# NTSB SEA00FA095: Cessna 414, N5113G, Monarch, MT, May 31, 2000 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: May 31, 2000, 17:28 local (23:28 UTC) - Place: Monarch, MT - Coordinates: 46.980735, -110.850593 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=46.9807&lon=-110.8506&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report July 2, 2001 - Report: Approved by Office Director - NTSB case key (mKey): 49339 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA00FA095 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/49339/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=49339 - Page: https://openairdocs.org/ntsb/SEA00FA095 ## Probable cause The failure of the pilot-in-command to ensure adequate airspeed for flight during a forced descent due to airframe icing, resulting in a stall. Factors included: freezing rain conditions, airframe icing, an improper decision by the pilot-in-command to turn toward mountainous terrain (where a turn toward lower and level terrain was a viable option), mountainous terrain, and insufficient altitude available for stall recovery. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, climb - weather condition - freezing rain (contributing factor) - airframe - ice (contributing factor) - climb - not possible - Loss of control - in flight, descent - flight to new destination - attempted, pilot in command - in-flight planning/decision - improper, pilot in command (contributing factor) - terrain condition - mountainous/hilly (contributing factor) - airspeed - not maintained, pilot in command (cause) - stall - encountered, pilot in command - In flight collision with terrain/water, descent - uncontrolled - altitude - not available (contributing factor) ## Analysis During climbout, the airplane encountered an area of freezing rain resulting in rapid airframe ice accretion and loss of climb capability. The pilot informed ATC that he was unable to maintain altitude and requested and received clearance back to Great Falls, the departure airport. ATC radar showed that the airplane then began a right turn over mountainous terrain extending up to 8,309 feet prior to loss of radar contact (lower and relatively flat terrain, down to less than 5,000 feet, was located to the left of the aircraft's track.) During the last minute of radar contact, the aircraft was in a right turn at a descent rate of about 400 feet per minute; the aircraft passed less than 1/2 mile from the 8,309-foot mountain summit just prior to loss of radar contact, at an altitude of 8,400 to 8,500 feet. The aircraft crashed on the southwest flank of the 8,309-foot mountain about 1/2 mile south of the last recorded radar position. Wreckage and impact signatures at the crash site were indicative of an inverted, steep-angle, relatively low-speed, downhill impact with the terrain. The investigation revealed no evidence of any aircraft mechanical problems. ## Factual narrative HISTORY OF FLIGHT On May 31, 2000, approximately 1728 mountain daylight time, radio and radar contact was lost with a Cessna 414, N5113G, being operated by Lynch Flying Service of Billings, Montana, on a 14 CFR 91 company business flight from Great Falls, Montana, to Billings. The wreckage of N5113G was located the following day, June 1, 2000, at approximately the 7,500-foot level on the southwest flank of 8,309-foot Barker Mountain, approximately 37 nautical miles southeast of Great Falls and 6 nautical miles east of Monarch, Montana. The airplane was destroyed, and all three of the aircraft's occupants (the airline transport pilot-in-command, a prospective-hire commercial pilot undergoing a pre-employment screening flight with Lynch Flying Service, and a Lynch Flying Service pilot being repositioned from Great Falls to Billings and riding aboard the aircraft as a passenger) were found dead at the accident scene. Instrument meteorological conditions were reported at Great Falls at 1656 and 1756, and the flight (which departed Great Falls at 1711) was on an instrument flight rules (IFR) flight plan. The accident flight was the return flight of a planned round trip from Billings to Great Falls and back. The purpose of the flight was to deliver another Lynch pilot to Great Falls to pick up another Lynch aircraft (a Cessna 402) and fly it back to Billings, and to pick up the pilot who had flown the Cessna 402 into Great Falls and return him to Billings. Additionally, the prospective-hire pilot was brought along on the trip to undergo a pre-employment screening evaluation. The pilot-in-command on the trip was Lynch's director of training (NOTE: Subsequent references to the "pilot" in this report are to the pilot-in-command, unless otherwise indicated.) The pilot who was delivered to Great Falls reported to the NTSB that on the flight to Great Falls, the pilot occupied the left seat, and the prospective hire occupied the right seat and flew the instrument approach into Great Falls. The Lynch pilot who rode to Great Falls also reported that the pilot told him that on the return flight to Billings, he intended to have the prospective hire occupy the left seat with the pilot-in-command in the right seat. Lynch's chief pilot reported to the NTSB that the pilot utilized the WeatherMation computerized weather briefing service at Lynch during preflight planning. Recordings of FAA air traffic control (ATC) and air traffic services communications disclosed that prior to departing Billings, the pilot also twice contacted the Great Falls FAA automated flight service station (AFSS) and requested weather information. During the first contact, at 1321, the Great Falls AFSS preflight briefer advised the pilot that Great Falls was reporting 1/4 mile visibility in heavy snow and fog, and that an AIRMET advisory was in effect for occasional moderate rime and mixed icing conditions in clouds and in precipitation from 6,000 feet to flight level (FL) 180. The briefer also relayed a pilot report (PIREP) from a Cessna 340 aircraft indicating moderate rime ice at FL 190, along with the area forecast for Montana, the Great Falls terminal aerodrome forecast (TAF), and radar information showing light to moderate (with embedded heavy to very heavy) precipitation over most of the state. The briefer indicated that since the reported weather at Great Falls was worse than had been forecast (the visibility had been forecast to be 6 miles, with occasional visibility down to 2 miles, for that time period), he expected the TAF to be amended. The pilot stated that he "might have to try it", but indicated that he would wait and see if the visibility at Great Falls improved beyond 1/4 mile. He then filed an IFR flight plan for the Billings-Great Falls flight, with an estimated departure time of 1430 from Billings. During the second contact, at 1516, the Great Falls AFSS briefer advised the pilot (who identified himself to the briefer as "Vince down at Lynch") of a convective SIGMET meteorological advisory for an area of thunderstorms around Billings. The pilot asked about any PIREPs of icing conditions. The briefer relayed PIREPs from Boeing 727 (B-727) and Beech Bonanza aircraft, which reported encountering light rime ice at 12,000 feet over Great Falls, and that at 15,000 feet, one of the aircraft had accumulated 1/2 inch of rime ice. The briefer also relayed to the pilot that he could expect to encounter shower activity almost immediately after departure from Billings, and that the precipitation would change to mixed rain and snow approximately 10 to 20 miles west of Lewistown. The briefer further stated that approaching Great Falls, the precipitation would change to light to moderate, and possibly heavy, snow showers. The pilot then revised his estimated time of departure from Billings to 1530, and also filed an IFR flight plan for the Great Falls-Billings flight. The pilot filed for a return flight departure time from Great Falls of 1700, with a cruising altitude of 17,000 feet. The flight subsequently departed Billings, and at 1616, while en route to Great Falls, contacted the Great Falls AFSS by radio and relayed a PIREP. During this report, the pilot reported he was 71 miles southeast of Great Falls at 16,000 feet, that he was in and out of instrument meteorological conditions (IMC), that the temperature was -11 degrees C, and that he was not encountering any icing or turbulence. The Great Falls AFSS inflight briefer advised the pilot that the flight was north of the convective SIGMET area and relayed the weather conditions at and around Great Falls, including moderate precipitation south to southeast of Great Falls with upslope conditions prevailing in the vicinity. The briefer then asked the pilot if he needed updates to the AIRMETS for icing, and the pilot replied in the negative, stating that he had them. Investigators interviewed the line service shift supervisor at Holman Aviation in Great Falls who was on duty at the time the accident airplane arrived. The shift supervisor reported that the aircraft arrived between 1630 and 1700, and remained on the ground for approximately 15 minutes. He stated that when the aircraft arrived, he observed approximately 1 inch of rime ice on the unprotected leading edge areas of the wing and tip tanks, and approximately 3/8 inch of ice on the aircraft's nose (he reported that the wing upper surfaces and deice boots appeared clean.) The shift supervisor stated that he removed a small amount of ice by hand from an area between the boot and the tip tank, and that he pointed out the ice to the crew, who replied with a statement to the effect of, "Yeah, we picked up some ice." The shift supervisor stated that the crew did not request that the aircraft be deiced, and that no deice fluid was applied to the aircraft before departure. The shift supervisor reported that the last time he saw the airplane, ice was still present on the airframe. Holman Aviation's president reported that while the crew was in the facility, he observed them looking at satellite weather in Holman's flight planning room (Holman Aviation subscribes to a weather briefing service provided by DTN, Inc.) Investigators interviewed the Lynch pilot who rode to Great Falls in the accident aircraft (hereafter referred to as the "Lynch relief pilot".) This pilot reported that on the way in to Great Falls, the aircraft picked up about 1/2 inch of ice which was successfully removed with the deice boots. The Lynch relief pilot also stated that the aircraft was "sloughing ice" on the instrument landing system (ILS) final approach into Great Falls. The Lynch relief pilot stated that when the aircraft landed at Great Falls, the only ice he observed on the aircraft was the chunk the lineman picked off the aircraft, which the lineman handed to him. He stated that this piece was approximately 6 inches long and 1/2 inch thick. The Lyn ## Aircraft - Registration: [N5113G](https://openairdocs.org/deregistered/N5113G-2000-09-25), registration cancelled 2000-09-25, S/N 414-0952 (OpenAirDocs) - Reported make and model: Cessna 414 - Registry model: [Cessna 414](https://openairdocs.org/model/cessna-414) (registry code 2075908) (OpenAirDocs) - Category: Airplane - Serial number: 4140952 - Airframe hours: 7406 - Engines: Continental TSIO-520-N 310 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Business, Part 91 - Registered owner: Lynch Flying Service Inc. - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, March 2, 2000, 53 hours before - Departed: GTF, GREAT FALLS, MT - Destination: BIL, BILLINGS, MT - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: right; toxicology performed; flight hours: 8,000 total, 7,000 as pilot in command, 105 in the last 90 days, 38 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Day - Wind: 304° at 10 knots - Visibility: 9 statute miles - Lowest ceiling: 400 ft overcast - Temperature: 34 °F, dew point 34 °F - Altimeter: 30.00 inHg - Observed at: GTF, 37 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 20000531012979A](https://openairdocs.org/incident/20000531012979A), May 31, 2000: Cessna 414, Monarch, MT, No damage, 3 fatal. (-23) Flight was reported to be an evaluation of a new hire. A/c departed from great falls to billings. They reported inability to climb because of severe… ## Docket (33 files) The files NTSB released with the investigation on May 7, 2001, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=49339. 10.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 351 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40422892&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Supplement A (item 2, .PDF, 254 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40138845&FileExtension=.PDF&FileName=Supplement%20A-Master.PDF - Supplement B (item 3, .PDF, 361 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40138846&FileExtension=.PDF&FileName=Supplement%20B-Master.PDF - Supplement E (item 4, .PDF, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40422891&FileExtension=.PDF&FileName=Supplement%20E-Redacted.PDF - Supplement I (item 5, .PDF, 122 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40138858&FileExtension=.PDF&FileName=Supplement%20I-Master.PDF - Supplement S (item 6, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40138848&FileExtension=.PDF&FileName=Supplement%20S-Master.PDF - Meteorological Factual Report (item 7, .PDF, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40422893&FileExtension=.PDF&FileName=Meteorological%20Factual%20Report-Redacted.PDF - Witness Statement Furnished with Operator's Accident Report (item 8, .PDF, 78 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40422894&FileExtension=.PDF&FileName=Witness%20Statement%20Furnished%20with%20Operator%27s%20Accident%20Report-Redacted.PDF - ATC Controller Statements (item 9, .PDF, 469 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40422895&FileExtension=.PDF&FileName=ATC%20Controller%20Statements-Redacted.PDF - Record of Interview with Lynch Flying Service Chief Pilot and Director of Operations (item 10, .PDF, 253 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40422896&FileExtension=.PDF&FileName=Record%20of%20Interview%20with%20Lynch%20Flying%20Service%20Chief%20Pilot%20and%20Director%20of%20Operations-Redacted.PDF - Witness Interview Records (item 11, .PDF, 167 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40422897&FileExtension=.PDF&FileName=Witness%20Interview%20Records-Redacted.PDF - Low Altitude Enroute Chart Excerpt of Planned Flight Area (item 12, .PDF, 160 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40138855&FileExtension=.PDF&FileName=Low%20Altitude%20Enroute%20Chart%20Excerpt%20of%20Planned%20Flight%20Area-Master.PDF - Great Falls Sectional Chart Excerpt (item 13, .PDF, 434 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40138856&FileExtension=.PDF&FileName=Great%20Falls%20Sectional%20Chart%20Excerpt-Master.PDF - Map of NTAP Positions vs. Terrain and Crash Site Location (item 14, .PDF, 391 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40138857&FileExtension=.PDF&FileName=Map%20of%20NTAP%20Positions%20vs.%20Terrain%20and%20Crash%20Site%20Location-Master.PDF - Transcript of Radio Communications (item 15, .PDF, 938 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40422898&FileExtension=.PDF&FileName=Transcript%20of%20Radio%20Communications-Redacted.PDF - FAA Accident Reports (item 16, .PDF, 244 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40138860&FileExtension=.PDF&FileName=FAA%20Accident%20Reports-Master.PDF - Teledyne Continental Motors Engine Analysis Report (item 17, .PDF, 339 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40422899&FileExtension=.PDF&FileName=Teledyne%20Continental%20Motors%20Engine%20Analysis%20Report-Redacted.PDF - Cessna Party Representative's Report (item 18, .PDF, 286 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40422900&FileExtension=.PDF&FileName=Cessna%20Party%20Representative%27s%20Report-Redacted.PDF - Great Falls Approach Raw Radar Data (Graphic Plot) (item 19, .PDF, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40138863&FileExtension=.PDF&FileName=Great%20Falls%20Approach%20Raw%20Radar%20Data%20(Graphic%20Plot)-Master.PDF - Salt Lake ARTCC Raw NTAP Radar Data Excerpt (item 20, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40138864&FileExtension=.PDF&FileName=Salt%20Lake%20ARTCC%20Raw%20NTAP%20Radar%20Data%20Excerpt-Master.PDF - Kavouras/DTN Weather Archive (item 21, .PDF, 354 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40138865&FileExtension=.PDF&FileName=Kavouras%2FDTN%20Weather%20Archive-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 22, .PDF, 145 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40422901&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 23, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40422902&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Reports (item 24, .PDF, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40422903&FileExtension=.PDF&FileName=Toxicological%20Reports-Redacted.PDF - Photo 1. Main wreckage, right side (looking approx. W). (item 25, .PDF, 207 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40138869&FileExtension=.PDF&FileName=Photo%201.%20%20Main%20wreckage,%20right%20side%20(looking%20approx.%20W).-Master.PDF - Photo 2. Main wreckage (looking approx. W). (item 26, .PDF, 219 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40138870&FileExtension=.PDF&FileName=Photo%202.%20%20Main%20wreckage%20(looking%20approx.%20W).-Master.PDF - Photo 3. Right wing. (item 27, .PDF, 189 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40138871&FileExtension=.PDF&FileName=Photo%203.%20%20Right%20wing.-Master.PDF - Photo 4. Left wing. (item 28, .PDF, 221 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40138872&FileExtension=.PDF&FileName=Photo%204.%20%20Left%20wing.-Master.PDF - Photo 5. Broken trees. (item 29, .PDF, 193 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40138873&FileExtension=.PDF&FileName=Photo%205.%20%20Broken%20trees.-Master.PDF - Photo 6. Ground slash with red anticollision beacon glass. (item 30, .PDF, 266 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40138874&FileExtension=.PDF&FileName=Photo%206.%20%20Ground%20slash%20with%20red%20anticollision%20beacon%20glass.-Master.PDF - Photo 7. Saw-cut tree. (item 31, .PDF, 124 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40138875&FileExtension=.PDF&FileName=Photo%207.%20%20Saw-cut%20tree.-Master.PDF - Photo 8. Left engine and propeller. (item 32, .PDF, 164 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40138876&FileExtension=.PDF&FileName=Photo%208.%20%20Left%20engine%20and%20propeller.-Master.PDF - Photo 9. Right propeller. (item 33, .PDF, 232 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40138877&FileExtension=.PDF&FileName=Photo%209.%20%20Right%20propeller.-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.