# NTSB SEA06FA068: Beech C99, N54RP, Butte, MT, March 18, 2006 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 18, 2006, 14:55 local (21:55 UTC) - Place: Butte, MT - Coordinates: 46.050743, -112.540428 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=46.0507&lon=-112.5404&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report April 25, 2007 - Report: Approved by Office Director - Parties: Ameriflight, Raytheon Aircraft Company, FAA/FSDO, Pratt & Whitney - NTSB case key (mKey): 63359 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA06FA068 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/63359/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=63359 - Page: https://openairdocs.org/ntsb/SEA06FA068 ## Probable cause The second pilot's failure to follow the published instrument approach procedure and the captain/PIC's inadequate supervision. Snow and mountain obscuration were factors. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, approach - iaf to faf/outer marker (ifr) - weather condition - obscuration (contributing factor) - weather condition - snow (contributing factor) - In flight collision with object, approach - faf/outer marker to threshold (ifr) - object - tree(s) - terrain condition - mountainous/hilly (contributing factor) - ifr procedure - not followed, copilot/second pilot (cause) - supervision - inadequate, pilot in command (cause) ## Analysis The cargo flight collided with mountainous terrain in controlled flight while executing an instrument approach procedure. Two pilots were aboard; the company's training and check captain/pilot-in-command in the right seat, and a newly hired commercial pilot in left seat, who was in training for captain The flight had been cleared for the VOR or GPS-B approach via the 7 DME arc. According to the approach plate, the transition to the approach is via a DME arc at 9,000 feet with no procedure turn. The flight is to track inbound on the 127 degree radial, descending down to, but no lower than, 7,700 feet to the initial approach fix (IAF). After crossing the IAF, the flight is to turn to 097 degrees for 10 nautical miles and descend to 6,900 feet. The remainder of the 1.5 nautical miles to the runway is to be flown under visual conditions. Documentation of the accident site indicated that the aircraft collided with trees and subsequently the mountainous terrain on a heading of approximately 127 degrees and about 6,900 feet mean sea level. The initial impact point was located approximately nine nautical miles on a magnetic bearing of 130 degrees from the IAF. Documentation of the horizontal situation indicator (HSI) on the left side instrument panel indicated that the course arrow was positioned to approximately 127 degrees, the inbound heading to the IAF. The co-pilot (right side) course arrow was positioned to 115 degrees. The location of the wreckage and the 127 degree heading on the HSI indicate that the pilots failed to follow the approach procedure and turn to a heading of 097 degrees after crossing the IAF. Instrument meteorological conditions were reported in the area consisting of icing conditions, heavy snow fall, with poor visibility and mountain obscuration. No pre-impact mechanical malfunctions or failures were identified. ## Factual narrative HISTORY OF FLIGHT On March 18, 2006, approximately 1455 mountain standard time, a Beech C99, N54RP, registered to and operated by Ameriflight Inc., as a 14 CFR Part 135 cargo flight, collided with trees and subsequently the terrain located approximately seven nautical miles southwest of the Bert Mooney Airport (BTM), Butte, Montana. Visual meteorological conditions prevailed at the airport, however instrument meteorological conditions were reported in the area of the accident site. An instrument flight rules flight plan was filed. The aircraft was substantially damaged by impact damage and a post-crash fire. The airline transport pilot-in-command and a newly hired commercial pilot were fatally injured. The flight departed from Helena, Montana, approximately 20 minutes prior to the accident. The aircraft was cleared for the VOR B approach to Butte at 1448. When the flight did not arrive at the airport a search was initiated. The wreckage was located in mountainous terrain by search and rescue personnel on March 20, about 0800, after a weak emergency locator transmitter signal was heard by other aircraft. At the time of the accident, a National Weather Service (NWS) volunteer weather spotter located about one and-a-half miles southeast from the accident site reported that a weather front had been approaching the area from the south to the north/northeast. At the time of the accident, and at their residence, the conditions included icing conditions followed by heavy snow fall with poor visibility and variable winds in the mountains surrounding the accident site. PERSONNEL INFORMATION The pilot sitting in the right seat was acting as pilot-in-command (PIC)/captain. At the time of the accident, the captain held commercial, airline transport pilot, certificated flight instructor in airplane single and multi-engine land aircraft, certificated instrument flight instructor and instrument and advanced ground instructor certificates. The captain held a second class medical certificate dated January 16, 2006, with a limitation that he must wear corrective lenses. Ameriflight company records indicated that the captain was hired by Ameriflight in January 2001. The most recent 14 CFR Part 135 PIC Check flight in the Beech 99 (BE-99) was on April 24, 2005. The captain was also one of the company's training and check captains in the BE-99. At the time of the accident the captain had accumulated a total flight time of 5,219 hours in all aircraft, with 5,109 hours as PIC. Approximately 2,616 hours had been accumulated in the BE-99, with 2,506 hours as PIC. Approximately 250 hours had been logged as giving flight instruction in the BE-99. Approximately 163 hours had been accumulated in the preceding 90 days in the BE-99. The captain's home base was located in Helena, Montana. The second pilot seated in the left seat had been hired by Ameriflight in February 2006. At the time of the accident, this pilot held commercial and flight instructor certificates and was rated for instrument flight and flight in airplane single engine land and multi-engine land aircraft. Under the flight instructor certificate, he was rated to give instruction in single-engine land aircraft and for instrument flight. The pilot held a first class medical certificate dated February 16, 2006, with a limitation that corrective lenses must be worn. At the time of the accident the second pilot had accumulated a total flight time in all aircraft of 2,023 hours, with 1,130 hours as PIC. A total flight time of 17 hours had been accumulated in the BE-99, with no time listed as PIC. Approximately 45 hours had been accumulated in all types of aircraft in the preceding 90 days with 17 hours in the BE-99. Company personnel records indicated that the second pilot had completed training for employment as Captain in the BE-99, and was scheduled to take his check ride the day following the accident. The pilot was hired in February 2006, and classroom training began in March 2006, in Burbank, California. The Line Training Qualification Check was accomplished on March 4, 2006. Company training lesson plans consisted of ground school classroom time, simulator time and flight time in the aircraft. Flight training and observation flights of the routing in Montana began on March 14, 2006. Flight scheduling records indicated that the pilot had been on board aircraft flying from his main base of operations in Helena, Montana, to Billings, Montana, and Great Falls, Montana. The last flight before the accident was on March 16, 2006. Each of the training and observation flights were with an instructor on-board who was acting as the Captain/PIC. This was the pilot's first flight with the company into the Bert Mooney Airport, Butte, Montana. AIRCRAFT INFORMATION At the time of the accident, the aircraft, a Beech C99, had accumulated a total airframe time (TAT) of approximately 22,169.5 hours and 35,539 cycles. Ameriflight maintenance personnel maintained the aircraft under an Approved Aircraft Inspection Program (AAIP). Ameriflight's computer generated aircraft maintenance status report dated March 16, 2006, indicated that an AAIP #3 Event was accomplished on December 6, 2005 at 22,065 hours TAT, and an AAIP routine inspection was accomplished on February 15, 2006, at 22,134 hours TAT. An avionics check A was accomplished on January 19, 2006. The aircraft was equipped with two Pratt & Whitney PT6A-36 engines. Maintenance records indicated that the left engine gas generator had accumulated a total time since overhaul (TSO) of 11,864 hours and 16,660 cycles since overhaul (CSO). The power section had accumulated 7,235 hours TSO and 9,866 CSO. The right engine gas generator had accumulated 5,042 hours TSO and 6,877 CSO. The power section had accumulated 5,042 hours TSO and 6,877 hours CSO. Review of maintenance records indicated that there were no open pilot squawks on the aircraft during the 5 days prior to the accident. One maintenance write-up (apparently during an inspection) reported that the right ice light was inoperative and it was replaced. No maintenance items were deferred on the minimum equipment list (MEL) or Continued Items program. METEOROLOGICAL INFORMATION At 1400, the weather reporting facility for BTM was reporting winds from 360 degrees at 6 knots, Visibility was 3 statute miles with light snow and mist. Few clouds were reported at 1,300 feet, broken clouds at 1,800 feet and overcast at 2,800 feet. The temperature and dew point were 01 degrees C. The altimeter was 29.73" Hg. At 1427, the wind was from 100 degrees at 5 knots. Visibility was 10 statute miles. Broken clouds were reported at 3,000 feet and 4,300 feet, with overcast at 5,000 feet. The temperature and dew point were 02 degrees C. The altimeter setting was 29.72" Hg. At 1453, the wind was from 360 degrees at 8 knots. Visibility was 10 statute miles. The clouds were broken at 6,000 feet. Temperature and dew point were 02 degrees C. The altimeter setting was 29.72" Hg. AIRMETs were in effect for Montana reporting instrument flight rule conditions; turbulence; icing, and mountain obscuration. Two National Weather Service weather spotters located about 1.5 miles southeast of the accident site and about 500 feet lower in elevation reported that on the day of the accident, the morning was clear. Clouds came in about noon and the temperature was about 35 degrees F. The afternoon storm moved into the area from the southwest to west and was moving in a northward to northeast direction. The wind was not over 20 miles per hour. The precipitation started at 1400 as light rain followed by snow. About 1630, wet snow had begun to accumulate. The spotters reported that the storm was typical for the time of year, and they felt there was no need to call the weather service. AIDS TO NAVIGATION The flight ## Aircraft - Registration: [N54RP](https://openairdocs.org/deregistered/N54RP-2007-05-18), registration cancelled 2007-05-18, S/N U-218 (OpenAirDocs) - Reported make and model: Beech C99 - Registry model: [Beech C-99](https://openairdocs.org/model/beech-c-99) (registry code 1154006) (OpenAirDocs) - Category: Airplane - Serial number: U-218 - Airframe hours: 22169 - Engines: Pratt & Whitney PT6A-36 715 horsepower turbo prop - Damage: Substantial damage - Fire: On-Ground - Flight: Part 135 - Registered owner: Ameriflight Inc. - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, February 1, 2006, 35 hours before - Departed: HLN, Helena, MT - Destination: BTM, Butte, MT - Flight plan: IFR - Airport: BTM, Bert Mooney ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 37; injuries: fatal; commercial, flight instructor, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2; last flight review October 1, 2005; seat: right; toxicology performed; flight hours: 5,219 total, 2,616 in this make and model, 5,109 as pilot in command, 237 in the last 90 days, 88 in the last 30 days, 4 in the last 24 hours - Other flight crew; injuries: fatal ## Weather - Conditions: Instrument (IMC), Day - Wind: 360° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: 6,000 ft broken - Temperature: 36 °F, dew point 30 °F - Altimeter: 29.71 inHg - Observed at: BTM, 6 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 20060318003429A](https://openairdocs.org/incident/20060318003429A), Mar 18, 2006: Beech C99, Butte, MT, Destroyed, 2 fatal. (-23) Pilot(s) failed to maintain approach procedures. Pilot(s) continued on a 127 degree flight path at the VOR b (coppertown) readial instead of coordinating… ## Docket (42 files) The files NTSB released with the investigation on March 9, 2007, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=63359. 37.9 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 651 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273362&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Witness Statements (item 2, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273363&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Wreckage Diagram (item 3, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273364&FileExtension=.PDF&FileName=Wreckage%20Diagram-Master.PDF - Site Locations Map (item 4, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273365&FileExtension=.PDF&FileName=Site%20Locations%20Map-Master.PDF - Weather Information (item 5, .PDF, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273366&FileExtension=.PDF&FileName=Weather%20Information-Redacted.PDF - Transcript of Radio Communications (item 6, .PDF, 345 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273367&FileExtension=.PDF&FileName=Transcript%20of%20Radio%20Communications-Redacted.PDF - ATC Personnel Statements (item 7, .PDF, 143 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273368&FileExtension=.PDF&FileName=ATC%20Personnel%20Statements-Redacted.PDF - Radar Data (item 8, .PDF, 6.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273369&FileExtension=.PDF&FileName=Radar%20Data-Master.PDF - BTM VOR Approcah Plate (item 9, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273370&FileExtension=.PDF&FileName=BTM%20VOR%20Approcah%20Plate-Master.PDF - Flight Inspection Report (item 10, .PDF, 171 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273371&FileExtension=.PDF&FileName=Flight%20Inspection%20Report-Master.PDF - Captain Side (Left) HSI (item 11, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273372&FileExtension=.PDF&FileName=Captain%20Side%20(Left)%20HSI-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 12, .PDF, 247 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273373&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Toxicological Reports (item 13, .PDF, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273374&FileExtension=.PDF&FileName=Toxicological%20Reports-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 14, .PDF, 59 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273375&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Image 1. Aerial view of main wreckage at tree line. (item 15, .PDF, 823 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273376&FileExtension=.PDF&FileName=Image%201.%20%20Aerial%20view%20of%20main%20wreckage%20at%20tree%20line.-Master.PDF - Image 2. Aerial view of approximate heading into terrain (127 degrees). (item 16, .PDF, 689 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273377&FileExtension=.PDF&FileName=Image%202.%20%20Aerial%20view%20of%20approximate%20heading%20into%20terrain%20(127%20degrees).-Master.PDF - Image 3. Aerial view facing back to the northwest. (item 17, .PDF, 822 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273378&FileExtension=.PDF&FileName=Image%203.%20%20Aerial%20view%20facing%20back%20to%20the%20northwest.-Master.PDF - Image 4. View of main wreckage at tree line heading 127 degrees. (item 18, .PDF, 715 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273379&FileExtension=.PDF&FileName=Image%204.%20%20View%20of%20main%20wreckage%20at%20tree%20line%20heading%20127%20degrees.-Master.PDF - Image 5. View facing approximately 305 degrees to area on opposite side of clearing. Additional wreckage located among trees. (item 19, .PDF, 811 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273380&FileExtension=.PDF&FileName=Image%205.%20%20View%20facing%20approximately%20305%20degrees%20to%20area%20on%20opposite%20side%20of%20clearing.%20%20Additional%20wreckage%20located%20among%20trees.-Master.PDF - Image 6. View of sections of inboard wing and fuselage. (item 20, .PDF, 816 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273381&FileExtension=.PDF&FileName=Image%206.%20%20View%20of%20sections%20of%20inboard%20wing%20and%20fuselage.-Master.PDF - Image 7. View of empennage. (item 21, .PDF, 835 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273382&FileExtension=.PDF&FileName=Image%207.%20%20View%20of%20empennage.-Master.PDF - Image 8. View of cabin section. (item 22, .PDF, 816 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273383&FileExtension=.PDF&FileName=Image%208.%20%20View%20of%20cabin%20section.-Master.PDF - Image 9. View of right engine. (item 23, .PDF, 815 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273384&FileExtension=.PDF&FileName=Image%209.%20%20View%20of%20right%20engine.-Master.PDF - Image 10. View of left engine. (item 24, .PDF, 822 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273385&FileExtension=.PDF&FileName=Image%2010.%20%20View%20of%20left%20engine.-Master.PDF - Image 11. View of left wing tip at beginning of wreckage path at tree line. (item 25, .PDF, 811 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273386&FileExtension=.PDF&FileName=Image%2011.%20%20View%20of%20left%20wing%20tip%20at%20beginning%20of%20wreckage%20path%20at%20tree%20line.-Master.PDF - Image 12. View of broken tree tops near wing tip sections. (item 26, .PDF, 822 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273387&FileExtension=.PDF&FileName=Image%2012.%20%20View%20of%20broken%20tree%20tops%20near%20wing%20tip%20sections.-Master.PDF - Image 13. View of right wing tip near beginning of wreckage path and collision with trees. (item 27, .PDF, 771 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273388&FileExtension=.PDF&FileName=Image%2013.%20%20View%20of%20right%20wing%20tip%20near%20beginning%20of%20wreckage%20path%20and%20collision%20with%20trees.-Master.PDF - Image 14. Left side horizontal stabilizer. (item 28, .PDF, 817 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273389&FileExtension=.PDF&FileName=Image%2014.%20%20Left%20side%20horizontal%20stabilizer.-Master.PDF - Image 15. Right side horizontal stabilizer. (item 29, .PDF, 813 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273390&FileExtension=.PDF&FileName=Image%2015.%20%20Right%20side%20horizontal%20stabilizer.-Master.PDF - Image 16. Left engine – left side view with propeller attached. (item 30, .PDF, 888 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273391&FileExtension=.PDF&FileName=Image%2016.%20%20Left%20engine%20%E2%80%93%20left%20side%20view%20with%20propeller%20attached.-Master.PDF - Image 17. Left engine – forward view with propeller attached. (item 31, .PDF, 882 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273392&FileExtension=.PDF&FileName=Image%2017.%20%20Left%20engine%20%E2%80%93%20forward%20view%20with%20propeller%20attached.-Master.PDF - Image 18. Left engine with propeller attached. (item 32, .PDF, 823 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273393&FileExtension=.PDF&FileName=Image%2018.%20%20Left%20engine%20with%20propeller%20attached.-Master.PDF - Image 19. Right engine – left side view. (item 33, .PDF, 797 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273394&FileExtension=.PDF&FileName=Image%2019.%20%20Right%20engine%20%E2%80%93%20left%20side%20view.-Master.PDF - Image 20. Right engine – forward view. (item 34, .PDF, 793 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273395&FileExtension=.PDF&FileName=Image%2020.%20%20Right%20engine%20%E2%80%93%20forward%20view.-Master.PDF - Image 21. Right side propeller assembly. (item 35, .PDF, 815 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273396&FileExtension=.PDF&FileName=Image%2021.%20%20Right%20side%20propeller%20assembly.-Master.PDF - Image 22. Left engine power turbine housing and power turbine guide vane ring. (item 36, .PDF, 816 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273397&FileExtension=.PDF&FileName=Image%2022.%20%20Left%20engine%20power%20turbine%20housing%20and%20power%20turbine%20guide%20vane%20ring.-Master.PDF - Image 23. Left engine combustion chamber liner and compressor turbine. (item 37, .PDF, 832 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273399&FileExtension=.PDF&FileName=Image%2023.%20%20Left%20engine%20combustion%20chamber%20liner%20and%20compressor%20turbine.-Master.PDF - Image 24. Right engine combustion chamber liner and compressor turbine. (item 38, .PDF, 807 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273401&FileExtension=.PDF&FileName=Image%2024.%20%20Right%20engine%20combustion%20chamber%20liner%20and%20compressor%20turbine.-Master.PDF - Image 25. Right engine power turbine housing and power turbine guide vane ring. (item 39, .PDF, 880 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273402&FileExtension=.PDF&FileName=Image%2025.%20%20Right%20engine%20power%20turbine%20housing%20and%20power%20turbine%20guide%20vane%20ring.-Master.PDF - Image 26. Right engine reduction gearbox first stage gearing. (item 40, .PDF, 841 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273403&FileExtension=.PDF&FileName=Image%2026.%20%20Right%20engine%20reduction%20gearbox%20first%20stage%20gearing.-Master.PDF - Image 27. Left side HIS. (item 41, .PDF, 765 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273404&FileExtension=.PDF&FileName=Image%2027.%20%20Left%20side%20HIS.-Master.PDF - Image 28. Right side HIS. (item 42, .PDF, 696 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273405&FileExtension=.PDF&FileName=Image%2028.%20%20Right%20side%20HIS.-Master.PDF From the NTSB's public API. 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