DEN05FA051

The air ambulance was dispatched from Steamboat Springs, Colorado (SBS), to pick up and transport a patient in serious condition from Rawlins Municipal Airport/Harvey Field (RWL) to Casper, Wyoming. Approaching RWL, the pilot initiated a right turn outbound to maneuver for the final approach course of the VOR/GPS approach to runway 22. On the inbound course to the airport, the airplane impacted mountainous terrain, approximately 2.5 nautical miles east-northeast of the airport. The airplane, configured for landing, struck the terrain wings level, in a 45-degree nose-down dive, consistent with impact following an aerodynamic stall. Approximately 5 minutes before the accident, RWL reported broken ceilings at 1,100 and 1,800 feet above ground level (agl), 3,100 feet agl overcast, visibility 2.5 statute miles with light snow and mist, temperature 33 degrees Fahrenheit (F), dew point 30 degrees F, winds 240 degrees at 3 knots, and altimeter 29.35 inches. Before departing SBS, the pilot received a weather briefing from Denver Flight Service. The briefer told the pilot that there was a band of light to moderate snow shower activity half way between Rock Springs and Rawlins, spreading to the northeast. The briefer told the pilot there were adverse conditions and flight precautions along his route for occasional mountain or terrain obscurations. The pilot responded that he planned to fly instrument flight rules for the entire flight. The National Weather Service, Surface Analysis showed a north-south stationary front positioned along the front range of the Rocky Mountains beginning at the Wyoming/Montana border and extending south into north-central Colorado. Station plots indicated patchy snow over western Colorado and Wyoming. The most recent AIRMET reported, "Occasional moderate rime or mixed icing in clouds and precipitation between the freezing level and flight level 220." The freezing level for the area encompassing the route of flight began at the surface. Witnesses in the vicinity of RWL reported surface weather conditions varying from freezing rain to heavy snow. An examination of the airplane showed clear ice up to 1 ½ inches thick adhering to the vertical stabilizer, the left and right wings, the right main landing gear tire, and the right propeller. The airplane's aerodynamic performance was degraded due to the ice contamination, leading to a stall. An examination of the airplane's systems revealed no anomalies. A human factors review of interviews and other materials showed insufficient evidence that the company placed pressure on the pilot to take the flight; however, the review did not rule out the pilot inducing pressure on himself. FAA Advisory Circular (AC) 135-15, Emergency Medical Services/Airplane (EMS/A) addresses several subject areas not practiced by the operator, including, "Additional considerations when planning IFR flights include the following: (1) Avoid flight in icing weather whenever possible."

History of flight

On January 11, 2005, approximately 2145 mountain standard time, a Beech E-90, N41WE, operating as Yampa Valley Air Ambulance, was destroyed when it impacted terrain while flying the VOR/GPS approach to runway 22 at Rawlins Municipal Airport/Harvey Field (RWL), Rawlins, Wyoming. The airline transport pilot (ATP) and two flight nurses were killed, and the flight paramedic was seriously injured. The airplane was owned and operated by Mountain Flight Service, Inc., of Steamboat Springs, Colorado. Night instrument meteorological conditions (IMC) prevailed at the time of the accident. The emergency medical services (EMS) repositioning flight was being conducted on an instrument flight rules flight plan under the provisions of 14 Code of Federal Regulation Part 91. The cross-country flight originated at Steamboat Springs, Colorado, about 2116.

About 2018, St. Anthony Hospital's dispatch in Denver, Colorado, sent a general launch page to Mountain Flight Service's on-call flight and medical crews to transport a patient from Rawlins, Wyoming, to Casper, Wyoming. About 2057, St. Anthony Hospital dispatch sent a general page indicating that N41WE was on the way to Rawlins with an estimated en route time of 30 minutes.

About 2112:04, the Sector 11 controller at Denver Air Route Traffic Control Center (ZDV) cleared the pilot for departure from Steamboat Springs Airport (SBS) to RWL, directing him to "climb and maintain one three thousand." About 2116:40, the pilot of N41WE contacted ZDV, stating "…out of nine thousand for one three thousand." The ZDV controller responded, "…thanks have you in radar, just a moment, climb and maintain one four thousand."

ZDV radar contact was established at 2116:52. Radar data indicate that the airplane took off to the south-southeast from SBS and climbed through an altitude of 9,400 feet mean sea level (msl) on a magnetic heading of 140 degrees. Approximately 5 miles south of SBS, ZDV radar showed the airplane make a climbing 207-degree right turn to a heading of 323 degrees. About 2117, the controller cleared N41WE to 16,000 feet msl and direct to RWL. At 2126:04, the pilot checked in with the ZDV Sector 22 controller and stated he was at 16,000 feet, direct RWL. At 2133:41, the pilot contacted ZDV and informed him, "...for planning purposes we'd like...clearance for the VOR/GPS runway 22 approach into Rawlins." ZDV cleared the pilot direct to the Rawlins VOR and told him to expect clearance for the approach.

About 2134:28, ZDV transmitted to N41WE, "...descent at pilot's discretion, maintain one one thousand, Rawlins altimeter two niner three five." The pilot responded with the altitude and altimeter setting. At 2136:31, ZDV told the pilot of N41WE to "cross Rawlins VOR at or above one one thousand, cleared VOR or GPS runway 22 approach to the Rawlins Airport," and the pilot acknowledged the transmission.

At 2140:14, the pilot reported, "...crossed over VOR at eleven for nine." ZDV told N41WE, "change to advisory approved you can recancel with me ah or through radio, have a good approach." The pilot responded, "With you or through radio…and the radio frequency on the ground at Rawlins is?" ZDV responded, "…I'm showing one twenty-two two." The pilot said, "Roger that same here…thank you." About this time, ZDV radar showed the airplane cross the RWL VOR and turn right to an outbound heading of 044 degrees. About 2142, radar contact with the airplane was lost. At the time radar contact was lost, the airplane was 8 miles east of the Rawlins Airport at 9,200 feet msl. The airplane was flying an approximate heading of 090 degrees, which is consistent with it being midway through the procedure turn inbound for the approach to runway 22.

A ground ambulance driver reported that she was dispatched to the airport to pick up the flight medical crew and take them to the hospital to pick up the patient. She stated that the runway lights were already on when she arrived at the airport and recalled that the time was 2138. She said the airplane was due in a little before 2200. The ambulance driver said she contacted the hospital to inquire about the flight crew and learned that the hospital had not heard anything. She stated that a little after 2200, the runway lights went off. The ambulance driver said she contacted the sheriff's dispatcher by phone, informed them the airplane was late, and inquired if they had heard anything. The dispatcher told her they had heard nothing. At that point, the ambulance driver contacted the emergency room at the hospital. About 2215, they were notified by sheriff's dispatch that the airplane had crashed.

At 2205:44, the Casper Flight Service Station (FSS) contacted the ZDV Sector 22 controller and asked about N41WE's status. The controller informed the FSS of the airplane's approach clearance, and the FSS indicated that the airplane had not arrived at RWL. After the airplane was reported overdue, search and rescue efforts were initiated. The airplane was located approximately 2.5 miles northeast of RWL in mountainous terrain about 0152on January 12, 2005.

The flight to Rawlins was originally scheduled with Wyoming Medical Center in Casper. A pilot for Wyoming Medical Center stated the flight had been pending for several hours. He said the weather was bad and that the pilot on duty before him declined the flight because of the weather, which was below Part 135 minimums. The pilot said he declined the flight initially but later accepted the flight as the weather at Rawlins improved. Before departure, Wyoming Medical Center received a more urgent call, and the mission was changed to Riverton.

Personnel information

The 35-year old pilot held an ATP certificate with a multiengine land airplane privileges dated December 22, 2002. The pilot's certificate showed a type rating in the SA-227 airplane and listed commercial privileges in single-engine land airplanes. The pilot also held a first-class medical certificate dated February 21, 2004, with the limitation, "Airman must wear corrective lenses while exercising the privilege of this certificate."

Company records showed the pilot had completed recurrent training in the B-100 King Air on June 19, 2004, and had successfully completed a proficiency check flight given by a Federal Aviation Administration (FAA) check pilot on November 16, 2004. According to company records, the pilot joined the company in June 2003 and, at that time, reported having approximately 3,800 total flying hours. Of that time, the pilot reported having 3,778 hours as pilot-in-command, 2,823 hours multiengine time, 1,000 hours flight time at night, and 200 hours actual instrument flight time.

Company time and duty records showed that since December 2003, the pilot logged 413.9 flying hours in the company's aircraft. The records also showed the pilot had logged 118.3 hours in the previous 90 days to the accident, 54.3 hours in the previous 30 days, and 1.7 hours within the 24 hours prior to the accident.

Aircraft information

The airplane was a 1978 Beech E-90 King Air, serial number (S/N) LW 280. The airplane was owned and operated by Mountain Flight Service, Inc., and was used for EMS transport. The airplane's registration was dated June 17, 2003.

The airplane was being maintained by Mountain Aircraft Maintenance, Inc., of Steamboat Springs, Colorado. The airplane was on a continuous maintenance schedule as prescribed by Raytheon Beech, the airplane manufacturer. The airplane underwent a Phase 3 and 4 inspection (required every 200 hours) on November 14, 2004. At the time of the inspection, the airframe time was 8,891.2 hours, the Hobbs time was 525.2 hours, and the airplane's cycles (one landing gear retraction and one landing gear extension) were 8,772.

The airplane's flight log and load manifest was recovered from the accident site. It showed that the airplane left SBS about 2110. T