SEA96MA043

NTSB accident investigation · Mitsubishi MU-2B-36 · Malad City, ID · January 15, 1996

Accident · FatalMajor investigationFinal report
Date
January 15, 1996, 06:18 local (13:18 UTC)
Place
Malad City, ID
Injuries
8 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N693PAMitsubishi MU-2B-36
Weather
Visual (VMC) · Night/bright
Status
Completed · report April 29, 1997
Report
Approved by Office Director
FAA report
19960115000389A
Case key
42471

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 NTSB’s determination of the probable cause, and any contributing factors.

continued flight by the flightcrew into icing conditions with known faulty deice equipment; structural (airframe) ice; and failure of the flight crew to maintain adequate airspeed, which resulted in the loss of aircraft control and collision with terrain. A factor relating to the accident was: the en route weather (icing) condition, which was not forecast (inaccurate forecast).

Analysis

A Mitsubishi MU-2 departed Salt Lake City, Utah, and climbed to 16,000 feet MS on an IFR flight to Pocatello, Idaho. While in cruise flight, the MU-2 encountered structural icing conditions. According to radar data, the MU-2 began slowing from a cruise speed of about 190 knots with slight deviations from heading and altitude. The airspeed decreased to about 100 knots, and the flight crew declared an unspecified emergency, then radio contact was lost. The MU-2 began a right turn, then it entered a steep descent and crashed. The pilot of a Beech 1900 (about 12 minutes in trail of the MU-2), stated that he encountered moderate rime icing at 16,000 feet. The Beech pilot activated his deice boots (3 times) and descended to 12,000 feet to exit the icing conditions. The MU-2 flight manual warned that during flight in icing conditions, stall warning devices may not be accurate and should not be relied upon; and to minimize ice accumulation, maintain a minimum cruise speed of 180 knots or exit the icing conditions. An investigation determined that the captain of the MU-2 was aware of deficiencies in the timer for the deice boots, as well as other maintenance deficiencies. The captain's medical certificate was dated 11/17/94; he was providing executive transportation for compensation under an agreement for "contractual flights," under 14 CFR 91. Although icing conditions were forecast in the destination area, no icing was forecast for the en route portion of the flight.

Factual narrative

The factual narrative1,282 words

History of flight

On January 15, 1996, at 0618 mountain standard time (MST), a Mitsubishi MU-2B-36, N693PA, was destroyed when it impacted terrain in a near-vertical attitude approximately eight miles northwest of Malad City, Idaho. The crew had declared an unspecified emergency moments before while in cruise flight at 15,700 feet MSL (mean sea level). The airline transport pilot and commercial pilot crew members, and the six passengers on board, were fatally injured. The aircraft, owned by Pro Air Services of Utah, LLC (a Utah limited liability company), was being operated by Pro Air Services of Salt Lake, LLC, for the purpose of transporting Swire Coca Cola, USA, executives from Salt Lake City, Utah, the departure point, to Pocatello, Idaho. The flight was one of a series of demonstration flights for which Pro Air Services of Salt Lake received compensation exceeding that stipulated in 14 CFR Part 91. An instrument flight rules (IFR) flight plan was filed for the flight, which had departed Salt Lake City International airport at 0548:40.

After departure from Salt Lake City, the aircraft had climbed to and leveled off at approximately 16,100 feet MSL and maintained about 190 knots indicated airspeed (KIAS for close to twelve minutes. The aircraft then performed a heading change of approximately 20 degrees to the east and a subsequent correction back to the original heading. An oscillatory descent to 15,700 feet MSL and a slow decrease in indicated airspeed to approximately 150 KIAS was noted from radar data over the next two minutes of flight following the initial change of heading. About 15 minutes after leveling off, at 0617, the crew advised Air Traffic Control (ATC) that they had an unspecified emergency. No further communications were made by the crew. Soon after that point, radar contact was lost. Radar data also showed the aircraft's indicated airspeed decreasing from about 190 knots indicated airspeed (KIAS) to about 100 knots (KIAS) in the six minutes immediately preceding the uncontrolled descent from 15,700 feet MSL. The wreckage was found in open hilly terrain, approximately 5240 feet MSL. There was no report of an ELT actuating. There was a post-crash fire.

Before this flight, the MU-2's captain (who was a registered agent and officer of both Pro Air Service of Utah and Pro Air Services of Salt Lake) had previously provided at least 14 "executive demonstration" flights in N693PA to executives of Swire Coca-Cola, USA, while doing business as Pro Air Services of Salt Lake, LLC. The flight was conducted under 14 CFR 91, and was described as a series of flights for a "road show" marketing program for Swire Coca-Cola, USA, which is a large regional bottler of Coca-Cola products. Passengers on board the aircraft included four upper-level Swire executives, and two executives of Scopes Garcie Carlisle, Swire Coca Cola's advertising agency. No evidence was found that either Pro Air Services of Utah, LLC, or Pro Air Services of Salt Lake, LLC, held a 14 CFR 135 air carrier certificate. (The airplane was, however, on 14 CFR 135 operating specifications for D and D Aviation, LC, of Salt Lake City, which had an approved minimum equipment list for the aircraft.)

A "flight management & consulting service agreement" existed between Swire Coca-Cola and Pro Air Services of Salt Lake, wherein a monthly stipend was paid by Swire Coca-Cola to Pro Air Services of Salt Lake, which would provide pilot services and management services, including making aircraft available which could be used for executive transportation. This agreement was signed August 1, 1995, and was to be valid for six months. A second agreement, also signed August 1, 1995, provided Swire Coca Cola with a list of aircraft "available for demonstration," with a price schedule based upon price per hour of utilization.

On the morning of the accident, at 0516, the Cedar City (Utah) Automated Flight Service Station (AFSS), received a telephone call from the pilot of N693PA requesting a weather briefing and expressing a desire to file an IFR flight plan. That person stated that he planned on departing Salt Lake for Pocatello, Idaho, in about 20 minutes. The FSS specialist asked if the pilot wanted just current reports or a standard briefing. The pilot stated that current reports were okay," 'cause it doesn't take very long to get up there."

The FSS specialist provided current Salt Lake City weather as "twenty thousand overcast, visibility ten, temperature thirty-one, dew point twenty-nine, winds calm. Pocatello is showing measured ceiling nine thousand overcast, visibility twenty, temperature forty-five, dew point twenty-one and the wind two-one zero at one three. [I] don't see any pilot reports and just to the northwest of Pocatello there is an airmet for occasional mountain obscuration right in the Pocatello area. To the north-northwest, northeast all the way around to the southwest, [an] airmet [exists] for occasional moderate rime icing from about six or ten thousand...somewhere between six and ten thousand feet all the way up to twenty thousand and then an airmet over Idaho for occasional moderate turbulence below sixteen thousand."

The pilot requested winds aloft at 18,000 feet MSL, which the FSS specialist provided for Salt Lake City, from 260 degrees at 44 knots, and Pocatello, from 270 degrees at 49 knots. The pilot then filed an IFR flight plan, specifying that the aircraft had "slant romeo" equipment available (meaning that the aircraft was equipped with RNAV, or area navigation, with transponder and altitude reporting encoder), 260 knots cruise speed, departure time 1235 Zulu [0535 MST], 17,000 feet MSL cruising altitude, fifty minutes time en route direct from Salt Lake City to Pocatello. He stated that he had four hours of fuel on board, eight persons on board, and a black, silver and white aircraft. The conversation with the FSS specialist was terminated at 0519. The pilot did not file an alternate destination.

According to IFR low altitude en route charts, the minimum en route altitude (MEA) for V-21, the airway that approximately underlies the proposed route of flight, was 10,000 feet MSL. Total distance was about 152 nautical miles. Pocatello VOR (a VHF omnigational range navigation facility) is 41 nautical miles from Malad City VOR; the crash site was approximately five miles north-northeast of Malad City VOR.

Hudson General, an aircraft fueling facility at Salt Lake City International airport, fueled the airplane prior to the flight. Their invoice for Jet-A fuel, dated January 15, 1996, indicated that the four wing tanks were to be topped, and 45 gallons were to be pumped in each tip tank. Total fuel delivered to the aircraft was 138 gallons. Refueling personnel observed the passengers and crew boarding the flight, and provided a ground-power unit (GPU) start for the airplane.

At 0542:33, the crew called Salt Lake City ATCT (Air Traffic Control Tower) ground control east by radio, advising that N693PA was at Hudson South and ready to taxi, and stated that they would "get their clearance on the way." At 0542:39, N693PA was cleared to taxi to runway 17.

At 0542:56, Salt Lake City ATCT (Air Traffic Control Tower) clearance delivery was contacted by the crew of N693PA, who requested their IFR clearance to Pocatello.

Clearance delivery provided an amended clearance to Pocatello, changing the pilots' filed routing to instead fly a heading of 160 degrees for a radar vector to V-21 to Malad, then direct to Pocatello; to climb and maintain eight thousand feet, and to expect 17,000 feet [MSL], ten minutes after departure. Departure control frequency of 135.5 Mhz (megahertz) and a transponder code of 4311 were also issued.

The crew read back their clearance. Their altitude restrictions were clarified by clearance delivery. At 0543:56, the crew acknowledged the correct clearance to expect a clim

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 encounter with weatherCruise - normal
Anti-ice/deice system,wing - inoperativeFactor
Operation with known deficiencies in equipment - performedPilot in commandFactor
Weather forecast - inaccurate
Weather condition - icing conditionsFactor
Flight into adverse weather - continuedFlightcrewCause
Airframe - iceCause
Loss of control - in flightCruise
Airspeed - not maintainedFlightcrewCause
In flight collision with terrain/waterDescent - uncontrolled

Aircraft

Registration
N693PA
Reported as
Mitsubishi MU-2B-36
Category
Airplane
Serial number
693
Engine
Garrett TPE-331-5-252, 776 horsepower, turbo prop
Damage
Destroyed
Fire
On-Ground
Flight
Executive/Corporate · Part 91
Operator
Pro Air Services Of Salt Lake
Registered owner
Pro Air Services Of Utah
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 2, 1995
Departed
SLC · Salt Lake City, UT
Destination
PIH · Pocatello, ID
Flight plan
IFR

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
48
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Invalid Medical for flight
Seat
Left
Flight hours
8,925 total · 1,200 in this make and model · 7,065 as pilot in command

Weather

Conditions
Visual (VMC) · Night/bright
Wind
310° at 4 knots
Visibility
10 statute miles
Lowest ceiling
12,000 ft overcast
Temperature
82 °F, dew point 77 °F
Altimeter
30.00 inHg
Observed at
MLD

FAA reports on this event · 1

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