# NTSB SEA04GA192: Cessna U206G, N206SM, Essex, MT, September 20, 2004 - Type: NTSB accident investigation - Classification: Accident · Fatal · Final report - Date: September 20, 2004, 15:30 local (21:30 UTC) - Place: Essex, MT - Coordinates: 48.316944, -113.736114 - Nearby events: https://openairdocs.org/map.md?lat=48.3169&lon=-113.7361&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal, 2 serious - Status: Completed, report September 13, 2005 - Report: Approved by Office Director - Parties: FAA, Helena FSDO, Teledyne Continental Motors, USDA, Forest Service, Cessna Aircraft Company - NTSB case key (mKey): 60179 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA04GA192 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/60179/pdf - Page: https://openairdocs.org/ntsb/SEA04GA192 ## Probable cause The pilot's misidentification of the airplane's location, which resulted in his improper decision to fly into the wrong drainage, and his failure to maintain terrain clearance while executing a turn to reverse course after he realized his navigational error. Contributing factors were the low visibility due to mist, obscuration of the mountainous terrain, and the pilot's lack of experience in back country flying. ## Analysis The purpose of the public use flight was to transport four United States Forest Service (USFS) employees to a remote back-country airstrip. The flight's departure was delayed 2 hours due to heavy rain showers and a thunderstorm. The planned flight route was to follow a highway through a river valley with high terrain (peaks above 8,000 feet) on both sides until reaching a point where the highway diverged from the river. At that point, the flight was to leave the highway and follow the river. Analysis of available weather data indicated that as the airplane proceeded along the river valley, ridge tops on both sides of the valley became obscured. Bases of the overcast were probably about 7,000 feet msl. Ragged clouds and mist were probably present beneath the overcast due to recent rain showers in the area. Slant visibility was likely diminished. Local pilots reported that in these type weather conditions the numerous drainages that feed into the river valley can be similar in appearance. The pilot made a position call about 15 minutes after takeoff stating that he was over a small town located close to the point where the flight was to leave the highway. This was the last radio communication received from the airplane. Analysis of radar data available for the first 8 minutes of the flight indicated the airplane was not at the position reported by the pilot, but was actually well short of this position. About 15 minutes later, witnesses heard and saw the airplane flying up a drainage located short of the reported position. This drainage ended in a box canyon. Inspection of the accident site indicated that the airplane was in a left climbing turn when it impacted steep terrain near the head of the drainage at an elevation of about 6,600 feet. The airplane nosed over, came to rest inverted, and a fire erupted. Three of the occupants exited the burning wreckage. All communications equipment, survival equipment and foul-weather gear aboard the airplane were destroyed in the fire. One of the three initial survivors died from his injuries the following morning. At that time, the remaining two survivors decided to depart the site for lower elevation due to extreme cold and precipitation. Searchers found the wreckage later that afternoon. The two survivors walked out to the highway 2 days after the accident. No abnormalities were noted during examination of the airplane that would have prevented normal operation. When the pilot took a check ride that allowed him to act as pilot in command of public use flights carrying passengers into the back-country, he reported to the check pilot that he had 100 hours flight time in "typical terrain (over mountains)." USFS standards required 200 hours flight time in typical terrain. However, the standards did not define typical terrain. Examination of the pilot's logbook revealed that it did not include a specific record of back country or mountain flying experience. Review of the past 2 years of logbook entries revealed a total of only 15 entries (14 hours flight time) that included a takeoff or landing at a back-country airport. ## Factual narrative HISTORY OF FLIGHT On September 20, 2004, approximately 1530 mountain daylight time, a Cessna U206G, N206SM, impacted mountainous terrain while maneuvering about 6 nautical miles northwest of Essex, Montana. The airplane was being operated under contract to the United States Department of Agriculture, Forest Service (USFS) by Edwards Jet Center of Kalispell, Montana, as a public use flight. The purpose of the flight was to transport a forest inventory team from Kalispell to the Schafer USFS Airport, Schafer, Montana. Four USFS employees and an Edwards pilot were on board. The pilot and two USFS employees were killed, and the other two USFS employees sustained serious injuries. Visual meteorological conditions prevailed for the airplane's departure at 1500 from Glacier Park International Airport in Kalispell. An FAA flight plan was not filed; however, the airplane was receiving flight following services from the USFS. According to USFS personnel, the flight was originally scheduled to depart at 1300. The scheduled departure was delayed from 1300 to 1500 due to weather conditions. The planned route of flight was to follow Highway 2 from Glacier Airport to a point about 3 miles south of the town of Essex, where the highway and the Middle Fork of the Flathead River separate. At this point, the flight was to leave the highway and follow the Middle Fork drainage to Schafer. According to personnel at the Glacier Airport Tower, their last contact with the airplane was at 1508, when the pilot reported that he was through "the canyon" (Badrock Canyon approximately 8 miles northeast of Glacier Airport) and switching to "backcountry frequency" (USFS dispatch). Examination of radar data confirmed that at 1508, the airplane was exiting Badrock Canyon heading northeast. Radar contact with the airplane was lost at this time due to mountainous terrain. From Badrock Canyon, the airplane's planned route proceeded along Highway 2, which follows a large bend in the Middle Fork of the Flathead, heading first northeast, then east, and finally southeast towards Essex. At 1515, the airplane checked in with USFS dispatch, and the pilot reported his position as "Essex, inbound for Schafer." This was the last radio communication received from the airplane. The distance from Badrock Canyon to Essex via Highway 2 is approximately 33 miles. In order for the airplane to reach Essex from Badrock Canyon in 7 minutes, it would have had to travel at a groundspeed of approximately 280 mph. According to the Cessna Model U206G Information Manual, the airplane's maximum airspeed for all operations (red line) was 211 mph (183 knots) and its maximum structural cruising airspeed (upper limit of green arc) was 172 mph (149 knots). At maximum structural cruising airspeed, the airplane would have traveled about 20 miles in 7 minutes, which would have placed it in the vicinity of Nyack at 1515. Nyack is a small town located about 13 miles north of Essex on Highway 2. One of the survivors reported that she was seated in the middle right seat and was wearing a headset that allowed her to hear the pilot and the right front seat passenger talking during the flight. She recalled the pilot making a radio call saying they were over Essex. About 5 minutes later, she noticed they were flying into a valley. At that time, the front passenger looked back and then asked the pilot, "Is that the Middle Fork?" The pilot replied, "Yes, that's the Middle Fork." The survivor recalled looking out the right side window and seeing snow on the peaks and then noticed they were "really close to the ground." She looked back forward and the airplane impacted. The other survivor reported that he was seated in the middle left seat and was not wearing a headset. He recalled they made a right turn out of the main river valley and started flying up "a pretty tight canyon." As they continued up the canyon, the "scenery got more and more dramatic" and "the canyon started to close in a little bit." He felt their elevation was not high enough and realized they were going to crash. Within seconds, the airplane impacted. About 1530, a USFS employee, located on Road 1637, observed an airplane flying up the Tunnel Creek drainage. Tunnel Creek originates from a small lake near the crest of the Flathead Range at an elevation of about 6,600 feet and flows east-northeast until it crosses Highway 2 and runs into the Middle Fork of the Flathead River about 7 miles south of Nyack and 6 miles north of Essex. The employee had been monitoring the radio in his vehicle and had heard the pilot of the airplane report over Essex. He estimated that it was approximately 15 minutes later that he made the sighting; at the time, he did not know if it was the accident airplane that he saw. The employee reported that the airplane was heading west to southwest, paralleling the ridge that forms the northern boundary of the Tunnel Creek drainage. The employee further reported that the airplane appeared to be in level flight, at an elevation near the top of the ridge, below a cloud layer that was obscuring the top of the ridge. About 1610, after hearing that a search for a missing airplane was in progress, the employee reported the sighting to USFS dispatch. Two bow hunters who were hunting in the vicinity of Road 1637 about 1530 reported hearing the sound of an airplane engine "laboring, then two pops, then nothing." This report was not made until about 1315 on September 21, when the two hunters were returning to their vehicle and encountered USFS personnel involved in the ground search for the airplane. When the airplane did not check in with USFS dispatch as expected at 1530, a search was initiated. An airplane from Edwards Jet Center and a helicopter under contract to the USFS searched by air until about 1725, when they were called back for the evening due to impending darkness and obscured mountain peaks. Based on the sighting of an airplane flying up the Tunnel Creek drainage by a USFS employee, the helicopter conducted a search of that drainage about 1700. According to the helicopter pilot, who viewed the accident site after it was discovered the following day, the cloud bases in the drainage prevented him from reaching the elevation of the accident site during his search on the day of the accident. At 1827, the airplane was officially declared missing having passed the time limit for fuel on board (3.5 hours). Montana Aeronautics Division assumed command of the aerial search, and the Flathead County Sheriff's Office assumed ground search responsibilities. About 0730 on September 21, a group of airplanes launched from Glacier Airport to search assigned grids. According to the aerial search coordinator, the airplane assigned to the grid where the accident site was eventually located flew along Highway 2 from Nyack towards Essex, but was unable to penetrate very far up the drainages from the Middle Fork of the Flathead due to low cloud bases. About 0945, while en route to his assigned grid, the pilot of the helicopter that had searched the Tunnel Creek drainage on the afternoon of the 20th, flew through the head of the Tunnel Creek drainage, but did not spot the wreckage. The pilot later reported that he was at a higher elevation in the drainage than the accident site when he made this over flight. The wreckage of the airplane was spotted by ground searchers about 1345 on September 21, 2004. Search and rescue personnel reached the accident site via helicopter about 1510. The Deputy Coroner for Flathead County inspected the scene and announced that all five occupants were fatally injured. The ground search was suspended. Approximately 1430 on September 22, 2004, the two survivors walked out of the Tunnel Creek drainage. PERSONNEL INFORMATION The pilot held an airline transport pilot certificate with a multi-engine land airplane rating and commercial privileges ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, cruise - weather condition - obscuration (contributing factor) - weather condition - drizzle/mist (contributing factor) - lack of total experience in type operation, pilot in command (contributing factor) - became lost/disoriented, pilot in command (cause) - in-flight planning/decision - improper, pilot in command (cause) - In flight collision with terrain/water, maneuvering - turn to reverse direction - terrain condition - mountainous/hilly (contributing factor) - evasive maneuver - attempted, pilot in command - clearance - not maintained, pilot in command (cause) ## Aircraft - Registration: [N206SM](https://openairdocs.org/deregistered/N206SM-2009-03-19), registration cancelled 2009-03-19, S/N U20606459, built 1982 (OpenAirDocs) - Reported make and model: Cessna U206G - Registry model: [Cessna U206G](https://openairdocs.org/model/cessna-u206g) (registry code 2073356) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: U20606459 - Airframe hours: 4224 - Engines: Teledyne Continental IO-520-F 300 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Public aircraft, Public use - Operator: USDA, Forest Service, Flathead National Forest - Registered owner: Edwards Jet Center of Montana - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 3, 2004 - Departed: FCA, Kalispell, MT - Destination: 8U2, Schafer, MT - Flight plan: Company VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 60; injuries: fatal; flight instructor, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; last flight review May 13, 2004; seat: left; toxicology performed; flight hours: 2,723 total, 15 in this make and model, 2,603 as pilot in command, 68 in the last 90 days, 15 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 170° at 10 knots - Visibility: 10 statute miles - Lowest ceiling: 1,800 ft broken - Temperature: 48 °F, dew point 45 °F - Altimeter: 30.02 inHg - Observed at: FCA, 21 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 20040920024719A](https://openairdocs.org/incident/20040920024719A), Sep 20, 2004: Cessna U206G, Essex, MT, Destroyed, 3 fatal. (-23) Witnesses stated that N206SM, a Cessna 206, departed kalispell (fca), Montana, with 1 pilot and 4 U.S. Forest service employees on board. Witnesses noted… 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.