DCA98MA002

NTSB accident investigation · Cessna 208B · Montrose, CO · October 8, 1997

Accident · FatalMajor investigationFinal report
Date
October 8, 1997, 07:23 local (13:23 UTC)
Place
Montrose, CO
Injuries
9 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N12022Cessna 208B
Weather
Instrument (IMC) · Day
Status
Completed · report June 29, 1999
Report
Approved by Office Director
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
19971008045849A
Case key
11044

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

the pilot's failure to maintain sufficient airspeed for undetermined reasons while maneuvering the airplane near the maximum gross weight and aft cg in or near instrument meteorological conditions, resulting in the loss of control and entry into a stall/spin. Factors contributing to the accident were the pilot's improper in-flight planning and decision-making and his failure to use proper stall/spin recovery techniques.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight encounter with weatherClimb
In-flight planning/decision - improperPilot in commandCause
Weather condition - cloudsFactor
Terrain condition - high terrainFactor
Weather condition - low ceilingFactor
Vfr flight into imc - inadvertentPilot in commandFactor
Lack of recent instrument timePilot in commandFactor
Loss of control - in flightClimb
Maneuver - initiatedPilot in commandCause
Physical impairment(anoxia/hypoxia)Pilot in command
Airspeed - not maintainedPilot in commandCause
Stall/spin - inadvertentPilot in commandCause
Remedial action - inadequatePilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - mountainous/hillyFactor

Analysis

The airplane departed under visual flight rules (VFR) for a flight over mountainous terrain. It was tracked by radar from the departure area to the accident site. While climbing at the normal rate of climb to 15,400 feet, the airplane abruptly disappeared from radar. The wreckage was located among pine trees and exhibited evidence of a steep flightpath angle and damage consistent with a stall/spin event. Investigation revealed no indication of airframe or flight control anomalies, and the powerplant and propeller damage was consistent with engine operation at moderate to high power. Evidence indicated that the airplane was free of airframe ice at impact. Postaccident calculations indicate that the airplane was near the maximum certificated gross weight and aft center of gravity limit. The pilot did not maintain instrument flying currency and reportedly avoided instrument meteorological conditions (IMC). Evidence indicated that the pilot did not use oxygen, as required (when flying above 12,000 feet). Ground observations and satellite and Doppler radar imagery indicated widespread cloudiness over the mountains west of Montrose on the day of the accident. Satellite data showed variable cloud tops higher than the airplane's flight altitude in the vicinity of the accident. The radar plot of the aircraft during the climb above 10,000 feet indicated course changes from the southwest to the northwest, back to the southwest and then a sharp turn to the right just prior to the rapid descent.

Factual narrative

History of flight

On October 8, 1997, at 0723 mountain daylight time, N12022, a Cessna 208B, departed controlled flight and collided with terrain at the 9,900 foot level on the Uncompahgre Plateau, about 18 nautical miles (nm) southwest of Montrose, Colorado. The pilot and all eight passengers were killed. The flight was an on-demand air charter operated by the Department of the Interior (DOI) under 14 CFR Part 135. The flight was chartered to transport eight employees of the Bureau of Reclamation from Montrose, Colorado, to Page, Arizona. The registered owner of the airplane was Scenic Airlines Inc., of North Las Vegas, Nevada.

The pilot operated the first leg of the roundtrip charter flight from Page, Arizona, to Montrose, Colorado, on October 6, 1997. The flight was uneventful, and the pilot departed the airport about 1800 for a local motel. The return flight was scheduled to depart Montrose at 1700 on October 7. The pilot called the Scenic Airlines scheduler about 1200 and stated his concern about the passage of a cold front and the presence of less-than-VFR weather along the route of flight. He called back about 1500 and, after discussion, delayed the return trip until 0700 the following day, October 8. The pilot returned to the motel for a second night. On the morning of the accident flight, the pilot and passengers were at the airport about 0630.

Visual meteorological conditions prevailed upon takeoff. The flight departed from runway 17 of Montrose Regional Airport (elevation 5,759 feet msl) on a company visual flight rules (VFR) flight plan about 0705.

About 0710, a Federal Aviation Administration (FAA) radar National Track Analysis Program (NTAP) database target squawking VFR transponder code 1200 was recorded on a track from the Montrose area to the accident site. During the climb from 10,000 feet, the target airplane's course changed from southwest to northwest, back to southwest, and then made a sharp turn to the right. Climb performance was similar to data provided in the Pilot's Operating Handbook. The recorded radar information indicated that the target airplane climbed to a peak altitude of 15,400 msl then disappeared from radar. No emergency locator transmitter (ELT) signal was received. The airplane was reported overdue and a ground search party located the airplane wreckage about 50 hours later in the vicinity of the last recorded radar position. The wreckage was situated among 60-foot-high pine trees with evidence of a steep flight path angle (about -65 degrees), an approximate flat pitch attitude, and little indication of forward speed. There was a fuel spill in the surrounding area but no evidence of fire, either postcrash or in flight. All of the airplane occupants were located within the airplane fuselage.

The accident occurred during daylight hours at 38 degrees, 19 minutes, 23.8 seconds North latitude, and 108 degrees, 12 minutes, 43.6 seconds West longitude.

Damage to the aircraft

Impact forces destroyed the airplane. The estimated value of the airplane was about $1.2 million.

Other damage

The crash site was unimproved range land. Although the immediate area received some ecological damage from spilled aviation fuel, overall damage was minimal.

Personnel information

The male pilot, age 63, possessed an FAA Airline Transport Pilot certificate issued in 1994. Ratings and limitations were: Airplane Multiengine Land, Commercial Privileges, Airplane Single-Engine Land. No type ratings were listed. His FAA First Class Medical Certificate, dated December 30, 1996, contained the limitation "must have available glasses for near vision."

The pilot was qualified to fly the Cessna 208B on May 9, 1995. Prior to that qualification, he was assigned as a second-in-command pilot on Scenic Airlines de Havilland Twin Otter airplanes. The pilot's most recent Part 135 proficiency check was administered April 18-22, 1997, in a Cessna 207. The handwritten statement "instrument competency demonstrated" appeared on FAA Form 8410-3, "Airman Competency/Proficiency Check." His most recent Part 135 line check was administered in a Cessna 208B on May 30, 1997.

The pilot's primary employment was to fly sightseeing trips in and around the Grand Canyon area of Arizona, Utah, and Nevada. Scenic Airlines records indicate the pilot had logged 12,900 hours of total flying time. Examination of the pilot's personal logbooks showed a total of 19.7 hours of flight in actual instrument conditions. This instrument experience was accumulated between 1987 and 1994. The pilot was not qualified to serve as a pilot in command of a 14 CFR 135 operation under instrument flight rules (IFR). He did not maintain instrument flying currency under 14 CFR 61.57, "Recent flight experience: Pilot in command." Colleagues described the pilot as one who had no intention of entering instrument meteorological conditions (IMC) at any time.

Aircraft information

The Cessna 208B, serial number 208B0432, was registered as N12022 to Scenic Airlines on August 17, 1995. The airplane was configured with nine passenger seats in addition to the pilot and copilot seats. On the accident flight, the copilot seat and the passenger seat immediately behind the pilot were not occupied.

Before the accident flight, the airplane total time and cycles were 2,598.5 hours/3,680 cycles. The airplane was equipped with a Pratt and Whitney PT6A-114A turbopropeller engine rated at 675 horsepower and a McCauley 3GFR34C703, three-bladed, constant-speed, full-feathering propeller. The engine, serial number 19315, and the propeller assembly had the same time and cycle history as the airframe. The airplane complied with all applicable airworthiness inspections and FAA airworthiness directives. There were no unresolved or recent, pertinent maintenance discrepancies.

The maximum certificated gross weight of the Cessna 208B is 8,750 pounds. The estimated takeoff weight of the accident flight was 8,874.5 pounds. The estimated ramp fuel load prior to the accident flight was 1,566 pounds of Jet A-1 fuel. Airplane operating manual climb charts indicate fuel required to climb to 15,400 feet is about 65 pounds. The certificated aft center of gravity (cg) limit is 204.35 inches aft of the datum. The estimated takeoff cg was 203.84 inches, within an area characterized by a Note in the operating manual which states, "...area should be used only if an accurate cg determination has been obtained for that loading."

The airplane was equipped with a supplemental oxygen system. The oxygen bottle contents were under pressure and discharged during the investigation. Postcrash inspection revealed one breathing mask in the airplane stowed near the right, front passenger entry door.

Meteorological information

Scenic Airlines flight-following personnel reported that the pilot communicated with them via telephone in the morning hours before the accident flight regarding the weather. They did not note or recall the specific details of that conversation. FAA records do not indicate that the pilot of N12022 received a weather briefing from an FAA facility on the morning of the accident flight.

The Surface Analysis chart prepared by the National Weather Service for 0600 October 8 showed a cold front extending through eastern Colorado, curving southwestward through southeastern New Mexico, and extending into northern Mexico. The chart also indicated a weak center of high pressure located over north central Arizona.

The Aviation Area Forecast for the Rocky Mountain Area, issued by the Aviation Weather Center at Kansas City, Missouri, and valid for Colorado during the accident period, indicated:

Mountains and west...scattered-broken 9,000 feet broken 11,000 feet top flight level 24,000 feet with occasional visibility 3-5 miles mist and widely scattered light rain showers. 1200 scattered 12,000 feet. Outlook... visual flig

Aircraft

Registration
N12022
Reported as
Cessna 208B
Category
Airplane
Serial number
208B0432
Airframe hours
2,599
Engine
P&W PT6A-114A, 675 horsepower, turbo prop
Damage
Destroyed
Flight
Part 135
Operator
Scenic Airlines Inc
Registered owner
Scenic Airlines, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · September 23, 1997 · 28 hours before
Departed
KMTJ · Montrose, CO
Destination
KPGA · Page, AZ
Flight plan
Company VFR
Airport
KMTJ · Montrose Regional, runway 17, 10,000 × 150 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
63
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
May 30, 1997
Seat
Left
Toxicology
Performed
Flight hours
12,900 total · 1,546 in this make and model · 11,300 as pilot in command

Weather

Conditions
Instrument (IMC) · Day
Wind
190° at 9 knots
Visibility
10 statute miles
Lowest ceiling
9,500 ft overcast
Temperature
45 °F
Altimeter
29.00 inHg
Observed at
MTJ, 18 nm away

Docket · 87

The files NTSB released with the investigation on August 10, 1998, on NTSB’s docket system: statements, records, photos and specialists’ reports. 23.1 MB in all.

Operations 2 - Group Chairman Factual ReportItem 1 · .PDF · 483 KBOperations 2 - Attachment 1 - Weight and Balance DiagramsItem 2 · .PDF · 226 KBOperations 2 - Attachment 2 - Type Certificate Data Sheet ExcerptsItem 3 · .PDF · 73 KBOperations 2 - Attachment 3 - Interview SummariesItem 4 · .PDF · 1.8 MBOperations 2 - Attachment 4 - Reference DocumentsItem 5 · .PDF · 498 KBOperations 2 - ATC Supplement to Operations Group Chairman's ReportItem 6 · .PDF · 1.1 MBOperations 2 - Medical Factors Supplement to Group Chairman's Factual ReportItem 7 · .PDF · 1.5 MBOperations 2 - Addendum to the Group Chairman's Factual ReportItem 8 · .PDF · 185 KBOperations 2 - Addendum 2 - Factual Report of Group ChairmanItem 9 · .PDF · 86 KBMeteorology 5 - Group Chairman Factual ReportItem 10 · .PDF · 565 KBMeteorology 5 - Attachment 1 - NCEP Surface Analysis chartItem 11 · .PDF · 196 KBMeteorology 5 - Attachment 2 - Various weather data including surface weather observations and KMTJ TAFItem 12 · .PDF · 352 KBMeteorology 5 - Attachment 3 - RAWS weather information and dataItem 13 · .PDF · 389 KBMeteorology 5 - Attachment 4 - DiagramItem 14 · .PDF · 7 KBMeteorology 5 - Attachment 4 - Skew-T Log-P plot for KGJTItem 15 · .PDF · 50 KBMeteorology 5 - Attachment 5 - Pilot report summaries for Colorado, New Mexico, Utah, and ArizonaItem 16 · .PDF · 189 KBMeteorology 5 - Attachment 6 - DiagramItem 17 · .PDF · 51 KBMeteorology 5 - Attachment 6 - KGJX four panel radar reflectivity and velocity product chartItem 18 · .PDF · 8 KBMeteorology 5 - Attachment 7 - DiagramItem 19 · .PDF · 6 KBMeteorology 5 - Attachment 7 - KGJX four panel radar reflectivity and velocity product chartItem 20 · .PDF · 49 KBMeteorology 5 - Attachment 8 - Wind DiagramItem 21 · .PDF · 10 KBMeteorology 5 - Attachment 8 - KGJX VAD Wind ProfilesItem 22 · .PDF · 80 KBMeteorology 5 - Attachment 9 - DiagramItem 23 · .PDF · 10 KBMeteorology 5 - Attachment 9 - KGJX Echo Tops ProductItem 24 · .PDF · 38 KBMeteorology 5 - Attachment 10 - Photo ImageItem 25 · .PDF · 6 KBMeteorology 5 - Attachment 10 - GOES-8 visible staellite imageItem 26 · .PDF · 95 KBMeteorology 5 - Attachment 11 - Photo imageItem 27 · .PDF · 6 KBMeteorology 5 - Attachment 11 - GOES-8 infrared satellite imageItem 28 · .PDF · 49 KBMeteorology 5 - Attachment 12 - HistogramItem 29 · .PDF · 5 KBMeteorology 5 - Attachment 12 - GOES-8 radiative temperature histogramItem 30 · .PDF · 30 KBMeteorology 5 - Attachment 13 - Forecast Winds Aloft (FDs)Item 31 · .PDF · 77 KBMeteorology 5 - Attachment 14 - Aviation Area Forecast (FA)Item 32 · .PDF · 267 KBMeteorology 5 - Attachment 15 - AIRMETsItem 33 · .PDF · 191 KBMeteorology 5 - Attachment 16 - PlotsItem 34 · .PDF · 6 KBMeteorology 5 - Attachment 16 - AIRMET plots (1)Item 35 · .PDF · 47 KBMeteorology 5 - Attachment 16 - AIRMET plots (2)Item 36 · .PDF · 50 KBMeteorology 5 - Attachment 16 - AIRMET plots (3)Item 37 · .PDF · 52 KBMeteorology 5 - Attachment 17 - Astrological informationItem 38 · .PDF · 20 KBPowerplants 8 - Group Chairman Factual ReportItem 39 · .PDF · 380 KBPowerplants 8 - Photo 1. Left, front 3/4-view of engine at the accident siteItem 40 · .PDF · 59 KBPowerplants 8 - Photo 2. Left side view of engine before examinationItem 41 · .PDF · 42 KBPowerplants 8 - Photo 3. Right side view of engine before examinationItem 42 · .PDF · 44 KBPowerplants 8 - Photo 4. Right, rear 3/4-view of engine before examinationItem 43 · .PDF · 45 KBPowerplants 8 - Photo 5. View of 1st-stage compressor blade leading edge damageItem 44 · .PDF · 37 KBPowerplants 8 - Photo 6. Circumferential rub marks on downstream side of compressor turbineItem 45 · .PDF · 46 KBPowerplants 8 - Photo 7. Circumferential rub marks on upstream side of power turbine guide vane ringItem 46 · .PDF · 42 KBPowerplants 8 - Photo 8. Circumferential rub marks on upstream side of power turbine disc, and trailing edge damage on power turbine guide vanesItem 47 · .PDF · 32 KBPowerpalnts 8 - Photo 9. Missing, bent and fractured power turbine blades and view of damage to downstream side of power turbine vane ringItem 48 · .PDF · 27 KBPowerplants 8 - Photo 10. View of typical bending damage to power turbine blade and tipItem 49 · .PDF · 36 KBPowerplants 8 - Photo 11. From the left, the No. 1, 2 and 3, propeller blades before examinationItem 50 · .PDF · 43 KBPowerplants 8 - Photo 12. From the right, the witness marks on the butts and plugs of the No. 1, 2 and 3 propeller bladesItem 51 · .PDF · 46 KBPowerplants 8 - Photo 13. Edge of pitch-change yoke and witness marks on No. 1 blade of model transferred from accident propeller for examinationItem 52 · .PDF · 29 KBPowerplants 8 - Photo 14. Actuating pin tip of the No. 3 blade aligned with witness mark on the No. 1 blade plug on model propeller during examinationItem 53 · .PDF · 29 KBPowerplants 8 - Photo 15. Edge of pitch-change yoke and witness marks on No. 1 blade of model transferred from accident propeller for examinationItem 54 · .PDF · 25 KBPowerplants 8 - Photo 16. Actuating pin tip of the No. 1 blade aligned with witness mark on the No. 2 blade plug on model propeller during examinationItem 55 · .PDF · 34 KBAircraft Performance 13 - Aircraft Performance StudyItem 56 · .PDF · 1.2 MBAircraft Performance 13 - Addendum 1 - (November 10, 1998)Item 57 · .PDF · 162 KBMaterials Laboratory 15 - Group Chairman Factual ReportItem 58 · .PDF · 650 KBAirworthiness Group Chairman's Factual ReportItem 59 · .PDF · 4.2 MBAirworthiness Group Chairman's Factual Report - Appendix A - Wreckage DiagramsItem 60 · .PDF · 282 KB
All 87 files on NTSB’s docket

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.