is situated at the departure end (the far end) of the primary runway
that it serves. Not infrequently, a given runway is served by an ILS approach to each end. In
some cases, these ILS approaches have the same frequency, in which case the ILS systems at
each end of the runway are not operated simultaneously. This was the case with the ILS serving
Runway 19R at Andrews. The tower controller would select which ILS system is active with a
45. The localizer provides lateral guidance to allow an aircraft to navigate to and
arrive at the approach end of the runway aligned with the runway. The glideslope provides
vertical guidance.
9 PHDATA 3353091_1
Case 8:11-cv-00094-DKC Document 1 Filed 01/12/11 Page 10 of 17
46. The instrument approach that Trooper 2 was cleared to execute is the ILS Runway
19R approach. A copy of the chart for this approach appears in Figure One, below.
CAMP SPRINGS, MARYLAND
APCII CR3 R’y Id9 9300
ILS or LOC R\A/Y 19R
bC -MXK
111.5 190" AL-561 (USAFI ANDREWS APE/NAP (KADW)
Elev
V When AL5 mop, mnc’ease CAT ABCDE RVR to 40 and yin to 4 mile, A SF-S MISSED APPROACH: Climb to 900,
WhenALS loop license CAT AR RVR to 50 and v ’o I mile, CAT CD RVR - - thee climbing let Irn to 2230
to 80 andvis to 1.’ iii en, CAT E eN to 11i miles,, -j direct R,ATTA and io d.
* * Circling nct autiorized V/of R’ey iL-i PR
A71 OTOMAC APP CON ANDREWS TOWER GND Cot-I CINC DEl.
113.1 251.05 119.3 335.5 1 118.4 349.0 121.8 275.8 127.55 285.475 ASR
WI’en AbS mop, Increase CAT AR RYR to 50
cod vie to 1 mile, CAT CD us 10 ilL miles, CAT
egD 4 V BALTIMORE
Eve to llrriles.
(I F’ t A Mm Rolling
alt 25DO
DCAR-D57
O 25 Do
Max holding
/
/
40W f 0 It 4030
Mci,c holding
\
1149 \
L_J 23OKIAS
\
/3
PUFFE Misnel approach requires AT
0-CA R-078
I 40W
RADAR monitoring.
I ,-.-
I -o A jJ I
803 ANDREWS
- A 438
\ 113.1ADW...l
/
Z
\\ N OPR
CO
I‘J R-098
\ WASHNGICN RATTA
- /
\’i it.o DCA AOW 0
-. /
ChOti 47
A
.,,__/ ADW
2
474 / L
o
/
LI1 co
0
N LOCALIZEI1 - n .s CD
0 I-MXK
EMERG SAFE ALT 100 NM 6300 - . - \ _- w
r FROM "ADW" VORTAC Ln
- -’ NOTTNGI-IAM
ELEY 280 I 266
i90 5.iNM’A
from FAT 306 161
bL
S269, A
GDC DA 0-057 200 2500 RAITA
0 010
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BARLS ACW
00 VORTAC VCbl angle and
ito (i-t not
-0" -. I , concidont with
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lhelSglide
slope orgle aid
435 I cc" I
CArEoRi A B 0 F
381 S ILS 19R * 473/18 200 (200- 4) 473/24 200 1200-2)
fi 0 680/50
TOZI Rwy 1L-9R 1L I IU S-LOC 19R - ’ 680/24 407 (400-1-3) 680/40 407 (400-i1) (4C0-il
HIRLalI Rsvp 7201 740 1 7-40 1‰
OC es to MAP (.6 NM CIRCLING 111- ,,’ 1 840-2 560 16Cc-S)
10 PHDATA 3353091_1
Case 8:11-cv-00094-DKC Document 1 Filed 01/12/11 Page 11 of 17
47. The "plan view" (or overhead view) section of the approach chart (see Figure
Two) 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; thus
0o to 1T$n,ilos, t\ \
/ t A
Mm holding
I/
oil 2500
ESUDE
Ma,, haIair
DCA R - 057
.11 4000
1149
/ D
ADW
-jIT , max holding
230 KIA
A
I e
P-56S
P-56A
Z3~ PIJFFF
OCA 5-078
M med opp-ooci. roqoiro ArC
8ADAR monitoring,
ADW
-
38A ED ANDREW S
I
685
\ A 438
\Or, All
S
"7 I WASHINGTON RATTA
11.0 DCA?
Ck c 47 I /: ADW
D P,
/ DOI
LOCALIZER 11 1.5
EMERG SAFE ALT 100 NM 6300
FROM ADW VORTAC -
-- 140T7INGHAM
I 268
190 1 NM
mm FAF X6 16
86,
Figure 2. Chart Plait View.
48. The "profile view" section of the approach chart (see Figure Three) shows that an
aircraft on the localizer and closer than 10 DME (nautical miles) to the Andrews VORTAC may
descend to an altitude of 2,000 feet or above. The lightning bolt pointing from "2000" to the Maltese
cross indicates that the glideslope intercept altitude is 2,000 feet MSL. The aircraft is to stay at or
above 2,000 feet until it intercepts the glideslope, at which point descent along the glideslope (while
following the localizer) is permitted. The "GS 3.00 " indicates that the glideslope centerline is at a
three degree upward angle from the transmitter. "TCH 58" means that an aircraft on the glideslope
centerline will cross the runway threshold 58 feet above the touchdown zone elevation.
11 PHDATA 33530911
Case 8:11-cv-00094-DKC Document 1 Filed 01/12/11 Page 12 of 17
<DND
49. The minima section of the chart (see Figure Four) shows various minima
applicable to the approach. Trooper 2 fell into approach category "A." The top minima line
indicates that, with both localizer and glideslope functioning (i.e., a "full" ILS approach), the
approach could be continued to a "decision altitude" of 473 feet MSL. The "18" following the
slash indicates that the visibility must be at or better than 1,800 feet at the runway. The "200"
indicates that the MSL altitude of 473 feet equates to 200 feet above the touchdown zone
fiI R 680/50
TD!L Rwy 1 L-1 R
HIRL all Rwy
11 510C 19R** 680/24
__________
407 (430-h)
(43 680/40 407 (400-( 407 (400.1) I
- 720-1 I 740-1 740-1Y2 I
Kiol
LOC RAF F0 MAP 4.6 \IM
60 90 120 I 150 180
CIRClI lJC
440(500-1) I 46D 500-1) 460(5(43-1 hIl
4l3- 560 (600.3)
50. This means that, as the aircraft reaches 473 feet, the pilot must make a decision
whether to continue the approach and make a landing or execute the missed approach procedure.
Those are the only two choices, and the decision to continue the approach requires the pilot to have
the runway or certain elements of the runway environment (such as its lights) in sight and be in a
position from which a normal landing can be made using normal procedures and maneuvers.
51. The second minima line is for approaches where the glide slope (whether the
altitude" is 680 feet MSL. The "24" following the slash indicates that the visibility must be at or
12 PHDATA3353O91I
Case 8:11-cv-00094-DKC Document 1 Filed 01/12/11 Page 13 of 17
better than 2,400 feet at the runway. The "407" indicates that the MSL altitude of 680 feet
equates to 407 feet above the touchdown zone elevation. The numbers in parentheses are for
military operations. In this situation, the approach becomes a "non-precision approach," and
different information from the profile view becomes relevant. The reason for the different names
of the minima for the full ILS or localizer-only approaches is the recognition that, if the aircraft
is descending along the glideslope, it will (due to reaction time and inertia) descend below the
decision altitude even if the decision to execute the missed approach is made at that point. With
approach, the missed approach is initiated at a missed approach point, which is determined either
by timing from the "final approach fix" or in the case of this approach by the BARLE fix, which
can be determined using distance measuring equipment or estimated using time, speed, and
distance calculations. A time table is presented on the approach chart, and pilots using the table
52. The final approach fix is marked by the Maltese cross and is identified by 6.1
DME from the Andrews VORTAC. BARLE is identified by 1.5 DME from Andrews
VORTAC. That the missed approach point is at BARLE is indicated by the approach course line
53. After the Potomac TRACON controller advised Trooper 2 to contract Andrews
Tower, the pilot advised Andrews Tower that Trooper 2 is "with you ah for on the localizer for
54. The Tower Controller cleared Trooper 2 for the option. Cleared for the option is
an 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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Case 8:11-cv-00094-DKC Document 1 Filed 01/12/11 Page 14 of 17
know that Trooper 2 was carrying patients or planned a full stop landing because the Potomac
55. After being cleared for the option to land at ADW, and just before midnight on
September 27, 2008, Trooper 2’s pilot advised the Tower Controller that he was not "picking up
the glideslope."
56. The Tower Controller replied, "it’s showing green on the panel but you’re the
only aircraft we’ve had in a long time so I don’t really know if it’s working or not."
57. Almost immediately thereafter, and at approximately three (3) minutes before
midnight, Trooper 2’s pilot requested an Airport Surveillance Radar ("ASR") approach. A
request for an ASR approach is a request from an aircraft to air traffic controllers to provide
58. The Tower Controller responded that she was not "current" on ASR approaches
and could not give one. Thereafter, she neither inquired as to the pilot’s intentions nor did she
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 Regional
Park 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 equipped
with a Tower Radar Display that displayed Trooper 2’s position, groundspeed, and altitude. The
61. Controllers are required to issue a safety alert to an aircraft if they are aware the
obstructions, or other aircraft. The issuance of a safety alert is considered a first priority duty
14 PHDATA3353O91I
Case 8:11-cv-00094-DKC Document 1 Filed 01/12/11 Page 15 of 17
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/limitations
of the radar system, and the available lead time to react are factors in determining whether it is
62. The Tower Controller did not have any higher priority duties. There was no
frequency congestion, and her workload was limited to one aircraft. Her inability to see outside
the tower cab, an aircraft that had reported trouble receiving the glideslope, and a denied
requested for an ASR approach justified rapt attention to the radar display.
63. The Tower Controller never advised Trooper 2 that he was descending too
rapidly, was unusually low, that she "lost him on radar," or that she could not see him because
64. The Tower Controller had the last clear chance to prevent this accident, but she
did not or even attempt to do so. Indeed, the evidence suggests that despite the fact that
Trooper 2 was the only aircraft she was in communication with at the time she was not paying
attention to Trooper 2.
65. Trooper 2 was destroyed in the crash and four of its five occupants were killed
66. Plaintiff The Insurance Company of the State of Pennsylvania insured the
helicopter operated as Trooper 2 against physical injury. As a result of its destruction, The
Insurance Company of the State of Pennsylvania paid plaintiff State of Maryland the insured
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NEGLIGENCE
67. Plaintiffs incorporate herein each of the allegations contained in paragraphs one
through 66.
68. The FAA, through its employees, has a duty to assign air traffic controllers to
work shifts so that competent personnel are available to perform the services offered by the
facilities 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 involvement
with Trooper 2 has been alleged, have a duty to act with reasonable care in performing their
official 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 involvement
with 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 took
place with a controller competent to issue ASR approaches or, alternatively,
issuing notices to airmen that ASRs were not available at specified times;
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Case 8:11-cv-00094-DKC Document 1 Filed 01/12/11 Page 17 of 17
71. The foregoing breaches of duty, individually and collectively, were a substantial
72. The State of Maryland and The Insurance Company of the State of Pennsylvania
WHEREFORE, Plaintiffs respectfully request that the Court grant judgment in their favor
against the United States of America and award them damages in the sum of $4,114,000.00 plus
costs.
BL( U2
Jonhan M. Stern (Trial Bar No. W 933)
jstern@schnader.com
Gordon S. Woodward (Trial Bar No. 14210)
gwoodwardschnader. corn
Mollie L. Finnan (Bar No. 17199)
mfinnan@schnader.com
750 Ninth Street, NW, Suite 550
Washington, DC 20001
Telephone: (202) 419-4202
Facsimile: (202) 419-4252
17 PHDATA 3353091_1