# NTSB DEN89MA130: Bell 206L-3, N76KM, Big Timber, MT, June 2, 1989

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Major investigation · Final report
- Date: June 1, 1989, 23:35 local (Jun 2, 1989, 05:35 UTC)
- Place: Big Timber, MT
- Coordinates: 45.959381, -109.850463 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=45.9594&lon=-109.8505&mi=10
- Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 4 fatal
- Status: Completed, report December 10, 1990
- Report: Approved by Office Director
- NTSB case key (mKey): 17790
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DEN89MA130
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/17790/pdf
- Page: https://openairdocs.org/ntsb/DEN89MA130

## 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

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of control - in flight, takeoff
  - light condition - dark night (contributing factor)
  - visual/aural perception, pilot in command (contributing factor)
  - aircraft control - not maintained, pilot in command (cause)
  - spatial disorientation, pilot in command (cause)
  - lack of recent instrument time, pilot in command
  - inadequate initial training, company/operator management (contributing factor)
  - lack of familiarity with geographic area, pilot in command (contributing factor)
  - insufficient standards/requirements,airman, company/operator mgmt (contributing factor)
- In flight collision with terrain/water, takeoff
  - 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](https://openairdocs.org/deregistered/N76KM-2014-12-18), registration cancelled 2014-12-18, S/N 51103, built 1984 (OpenAirDocs)
- Reported make and model: BELL 206L-3
- Registry model: [Bell 206L-3](https://openairdocs.org/model/bell-206l-3) (registry code 1182108) (OpenAirDocs)
- Registry engine: [Allison 250-C30 series](https://openairdocs.org/engine/allison-250-c30-series) (registry code 03015, turbo-shaft) (OpenAirDocs)
- Category: Helicopter
- Serial number: 51103
- Airframe hours: 1816
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 47; 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 (OpenAirDocs).

- [Accident 19890601013929A](https://openairdocs.org/incident/19890601013929A), Jun 1, 1989: Bell 206L3, Rapelje, MT, Destroyed, 4 fatal. Lifted off at night in steep climbing turn and erratic flight. Crashed in unlit area. Lab report: nicotine, 6%.

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.

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