DEN89MA130

NTSB accident investigation · Bell 206L-3 · Big Timber, MT · June 2, 1989

Accident · FatalMajor investigationFinal report
Date
June 1, 1989, 23:35 local (Jun 2, 1989, 05:35 UTC)
Place
Big Timber, MT
Injuries
4 fatal
Damage
Destroyed
Phase of flight
Takeoff
Aircraft
N76KMBell 206L-3
Weather
Visual (VMC) · Night/dark
Status
Completed · report December 10, 1990
Report
Approved by Office Director
FAA report
19890601013929A
Case key
17790

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

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Probable cause

Failure of the pilot to maintain control of the aircraft during takeoff, due to spatial disorientation, which resulted in a collision with the terrain. Contributing factors were: dark night, pilot's visual perception, inadequate initial training of the pilot by the operator, the pilot's lack of familiarity with the geographical area, and the company's insufficient standards/requirements.

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.

Loss of control - in flightTakeoff
Light condition - dark nightFactor
Visual/aural perceptionPilot in commandFactor
Aircraft control - not maintainedPilot in commandCause
Spatial disorientationPilot in commandCause
Lack of recent instrument timePilot in command
Inadequate initial trainingCompany/operator managementFactor
Lack of familiarity with geographic areaPilot in commandFactor
Insufficient standards/requirements,airmanCompany/operator mgmtFactor
In flight collision with terrain/waterTakeoff
Terrain condition - mountainous/hilly

Analysis

At abt 2158 MDT, the emerg med svc (ems/medevac) helicopter (hel) plt ctcd billings twr & adzd he would be making apchs to saint vincents hosp for (ngt) currency. Aprx 9 min later, he ctcd the twr again & adzd he was being dispatched on an EMS flt. The EMS flt was to a ranch (wnw of billings). The plt had difficulty finding the ranch at ngt, but arrived at 2238 MDT. The patient was loaded & the plt was adzd of trrn conds. A witness said the hel lifted off fast, then swiveledarnd quickly (toward east) & took off w/o hesitation. After depg, the hel crossed a hill & crashed at hi spd on lwr trrnin a slgt nose low, rgt bank attitude, hdg 330 deg. No preimpact mech prblm was fnd. The plt had been recently hired by the operator; prev employment involved flying a dissimilar hel (BK-105) in the gulf of Mexico area, limited to day VFR. The plt's last recorded ngt flt was on 6/16/87; his last recorded inst flt was prior to June 1984. No record was fnd of familiarization training for the geographical area. Relatives of the patient described the acdnt area as a black hole.

Aircraft

Registration
N76KM
Reported as
Bell 206L-3
Category
Helicopter
Serial number
51103
Airframe hours
1,816
Engine
Allison 250-C30P, 650 horsepower, turbo shaft
Damage
Destroyed
Flight
Part 135
Registered owner
Rocky Mountain Helicopter, Inc
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · May 22, 1989 · 20 hours before
Departed
NONE
Destination
NONE · Billings, MT

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
47
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine sea, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Right
Toxicology
Performed
Flight hours
9,036 total · 915 in this make and model · 51 in the last 90 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/dark
Wind
140° at 8 knots
Visibility
20 statute miles
Lowest ceiling
10,000 ft broken
Temperature
63 °F, dew point 48 °F
Altimeter
30.00 inHg
Observed at
BIL, 35 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.