# NTSB DEN08FA003: Raytheon C90A, N590GM, Pagosa Springs, CO, October 5, 2007 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: October 4, 2007, 23:17 local (Oct 5, 2007, 05:17 UTC) - Place: Pagosa Springs, CO - Coordinates: 37.183612, -106.584442 - Nearby events: https://openairdocs.org/map.md?lat=37.1836&lon=-106.5844&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report August 28, 2008 - Report: Approved by Office Director - Parties: Hawker Beechcraft Corporation, Transportation Safety Board - Canada, NATCA, Eagle Air Med, FAA Flight Standards District Office, Pratt & Whitney Canada, FAA - AAI - 100 - NTSB case key (mKey): 66849 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DEN08FA003 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/66849/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=66849 - Page: https://openairdocs.org/ntsb/DEN08FA003 ## Probable cause The pilot's failure to maintain clearance from mountainous terrain. Contributing to the accident was the pilot's inadequate preflight planning, improper in-flight planning and decision making, the dark night, and the controller's failure to issue a safety alert to the pilot. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, descent - normal - preflight planning/preparation - poor, pilot in command (contributing factor) - altitude/clearance - not maintained, pilot in command (cause) - in-flight planning/decision - improper, pilot in command (contributing factor) - light condition - dark night (contributing factor) - safety advisory - not issued, atc personnel(artcc) (contributing factor) - terrain condition - mountainous/hilly - In flight encounter with weather, descent - normal - vfr flight into imc - inadvertent, pilot in command - weather condition - low ceiling ## Analysis The pilot contacted air traffic control, using the wrong call sign, requesting radar flight following. The airplane initially climbed to 13,500 feet, descended to 11,500 feet, climbed to 13,500 feet, and then began a descent until it impacted terrain at 11,900 feet. One minute prior to impact, the pilot asked the air traffic controller about various minimum altitudes for his route of flight. The controller responded with a minimum instrument altitude of 15,000 to 15,300 feet. A review of the handling of the accident flight showed that the controller was aware of the airplane's position, altitude, general route of flight, and its proximity to terrain. No safety alert was issued to the accident flight. Weather depiction charts, infrared satellite imagery, and local weather observations indicate instrument meteorological conditions prevailed along the route of flight, closest to the accident location. The moon had set at 1539 on the day of the accident. The pilot reported a planned flight altitude of 12,500 feet to his dispatcher. No record of a preflight weather briefing was located. An examination of the airplane, engines, and related systems revealed no anomalies. ## Factual narrative Company Information Scenic Aviation Inc. was issued an operating certificate by the FAA in 1979 to conduct on-demand air taxi operations under the provisions of Title 14 CFR Part 135. In 2000, the FAA approved Scenic Aviation to operate under the business name of Eagle Air Med. At the time of the accident, Eagle Air Med conducted air ambulance operations in the states of Arizona, Colorado, New Mexico, and Utah. The company based airplanes and crew in Chinle and Kayenta, Arizona, and Alamosa, Colorado. The corporate headquarters was located in Blanding, Utah, and the Director of Operations, Chief Pilot, and Safety Officer were located in Chinle, Arizona. The operating certificate was managed by the FAA Flight Standards District Office in Salt Lake City, Utah. At the time of the accident, the company was operating seven King Air C90 aircraft and employed 12 pilots. Prior to employment, each pilot was required to have a minimum of 3,000 hours total time, 1,500 of which was in multi-engine airplanes. In addition, each pilot was required to hold an airline transport pilot certificate and a valid first class medical certificate. Each pilot attended initial and recurrent simulator training at SimCom. In addition, each new hire went through the FAA approved ground and flight training and initial operating experience prior to flying with patients. Audits and Accreditation In July 14, 2004, Eagle Air Med was awarded accreditation with the Commission on Accreditation of Medical Transport Systems (CAMTS). Their last audit was conducted in May of 2007. They maintained this status with CAMTS and were current at the time of the accident. The standards from CAMTS require that each pilot have a minimum of 2,000 hours total time; 1,000 hours of which must be as pilot-in-command (PIC), 500 hours of which must be as PIC in multi-engine airplanes, and 100 hours of which must be as PIC in night conditions. In addition, the pilot is to have a minimum of 25 hours of training in the specific make and model of aircraft being utilized on patient missions. In January of 2007, an independent audit of the Eagle Air Med operations was conducted by a consultant for a hospital located in northern Colorado. The results of the audit outlined the pilot training and experience requirements, the company's history, maintenance procedures, and medical staff training and experience. The auditor concluded that Eagle Air Med was a "quality, safe, and patient oriented air ambulance provider." In addition, Eagle Air Med has been a member of the Association of Air Medical Services for six years. Operations Manual A copy of Eagle Air Med's Operations Manual (Revision 24, September 19, 2006) was provided for review during the course of the investigation. Section 3.9 - Pilot in Command - Duties and Responsibilities included the following aspects for operational control: "A. Contact an FAA facility to obtain access to the necessary information for the safe conduct of the flight (such as weather, NOTAMS, and airport analysis.) B. File a flight plan with an appropriate FAA facility (considering factors such as altitude, terrain, weather…)" It was clarified during the investigation that Part 91 legs did not require a flight plan if operated in VFR conditions. After the accident, the company modified their operations manual to require an IFR flight plan for all night operations, regardless of the Part it was being operated under. Section 6.5 - Weather Briefings, required the pilot to "obtain a weather briefing prior to all flight operations, VFR, or IFR." Section 6.24 - "Company Bases Standard Operating Procedures", Part V. "En Route", stated that the company's "area of operation is considered mountainous terrain, therefore the PIC must exercise caution and fly at altitudes that will provide sufficient obstacle clearance…" Eagle Air Med Guidelines A copy of Eagle Air Med's Company Guidelines was provided for review during the course of the investigation. Section 9.g - Flight Following stated that every pilot "must obtain flight following from [Air Traffic Control] when [operating] under VFR flight rules." It went on to state that "the pilot must plan on flying at a VFR altitude that will allow radar contact with ATC. This is mandatory for any flights of 100 nautical miles or more." Pre-flight Risk Assessment Prior to every flight, each pilot is required to utilize the "Eagle Air Med Risk Assessment Tool." Thirteen questions for consideration and seven scored questions are printed on a 2 ¼ inch by 3 ½ inch card. Questions for consideration include weather conditions at the departure airport, destination airport, and en route, night operations, moonlight availability, familiarity with the destination, airplane problems, and any personal experience, training, or rest issues. Scored questions include pilot experience (in years), night flight conditions, late night flight conditions (between the hours of 0200 and 0500), destination airport being controlled or uncontrolled, inoperative equipment, greater than three patient transports in one shift, and weather conditions including ceiling and visibility at landing minimums and icing conditions along the route of flight. Each area is scored as follows: Pilot experience less than 2 years - 6 points; 2 to 3 years - 4 points; 4 to 5 years - 2 points; and 5 plus years 0 points Night flight conditions - 3 points Late night flight conditions - 3 points Familiarity with destination airport controlled - 4 points; uncontrolled - 6 points Inoperative Equipment - 3 points More than three patient transports in one shift - 3 points Weather - 5 points A score of 16 or less is left to the crew to make the go, no-go decision. A score of 17 or more requires contact with the director of operations, chief pilot, or safety officer. During interviews with the staff from Eagle Air Med, the director of operations, chief pilot, safety officer, and the president of the company all emphasized that the final authority on the operation of the flight lies with the pilot in command. The director of operations stated that a pilot may still elect not to accept a flight based upon circumstances not addressed by the card. The pilot reported a risk assessment value of 6-3-3 (total of 12) to the dispatcher. Altitude Alert Unit According to Hawker Beechcraft, the altitude alert unit monitors the altitude displayed on the pilot altimeter and compares that with the altitude set on the alert unit. The desired altitude can be pre-selected in increments of 100 feet. As the set altitude is approached on the outer limit (plus or minus 1,000), visual warnings and a two-second audio warning begins. The visual warnings remain on until the inner limit (plus or minus 200 feet) of the set altitude is reached. Deviations outside the inner limit will reactivate both the two-second audio warning and the visual warning. Safety Alerts According to the Aeronautical Information Manual, paragraph 4-1-15, "Safety Alert,": "A safety alert will be issued to pilots of aircraft being controlled by ATC if the controller is aware the aircraft is at an altitude which, in the controller's judgment, places the aircraft in unsafe proximity to terrain, obstructions, or other aircraft. The provision of this service is contingent upon the capability of the controller to have an awareness of a situation involving unsafe proximity to terrain, obstructions, and uncontrolled aircraft. The issuance of a safety alert cannot be mandated, but it can be expected on a reasonable, though intermittent basis. Once the alert is issued, it is solely the pilot's prerogative to determine what course of action, if any, to take. This procedure is intended for use in time critical situations where aircraft safety is in question. Noncritical situations should be handled via the normal traffic alert procedures. a. Terrain or Obstruction Alert 1. Control ## Aircraft - Registration: [N590GM](https://openairdocs.org/deregistered/N590GM-2011-04-07), registration cancelled 2011-04-07, S/N LJ-1594, built 2000 (OpenAirDocs) - Reported make and model: Raytheon Aircraft Company C90A - Registry model: [Raytheon C90A](https://openairdocs.org/model/raytheon-c90a) (registry code 7150004) (OpenAirDocs) - Registry engine: [Pratt & Whitney PT6A series](https://openairdocs.org/engine/pratt-whitney-pt6a-series) (registry code 52032, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: LJ-1594 - Airframe hours: 3925 - Engines: Pratt & Whitney Canada PT6A-21 750 horsepower turbo prop - Damage: Destroyed - Fire: On-Ground - Flight: Positioning, Part 91 - Operator: Scenic Aviation Inc - Registered owner: Scenic Aviation Inc - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, September 1, 2007 - Departed: E91, Chinle, AZ - Destination: ALS, Alamosa, CO - Flight plan: Company VFR - Airport: Not Applicable ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 46; injuries: fatal; flight instructor, commercial, airline transport; airplane ratings: multi-engine sea, single-engine land, multi-engine land, single-engine sea; instrument ratings: helicopter, airplane; medical: class 1, without waivers/limitations; last flight review August 1, 2007; seat: left; toxicology performed; flight hours: 12,650 total, 84 in this make and model, 6,000 as pilot in command, 84 in the last 90 days, 20 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 220° at 14 knots, gusting 21 - Visibility: 0.25 statute miles - Lowest ceiling: 200 ft overcast - Temperature: 37 °F, dew point 30 °F - Altimeter: 30.28 inHg - Observed at: CPW, 18 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20071004832499A](https://openairdocs.org/incident/20071004832499A), Oct 4, 2007: Raythe C90A, Pagosa Springs, CO, Destroyed, 3 fatal. Plan to make a recommendation that all fixed wing EMS flight operate uner IFR flight plans before, during and after patient pickup. ## Docket (25 files) The files NTSB released with the investigation on July 31, 2008, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=66849. - Supplement S (item 1, .PDF, 14 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293738&FileExtension=.PDF&FileName=Supplement%20S-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 2, .PDF, 716 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293739&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Field Notes (item 3, .PDF, 69 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40297858&FileExtension=.PDF&FileName=Field%20Notes-Master.PDF - Document Examination Notes (item 4, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40297859&FileExtension=.PDF&FileName=Document%20Examination%20Notes-Master.PDF - ATC 3 - Factual Report of Group Chairman (item 5, .PDF, 422 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295409&FileExtension=.PDF&FileName=ATC%203%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - ATC 3 - Aircraft Accident Package (item 6, .PDF, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40291187&FileExtension=.PDF&FileName=ATC%203%20-%20Aircraft%20Accident%20Package-Master.PDF - ATC 3 - NTAP Radar Data (item 7, .TXT): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40291189&FileExtension=.txt&FileName=ATC%203%20-%20NTAP%20Radar%20Data-Master.txt - Interview Summary Notes (item 8, .PDF, 108 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40297863&FileExtension=.PDF&FileName=Interview%20Summary%20Notes-Master.PDF - Record of Telephone Conversation (item 9, .PDF, 139 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383634&FileExtension=.PDF&FileName=Record%20of%20Telephone%20Conversation-Redacted.PDF - Maps or Charts of Accident Area (item 10, .PDF, 14.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40297868&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area-Master.PDF - Weather Information (item 11, .PDF, 575 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293740&FileExtension=.PDF&FileName=Weather%20Information-Master.PDF - Toxicological Report (item 12, .PDF, 487 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293741&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Company Dispatch and Pilot Communications Transcript (item 13, .PDF, 23 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40297870&FileExtension=.PDF&FileName=Company%20Dispatch%20and%20Pilot%20Communications%20Transcript-Master.PDF - Risk Assessment Card (item 14, .PDF, 71 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293742&FileExtension=.PDF&FileName=Risk%20Assessment%20Card-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 15, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293743&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Wreckage Release (item 16, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383632&FileExtension=.PDF&FileName=Wreckage%20Release-Redacted.PDF - Photograph 01 - Initial Impact Point - View to West (item 17, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293548&FileExtension=.PDF&FileName=Photograph%2001%20-%20Initial%20Impact%20Point%20-%20View%20to%20West-Master.PDF - Photograph 02 - Initial Debris Path (item 18, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293549&FileExtension=.PDF&FileName=Photograph%2002%20-%20Initial%20Debris%20Path-Master.PDF - Photograph 03 - Portion of Wing (item 19, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293550&FileExtension=.PDF&FileName=Photograph%2003%20-%20Portion%20of%20Wing-Master.PDF - Photograph 04 - Continuation of Debris Path and Fuselage - Looking to the East (item 20, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293551&FileExtension=.PDF&FileName=Photograph%2004%20-%20Continuation%20of%20Debris%20Path%20and%20Fuselage%20-%20Looking%20to%20the%20East-Master.PDF - Photograph 05 - Fuselage - View to North (item 21, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293552&FileExtension=.PDF&FileName=Photograph%2005%20-%20Fuselage%20-%20View%20to%20North-Master.PDF - Photograph 06 - Fuselage and Empennage - View to South (item 22, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293553&FileExtension=.PDF&FileName=Photograph%2006%20-%20Fuselage%20and%20Empennage%20-%20View%20to%20South-Master.PDF - Photograph 07 - Engine (item 23, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293554&FileExtension=.PDF&FileName=Photograph%2007%20-%20Engine-Master.PDF - Photograph 08 - Propeller Blade (item 24, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293555&FileExtension=.PDF&FileName=Photograph%2008%20-%20Propeller%20Blade-Master.PDF - Cockpit Voice Recorder 12 - Specialist's Factual Report (item 25, .PDF, 176 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40340791&FileExtension=.PDF&FileName=Cockpit%20Voice%20Recorder%2012%20-%20Specialist%27s%20Factual%20Report-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.