CHI04FA066

The emergency medical services (EMS) airplane was destroyed by terrain impact and post impact fire about 7 nautical miles (nm) west of its destination airport, Dodge City Regional Airport (DDC), Dodge City, Kansas. The 14 Code of Federal Regulations Part 91 positioning flight departed the Wichita Mid-Continental Airport (ICT), Wichita, Kansas, about 0215 central standard time and was en route to DDC. Night visual meteorological conditions prevailed when the accident occurred about 0257 central standard time. The flight had been on an instrument flight rules (IFR) flight plan, but the pilot cancelled the IFR flight plan about 34 nm east of DDC and initiated a descent under visual flight rules. Radar track data indicated that the airplane maintained a magnetic course of about 265 degrees during the flight from ICT to DDC. The rate of descent was about 850 to 950 feet per minute. During the descent, the airplane flew past the airport on a 270 degree course. Witnesses in the area reported hearing the engine noise of a low-flying airplane followed by the sound of impact. One of the witnesses described the engine noise as sounding like the engines were at "full throttle." The on-site inspection revealed that the airplane impacted the terrain in a gear-up, wings-level attitude. The inspection of the airplane revealed no anomalies to the airframe or engines. A review of the pilot's 72-hour history before the accident revealed that it had been 14 hours and 32 minutes from the time the pilot reported for duty about 1225 central standard time until the time of the accident. It had been 20 hours 57 minutes from the time the pilot awoke (0600) on the morning before the accident until the time of the accident. No evidence of pilot impairment due to carbon monoxide, drugs, or medical incapacitation was found. The accident occurred during a time of day that was well past the pilot's normal bedtime and also at a time of day when the physiological need to sleep is especially strong. The findings from a Safety Board's human performance analysis indicates that the pilot was likely fatigued. A review of 14 CFR 135.267 indicated that the pilot had adhered to the flight time limitations and rest requirements specified in the regulation.

History of flight

On February 17, 2004, about 0257 central standard time, a Beech B90, N777KU, operated by Ballard Aviation, Inc., as EagleMed 4, was destroyed by impact with terrain and postimpact fire approximately 7 nautical miles (nm) west of Dodge City Regional Airport (DDC), Dodge City, Kansas. The pilot, flight nurse, and flight paramedic were killed. Night visual meteorological conditions prevailed for the 14 Code of Federal Regulations (CFR) Part 91 emergency medical services (EMS) positioning flight, which departed Wichita Mid-Continental Airport (ICT), Wichita, Kansas, about 0215 and was en route to DDC. The flight was on an instrument flight rules (IFR) flight plan, but the pilot cancelled the IFR flight plan at an altitude of about 12,000 feet mean sea level (msl) approximately 34 nm east of DDC and proceeded under visual flight rules.

The transcript of the radio transmissions between EagleMed 4 and air traffic control (ATC) during the accident flight indicated that EagleMed 4 received its IFR clearance about 0211 and departed ICT about 0215. The flight climbed to a cruise altitude of 12,000 feet msl on a magnetic course of about 265 degrees. At 0244:13, the pilot of EagleMed 4 reported that he had DDC in sight, and at 0244:22, ATC cleared EagleMed 4 for a visual approach to DDC. At 0244:27, EagleMed 4 stated, "Cleared for the approach (unintelligible). Go ahead and cancel IFR for Eagle Med Four." At 0244:37, ATC stated, "Eagle Med Four, roger, squawk one two zero zero. Frequency change is approved and have a good morning." The last recorded radio transmission from EagleMed 4 was at 0244:43, when the pilot stated, "You too." At 0244:48, EagleMed 4 began to transmit VFR transponder code 1200.

Radar track data indicated that EagleMed 4 maintained a magnetic course of about 265 degrees with a calibrated airspeed (CAS) of about 180 to 185 knots (kts) during the flight from ICT to DDC. The radar data indicated that the airplane initiated a descent on a magnetic course of 265 degrees. The rate of descent was about 850 to 950 feet per minute, and the CAS increased from about 180 to about 214 kts. The airplane flew past DDC about .8 nm to the north as it continued on a magnetic course of about 270 degrees. The last radar contact occurred at 0256:10, when the airplane was about 4.7 nm west of the airport at 3,200 feet msl. The airplane impacted the terrain about 7 nm west of DDC.

Witnesses in the area reported hearing engine noises consistent with a low-flying airplane followed by the sound of an impact. One of the witnesses described the engines as sounding like they were at "full throttle." Another witness reported seeing multiple "fireballs" on the ground after the impact.

Personnel information

The pilot was hired by Ballard Aviation in November 2002 as a Beech B90 pilot and was one of two pilots based out of Dodge City, Kansas. According to company records, he held a commercial certificate with single-engine and multiengine land airplane ratings and an airplane instrument rating. He was also a certified flight instructor with single-engine land and airplane instrument ratings and held a first-class medical certificate. He had about 3,066 hours of total flight time, including 2,166 hours in multiengine aircraft. He had about 666 flight hours in a Beech B90 and had flown about 102 hours in the last 90 days and 24 hours in the last 30 days.

According to Ballard, the duty schedule for the pilots based at DDC was 7 24?hour-days on and 7 days off. A review of the pilot's 72-hour history prior to the accident revealed that the he was off duty from flying on February 14 and February 15, 2004 (the off-duty period having begun February 10). On Saturday, February 14, the pilot went to sleep about midnight. On February 15, he awoke about 0830 and engaged in normal activities. He worked from 1700 to 2200 at his job as a valet and went to bed around 2300.

On Monday, February 16, he awoke about 0600. He commuted to Wichita, Kansas, as a deadhead passenger on an airfreight flight that departed Dallas about 0710 and arrived in Wichita about 1015. At Wichita, the headquarters for EagleMed, the accident pilot picked up his spare car and drove to Dodge City. He arrived there about 1225 (25 minutes after his shift began), having telephoned ahead to indicate that he would arrive late.

After arriving at Dodge City, the pilot was assigned a mission to deliver a patient from Lamar, Colorado, to Pueblo, Colorado. He departed DDC about 1426, arrived at Lamar about 1504, departed Lamar about 1628 with the patient, and arrived at Pueblo about 1654. After medical personnel returned from delivering the patient to the medical center, the pilot departed Pueblo about 1816 and returned to DDC about 1919.

Other employees of Ballard Aviation reported that it would have been normal for the pilot to return to the pilot watch house located at DDC so he could eat and rest in preparation for further missions. They reported that they found dirty dishes in the sink at the watch house, which would be consistent with the pilot eating a meal.

After receiving a new assignment to deliver a patient from DDC to Wichita, Kansas, the pilot departed DDC with the patient between 2130 and 2200 and arrived at Wichita's Jabarra Airport (AAO) between 2200 to 2215. According to his girlfriend, who spoke to him by telephone soon after he arrived, the pilot sounded in good spirits and indicated that he might remain on duty until as late as 0400. He had already received a new mission to transport a patient from Independence, Kansas, back to Wichita.

He departed AAO about 2258, arrived at Independence about 2339, departed with the patient about 0029, and arrived at ICT about 0102 on February 17. The pilot waited in the pilot lounge at EagleMed company headquarters while medical personnel delivered the patient to medical treatment and returned for the final flight leg back to DDC. Two pilots observed the accident pilot in the pilot lounge and said that he was active, ate snacks, and seemed alert and normal. They reported that he did not rest on the available couches. After the medical personnel returned, the pilot departed ICT about 0215 with a scheduled arrival time at DDC of 0256. The accident occurred about 0257.

It had been 14 hours and 33 minutes from the time that the pilot had reported for duty at 1225 until the time of the accident. It had been 20 hours 58 minutes from the time the pilot awoke on February 16 until the time of the accident.

Aircraft information

The twin-engine Beech B90, serial number LJ377, was configured for EMS operations and had a maximum gross weight of 9,705 pounds. The engines were 550 horsepower Pratt & Whitney PT6A-20 engines. The airplane was part of an approved aircraft inspection program (AAIP) and was last inspected on February 13, 2004. The airplane had flown 8 hours since the inspection and had accumulated a total airframe time of 9,006 hours.

A Federal Aviation Administration (FAA) airworthiness inspector examined the aircraft records and applicable airworthiness directives and found no anomalies.

Meteorological information

The 0253 observed weather at DDC was as follows:

Winds 320 degrees at 6 knots, visibility 7 statute miles, clear sky, temperature - 6 degrees C, dew point - 8 degrees C, altimeter 30.39 inches of mercury.

Wreckage and impact information

The airplane impacted the terrain about 7 nm west of DDC in a rural area that had been a World War II Army airfield. The wreckage path was about 0.26 statute miles long on about a 266 degree magnetic bearing. The main wreckage came to rest next to an old dump truck at coordinates 37 degrees 47.510 minutes north, 100 degrees 06.722 minutes west. The on-site inspection confirmed that the fuselage, empennage, wings, and all flight control surfaces were located at the accident site.

A four-w