SEA07FA051

NTSB accident investigation · Beech 200 · Belgrade, MT · February 7, 2007

Accident · FatalField investigationFinal report
Date
February 6, 2007, 21:04 local (Feb 7, 2007, 04:04 UTC)
Place
Belgrade, MT
Injuries
3 fatal
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N45MFBeech 200
Weather
Visual (VMC) · Night/dark
Status
Completed · report January 31, 2008
Report
Approved by Office Director
Parties
FAA FSDO, Hawker Beechcraft Corporation, Pratt & Whitney Canada, Metro Aviation, FAA
FAA report
20070206003029A
Case key
65180

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

The pilot's failure to maintain an adequate altitude and descent rate during a night visual approach. Dark night conditions and mountainous terrain are factors in the accident.

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.

In flight collision with terrain/waterDescent
Terrain condition - risingFactor
Altitude/clearance - not maintainedPilot in commandCause
Descent - not maintainedPilot in commandCause
Terrain condition - mountainous/hillyFactor
Light condition - dark nightFactor

Analysis

The cross-country flight was on an instrument flight rules (IFR) flight plan, approximately 42 nautical miles from the tower-controlled destination airport, when the pilot was cleared for the visual approach. Dark night visual meteorological conditions prevailed, and there was an overcast layer of clouds at 11,000 feet. After the en route radar service was terminated, the pilot contacted the local control tower and made a garbled and partially unintelligible transmission. Shortly after the time of the transmission, local law enforcement personnel received reports of a downed aircraft. The wreckage was located later that evening approximately 80 feet below the peak of a ridge that rose to an elevation of approximately 5,700 feet. From the initial point of contact with terrain, the debris path was scattered over the crest of the ridge and continued down the opposing side, in a south-southeast direction, toward the airport. The ridge was the highest obstruction between the accident location and the destination airport. The airport is located in a large valley and is surrounded by rising mountainous terrain. At night, clouds and terrain are difficult for pilots to see, and a gradual loss of visual cues can occur as flight is continued toward darker terrain. Additionally, the horizon is less visible and less distinct at night than during the day. Because the pilot was descending the airplane over rural, mountainous terrain that provided few visual ground reference cues, and because the overcast cloud layer would have prevented moonlight from illuminating the terrain, it is likely that the pilot did not see the rising terrain as the airplane continued toward it. The airplane was equipped with an Enhanced Ground Proximity Warning System; however, impact damage to the unit precluded post accident testing. It is not known how the unit was configured during the flight or what type of alerts the pilot received prior to impact. Post accident examination of the wreckage, to include both engines, did not disclose evidence of a mechanical malfunction prior to impact. Additionally, no evidence was found to suggest an in-flight structural failure.

Factual narrative

This report was modified on January 6, 2008.

History of flight

On February 6, 2007, at 2104 mountain standard time, a Beech 200 King Air airplane, N45MF, registered to and operated by Metro Aviation, Inc., of Shreveport, Louisiana, collided with sparsely populated mountainous terrain approximately 13 nautical miles (nm) north-northwest of the Gallatin Field Airport (BZN), Belgrade, Montana. The Emergency Medical Services (EMS) positioning flight was operated under the provisions of 14 Code of Federal Regulations (CFR) Part 91, and an instrument flight rules (IFR) flight plan was in effect. The airplane sustained substantial damage and the three occupants, an airline transport pilot, flight paramedic and flight nurse, were killed. The air ambulance was under contract to Benefis Healthcare/Mercy Flight, Great Falls, Montana. The flight departed Great Falls International Airport, Great Falls, Montana, at 2040 with an intended destination of BZN (approximately 103 nm from the departure airport). Instrument meteorological conditions prevailed at the departure airport and dark night visual meteorological conditions prevailed at the destination airport.

A review of the Air Traffic Control (ATC) transcripts for the flight indicated that radio communications with the airplane was lost shortly after the pilot was cleared for the visual approach to runway 12 at BZN.

At 2108 the Gallatin County Sheriff's Office received reports of a downed aircraft.

The wreckage was located about 2230 that evening approximately 80 feet below the peak of a ridge that rose to an elevation of approximately 5,700 feet. From the first identified point of contact with terrain, the debris path tracked over the crest of the ridge and continued down the opposing side, in a south-southeast direction, for approximately 1,575 feet.

Satellite based flight-tracking data (OuterLink) provided by the Operator indicated the airplane started a descent, from 15,000 feet mean sea level (MSL), approximately 42 nm north of the airport. The last data transmission from the airplane was received approximately six minutes later in the general area where the wreckage was located.

Personnel information

Pilot-in-Command (PIC)

At the time of the accident, the PIC, age 59, held an airline transport pilot (ATP) certificate with a rating for airplane multiengine land, a commercial pilot certificate with a rating for airplane single-engine land and a type rating in the BE-300 King Air. The pilot's most recent Federal Aviation Administration (FAA) second-class airman medical certificate was issued on November 10, 2006, with the limitation that he must wear corrective lenses.

Personnel records maintained by the operator indicated that Metro Aviation hired the pilot in November of 1999. Preceding his employment with Metro Aviation, the pilot was employed by Lynch Flying Service (beginning in 1996) as an air ambulance pilot.

Company personnel records revealed that the pilot had accumulated 17,608 hours total flying time, which included 1,318 hours PIC in the King Air 200. The pilot had flown 66 hours in the previous 90 days, 45 hours in the previous 30 days and approximately 25 minutes (the accident flight) in the previous 24 hours.

Training records indicated that the pilot successfully completed initial King Air (BE90 and 100) training in March of 1996, while employed by Lynch Flying Service of Billings, Montana.

On April 2, 2000, the pilot successfully completed King Air 200 initial/upgrade training with SimuFlite in Dallas, Texas. The completion of the course, which included ground and simulator training, qualified the pilot as PIC for the King Air 200. In conjunction with the King Air 200 curriculum at SimuFlite, the pilot completed King Air BE90 and A100 recurrent and differences training.

The pilot's most recent recurrent training for the King Air 200 was successfully completed with SimuFlite, in Dallas, Texas, on March 31, 2006. The recurrent training included ground and simulator training and fulfilled the recurrent Part 135 pilot testing requirements.

The pilot's most recent Part 135 line check and IFR proficiency check were successfully completed on October 12, 2006.

Flight and Duty Time

The accident date, February 6, 2007, was the pilot's fifth consecutive duty day of a seven day rotation cycle. His duty day began at 2100 hours and was scheduled to end at 0700 on February 7. The accident flight was the pilot's first flight of the shift. Flight and duty times for the 5 days preceding the accident were:

On February 5, the pilot's duty day began at 1900 and ended at 0700 the following morning. There were no flight operations during the pilot's duty day.

On February 4 the pilot's duty day began at 1900, and ended at 0700 the following morning. The pilot completed one flight (.8 hours) during the duty period.

On February 3, the pilot's duty day began at 1900, and ended at 0700 the following morning. There were no flight operations during the pilot's duty day.

On February 2, the pilot's duty day began at 1900, and ended at 0700 the following morning. There were no flight operations during the pilot's duty day.

On February 1, the pilot was not on duty.

In the six months preceding the accident, the pilot flew a total of 73.4 hours.

Review of pilot records, and subsequent conversations with the operator, indicated the pilot had flown this particular route of flight and was familiar with the terrain.

Aircraft information

The accident airplane, a Beech King Air 200 (serial number BB-234) was manufactured in 1977 and, since the date of manufacture, had accumulated 5,992 total flight hours. The airplane was equipped with two Pratt & Whitney Canada turbo propeller PT6A-41 engines.

The airplane was being maintained in accordance with the manufacture's inspection program. Review of the aircraft logbooks revealed that the airplane's most recent inspection, a phase four inspection, was completed on September 21, 2006, at 5,827 total flight hours. There were no reported open maintenance discrepancies with the airplane at the time of the accident.

The airplane was equipped with a Bendix/King Enhanced Ground Proximity Warning System (EGPWS). The EGPWS is classified as a class B Terrain Awareness and Warning System (TAWS). The EGPWS is a terrain warning system that provides relevant real-time terrain information. The system evaluates the aircraft flight parameters and compares it with an onboard terrain, obstacle and airport database. When the system predicts potential conflicts between the aircraft and terrain it alerts the flight crew of the conflict(s) via audio caution. The system incorporates an inhibit switch in the cockpit. When engaged by the pilot, the switch will silence terrain alerts generated by the system. The airplane was not equipped with a TAWS graphic display.

Post accident data recovery from the component's non-volatile memory was unsuccessful due to the extent of damage sustained during the impact sequence.

Meteorological information

The closest weather observation facility to the accident site was the destination airport, Gallatin Field Airport, Belgrade, Montana, located approximately 13 nm from the accident site at an elevation of 4,471 feet msl. The airport is equipped with an Automated Surface Observing System (ASOS). The following weather observations (METAR format) were issued surrounding the time period of the accident:

On February 6, at 2056, the observation was, in part, wind from 300 degrees at 4 knots, visibility unrestricted at 10 miles, overcast ceiling at 11,000 feet, temperature 3 degrees Celsius (C), dew point minus 1 degrees C, altimeter 30.30 inches of Hg.

At 2145, the observation was, in part, wind from 260 degrees at 4 knots, visibility unrestricted at 10 miles, overcast ceiling at 11,000 feet, temperature 4 degrees C, dew

Aircraft

Registration
N45MF
Reported as
Beech 200
Category
Airplane
Serial number
BB234
Airframe hours
5,992
Engines
Pratt & Whitney Canada PT6A-41, 850 horsepower, turbo propPratt & Whitney Canada PT6A-41, 850 horsepower, turbo prop
Damage
Substantial damage
Fire
On-Ground
Flight
Positioning · Part 91
Registered owner
Metro Aviation, Inc
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · September 1, 2006 · 5,827 hours before
Departed
GTF · Great Falls, MT
Destination
BZN · Belgrade, MT
Flight plan
IFR
Airport
BZN · Gallatin Field

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
59
Injuries
Fatal
Certificates
Airline transport, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
October 1, 2006
Toxicology
Performed
Flight hours
17,608 total · 1,318 in this make and model · 17,358 as pilot in command · 66 in the last 90 days · 45 in the last 30 days

Weather

Conditions
Visual (VMC) · Night/dark
Wind
300° at 4 knots
Visibility
10 statute miles
Lowest ceiling
11,000 ft overcast
Temperature
37 °F, dew point 30 °F
Altimeter
30.00 inHg
Observed at
KBZN, 13 nm away

Docket · 50

The files NTSB released with the investigation on January 23, 2008, on NTSB’s docket system: statements, records, photos and specialists’ reports.

ATC 3 - ATC Radar StudyItem 1 · .PDF · 4 photos · 1.4 MBATC 3 - Salt Lake ARTCC NTAP FilesItem 2 · .TXTATC 3 - Salt Lake ARTCC DART fileItem 3 · .TXTPilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 4 · .PDF · 345 KBWitness StatementsItem 5 · .PDF · 179 KBPhoto 1. Part of Witness Statement for Denise J. SebockItem 6 · .PDF · 125 KBPhoto 2. Part of Witness Statement for Denise J. SebockItem 7 · .PDF · 166 KBPhoto 3. Part of Witness Statement for Denise J. SebockItem 8 · .PDF · 166 KBPhoto 4. Part of Witness Statement for Denise J. SebockItem 9 · .PDF · 179 KBMaps and ChartsItem 10 · .PDF · 2.2 MBWeather DataItem 11 · .PDF · 597 KBTranscript of Radio CommunicationsItem 12 · .PDF · 517 KBRadar Data PlotsItem 13 · .PDF · 478 KBOuterLink Tracking DataItem 14 · .PDF · 64 KBPratt and Whitney Canada Field NotesItem 15 · .PDF · 28 photos · 2.6 MBBeechcraft Hawker ReportItem 16 · .PDF · 213 KBIntel Examination ReportItem 17 · .PDF · 224 KBStatement of Party Representatives to NTSB InvestigationItem 18 · .PDF · 118 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 19 · .PDF · 75 KBToxicological ReportItem 20 · .PDF · 36 KBImage 1. Aerial overview.Item 21 · .PDF · 1.8 MBImage 2. Cabin section located along debris path.Item 22 · .PDF · 1.4 MBImage 3. Cabin section located along debris path.Item 23 · .PDF · 1.7 MBImage 4. Cockpit (pre accident).Item 24 · .PDF · 193 KBImage 5. Cabin door.Item 25 · .PDF · 1.0 MBImage 6. EGPWS.Item 26 · .PDF · 683 KBImage 7. EGPWS.Item 27 · .PDF · 638 KBImage 8. Tree located at the start of the debris field.Item 28 · .PDF · 419 KBImage 9. Tree located at the start of the debris field.Item 29 · .PDF · 417 KBImage 10. Left aileron.Item 30 · .PDF · 1.2 MBImage 11. Left engine.Item 31 · .PDF · 597 KBImage 12. Left stabilizer.Item 32 · .PDF · 1.4 MBImage 13. Left stabilizer and elevator.Item 33 · .PDF · 1.3 MBImage 14. Piece of left wing.Item 34 · .PDF · 1.3 MBImage 15. Left aileron.Item 35 · .PDF · 1.1 MBImage 16. North side of hill.Item 36 · .PDF · 744 KBImage 17. Printed circuit board (EGPWS).Item 37 · .PDF · 690 KBImage 18. Right aileron (mislabeled in picture).Item 38 · .PDF · 1.0 MBImage 19. Right engine.Item 39 · .PDF · 467 KBImage 20. Right elevator.Item 40 · .PDF · 1.0 MBImage 21. Right elevator.Item 41 · .PDF · 916 KBImage 22. Right engine.Item 42 · .PDF · 453 KBImage 23. Right stabilizer.Item 43 · .PDF · 1.1 MBImage 24. Right wing skin.Item 44 · .PDF · 1.2 MBImage 25. Wing spar right.Item 45 · .PDF · 1.2 MBImage 26. Rudder.Item 46 · .PDF · 889 KBImage 27. South side of hill.Item 47 · .PDF · 748 KBImage 28. Wreckage path.Item 48 · .PDF · 1.2 MBImage 29. Wreckage empennage.Item 49 · .PDF · 1.1 MBImage 30. Wreckage fuselage.Item 50 · .PDF · 1.2 MB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.