NTSB Factual Report

HISTORY OF FLIGHT

On October 8, 1997, at 0723 mountain daylight time, N12022, a Cessna 208B, departed controlled flight and collided with terrain at the 9,900 foot level on the Uncompahgre Plateau, about 18 nautical miles (nm) southwest of Montrose, Colorado. The pilot and all eight passengers were killed. The flight was an on-demand air charter operated by the Department of the Interior (DOI) under 14 CFR Part 135. The flight was chartered to transport eight employees of the Bureau of Reclamation from Montrose, Colorado, to Page, Arizona. The registered owner of the airplane was Scenic Airlines Inc., of North Las Vegas, Nevada.

The pilot operated the first leg of the roundtrip charter flight from Page, Arizona, to Montrose, Colorado, on October 6, 1997. The flight was uneventful, and the pilot departed the airport about 1800 for a local motel. The return flight was scheduled to depart Montrose at 1700 on October 7. The pilot called the Scenic Airlines scheduler about 1200 and stated his concern about the passage of a cold front and the presence of less-than-VFR weather along the route of flight. He called back about 1500 and, after discussion, delayed the return trip until 0700 the following day, October 8. The pilot returned to the motel for a second night. On the morning of the accident flight, the pilot and passengers were at the airport about 0630.

Visual meteorological conditions prevailed upon takeoff. The flight departed from runway 17 of Montrose Regional Airport (elevation 5,759 feet msl) on a company visual flight rules (VFR) flight plan about 0705.

About 0710, a Federal Aviation Administration (FAA) radar National Track Analysis Program (NTAP) database target squawking VFR transponder code 1200 was recorded on a track from the Montrose area to the accident site. During the climb from 10,000 feet, the target airplane's course changed from southwest to northwest, back to southwest, and then made a sharp turn to the right. Climb performance was similar to data provided in the Pilot's Operating Handbook. The recorded radar information indicated that the target airplane climbed to a peak altitude of 15,400 msl then disappeared from radar. No emergency locator transmitter (ELT) signal was received. The airplane was reported overdue and a ground search party located the airplane wreckage about 50 hours later in the vicinity of the last recorded radar position. The wreckage was situated among 60-foot-high pine trees with evidence of a steep flight path angle (about -65 degrees), an approximate flat pitch attitude, and little indication of forward speed. There was a fuel spill in the surrounding area but no evidence of fire, either postcrash or in flight. All of the airplane occupants were located within the airplane fuselage.

The accident occurred during daylight hours at 38 degrees, 19 minutes, 23.8 seconds North latitude, and 108 degrees, 12 minutes, 43.6 seconds West longitude.

DAMAGE TO THE AIRCRAFT

Impact forces destroyed the airplane. The estimated value of the airplane was about $1.2 million.

OTHER DAMAGE

The crash site was unimproved range land. Although the immediate area received some ecological damage from spilled aviation fuel, overall damage was minimal.

PERSONNEL INFORMATION

The male pilot, age 63, possessed an FAA Airline Transport Pilot certificate issued in 1994. Ratings and limitations were: Airplane Multiengine Land, Commercial Privileges, Airplane Single-Engine Land. No type ratings were listed. His FAA First Class Medical Certificate, dated December 30, 1996, contained the limitation "must have available glasses for near vision."

The pilot was qualified to fly the Cessna 208B on May 9, 1995. Prior to that qualification, he was assigned as a second-in-command pilot on Scenic Airlines de Havilland Twin Otter airplanes. The pilot's most recent Part 135 proficiency check was administered April 18-22, 1997, in a Cessna 207. The handwritten statement "instrument competency demonstrated" appeared on FAA Form 8410-3, "Airman Competency/Proficiency Check." His most recent Part 135 line check was administered in a Cessna 208B on May 30, 1997.

The pilot's primary employment was to fly sightseeing trips in and around the Grand Canyon area of Arizona, Utah, and Nevada. Scenic Airlines records indicate the pilot had logged 12,900 hours of total flying time. Examination of the pilot's personal logbooks showed a total of 19.7 hours of flight in actual instrument conditions. This instrument experience was accumulated between 1987 and 1994. The pilot was not qualified to serve as a pilot in command of a 14 CFR 135 operation under instrument flight rules (IFR). He did not maintain instrument flying currency under 14 CFR 61.57, "Recent flight experience: Pilot in command." Colleagues described the pilot as one who had no intention of entering instrument meteorological conditions (IMC) at any time.

AIRCRAFT INFORMATION

The Cessna 208B, serial number 208B0432, was registered as N12022 to Scenic Airlines on August 17, 1995. The airplane was configured with nine passenger seats in addition to the pilot and copilot seats. On the accident flight, the copilot seat and the passenger seat immediately behind the pilot were not occupied.

Before the accident flight, the airplane total time and cycles were 2,598.5 hours/3,680 cycles. The airplane was equipped with a Pratt and Whitney PT6A-114A turbopropeller engine rated at 675 horsepower and a McCauley 3GFR34C703, three-bladed, constant-speed, full-feathering propeller. The engine, serial number 19315, and the propeller assembly had the same time and cycle history as the airframe. The airplane complied with all applicable airworthiness inspections and FAA airworthiness directives. There were no unresolved or recent, pertinent maintenance discrepancies.

The maximum certificated gross weight of the Cessna 208B is 8,750 pounds. The estimated takeoff weight of the accident flight was 8,874.5 pounds. The estimated ramp fuel load prior to the accident flight was 1,566 pounds of Jet A-1 fuel. Airplane operating manual climb charts indicate fuel required to climb to 15,400 feet is about 65 pounds. The certificated aft center of gravity (cg) limit is 204.35 inches aft of the datum. The estimated takeoff cg was 203.84 inches, within an area characterized by a Note in the operating manual which states, "...area should be used only if an accurate cg determination has been obtained for that loading."

The airplane was equipped with a supplemental oxygen system. The oxygen bottle contents were under pressure and discharged during the investigation. Postcrash inspection revealed one breathing mask in the airplane stowed near the right, front passenger entry door.

METEOROLOGICAL INFORMATION

Scenic Airlines flight-following personnel reported that the pilot communicated with them via telephone in the morning hours before the accident flight regarding the weather. They did not note or recall the specific details of that conversation. FAA records do not indicate that the pilot of N12022 received a weather briefing from an FAA facility on the morning of the accident flight.

The Surface Analysis chart prepared by the National Weather Service for 0600 October 8 showed a cold front extending through eastern Colorado, curving southwestward through southeastern New Mexico, and extending into northern Mexico. The chart also indicated a weak center of high pressure located over north central Arizona.

The Aviation Area Forecast for the Rocky Mountain Area, issued by the Aviation Weather Center at Kansas City, Missouri, and valid for Colorado during the accident period, indicated:

Mountains and west...scattered-broken 9,000 feet broken 11,000 feet top flight level 24,000 feet with occasional visibility 3-5 miles mist and widely scattered light rain showers. 1200 scattered 12,000 feet. Outlook... visual flight rules.

A National Weather Service Airman's Meteorological Information (AIRMET) weather advisory valid for the accident area and time indicated:

Occasional moderate rime/mixed icing in cloud in precipitation between freezing level and flight level 20,000 feet. Freezing level surface-8,000 feet west of GJT-RIW-50NNW ISN line...8,000-12,000 feet east of that line. Conditions moving eastward.

No National Weather Service Significant Meteorological Information (SIGMET) weather advisory or Convective SIGMETs were valid for southwestern Colorado around the accident time. The Denver Center Weather Service Unit issued no center weather advisories that were valid for the accident area.

The surface weather observations for the Montrose Airport, located about 4,000 feet below and 18 nm northeast of the accident location closest to the departure time, were as follows:

Time-0653; type-METAR; wind-190 degrees at 9 knots; visibility-10 miles; present weather-none; sky condition-overcast 9,500 feet; temperature-7 degrees C; dew point-0 degree C; altimeter setting-29.86 inches hg; remarks-thunderstorm information not available.

Time-0753; type-METAR; wind-210 degrees at 4 knots; visibility-10 miles; present weather-none; sky condition-scattered 5,000 feet broken 6,500 feet overcast 9,500 feet; temperature-7 degrees C; dew point-0 degree C; altimeter setting-29.89 inches hg; remarks-thunderstorm information not available.

Radar data from the Grand Junction Weather Surveillance Radar-1988, Doppler System (WSR-88D) for the time of the accident indicate reflectivity consistent with visible moisture from clouds in the vicinity of N12022's last recorded radar position and flight altitude.

Geostationary Operational Environmental Satellite-8 data for the time of the accident indicate variable cloud tops over the mountains west of Montrose. The radiative temperature in the vicinity of N12022's last recorded radar position compared to the Grand Junction upper air sounding temperature gradient is consistent with cloud tops around 16,000 feet msl.

A hunting party located within about a mile of the crash site reported that the area of the Uncompahgre Plateau was obscured with fog throughout the day of the accident.

COMMUNICATIONS

No distress calls were reported from aircraft in the area within the timeframe of the accident, and no air/ground communications from the accident aircraft were recorded. The departure point, Montrose Regional Airport, does not have an air traffic control (ATC) tower. Users of the airport common traffic advisory (CTAF) frequency had no recollection of any communications with the departing Scenic Airlines airplane. There are no requirements for the pilot of this VFR flight to have initiated any ATC communications.

WRECKAGE AND IMPACT INFORMATION

The airplane impacted wooded terrain that consisted of numerous pine trees averaging 60 feet in height and a packed mud surface. No evidence of freshly sheared tree tops or branches was found at the site. The entire airframe remained intact and was lying upright within the confines of its preimpact dimensions. The engine and one propeller blade remained attached to the fuselage structure; the other two propeller blades were nearby.

The magnetic bearing of the longitudinal axis of the airplane was 146 degrees. A ground scar in the shape of the base of the tail of the airplane was found under the rear portion of the wreckage; the magnetic bearing of its longitudinal axis was 160 degrees. The aircraft was severely crushed along its vertical axis. Except for the vertical stabilizer, the height of the wreckage did not extend more than 3 feet above the ground. When the wreckage was removed from the site, a depression of 12 to 18 inches remained in the ground.

The engine cowling, magnetic compass, and pieces of the windshield were distributed to the northeast of the airplane's nose for about 35 feet. A piece of wheel/brake assembly was found about 75 feet to the west of the wreckage. The remainder of the area was undisturbed. There was no evidence of an in-flight structural failure or fire.

The engine, nacelle, and propeller displayed moderate impact damage and no indications of fire damage. Examination disclosed no preexisting failures or conditions that would have prevented normal engine operation. The propeller displayed bending signatures and witness marks that indicated moderate to high power output from the engine. Plastic windscreen and wiring fragments had melted and adhered to the engine ducts; however, there was no evidence of combustion. The cockpit instruments disclosed engine oil pressure, oil temperature, interturbine temperature, torque, propeller revolutions per minute (rpm), and gas generator rpm indications consistent with engine operation at impact.

The fiberglass cargo pod installed on the belly of the fuselage were crushed and embedded into the ground. Miscellaneous cargo and baggage was found within the pod underneath the fuselage. The total weight of the cargo and baggage within the pod was 243 pounds. One cargo item, a Bureau of Reclamation electrical test set with support equipment, was found in the fuselage aft cargo compartment. It weighed 212 pounds. It did not appear to have been tied down within the compartment.

No evidence of a preimpact flight control malfunction was found. Flight control cable continuity for the rudder and elevator was established from the control surface through the rear bellcrank and pulley sector to the aft cabin partition. Flight control cable continuity for the ailerons and roll spoilers was established from the control surfaces through the wing roots.

The airspeed indicator needle indicated 35 knots. The altimeter indicated 0 feet. The altimeter setting read 29.88 inches Hg. The directional heading indicator was destroyed. The attitude indicator was partially crushed and indicated a 20 degree, nose-down pitch attitude with wings level. The vacuum-driven gyro in the attitude indicator was extracted from its housing, and an examination of the outer surface of the rotor revealed rotational scoring. The turn/bank coordinator was destroyed. No useful reading could be obtained from the vertical speed indicator.

The autopilot flight computer received severe impact damage; no reliable switch positions could be obtained.

All cockpit switches, circuit breakers, and controls associated with the pitot/static system received severe impact damage; no reliable switch positions could be obtained.

The airplane was equipped with an icing equipment package certified for flight in icing conditions. The package included pneumatic deicing boots on the wings, wing struts, horizontal stabilizer, and vertical stabilizer. The package also included electrically heated propeller blade anti-ice boots, a detachable electrical windshield anti-ice panel, a pitot/static heat system, and a standby electrical system. The detachable electrical windshield anti-ice panel was not installed and was found in the aft cargo compartment area of the wreckage. The airplane was not equipped with any ice protection for the landing gear struts or cargo pod. The engine inertial separator vane within the engine air inlet duct was in the normal mode.

All cockpit anti-ice/deice switches and controls were either broken or missing. No reliable information regarding preimpact positions could be extracted.

The deice boots for the horizontal stabilizers were found intact. No ice was found on them, and evidence of mud splatter was seen along the span of each boot. The deice boots for the vertical stabilizer were intact and clean and did not exhibit evidence of ice accretion. The deice boots from the wings and wing struts received severe impact damage and were partially separated.

The airplane was equipped with a Pointer, Inc. ELT that was compliant with the requirements of FAA Technical Standard Order (TSO) C91. It had separated from its mounting bracket and was found lying loose inside the aft fuselage. One end of the ELT's antenna coaxial cable was secured to the ELT antenna receptacle, and the other end was secured to the fuselage antenna. The antenna remained intact at its mounting located on top of the tailcone.

The ELT master switch was found in the "AUTO"

NTSB Probable Cause

the pilot's failure to maintain sufficient airspeed for undetermined reasons while maneuvering the airplane near the maximum gross weight and aft cg in or near instrument meteorological conditions, resulting in the loss of control and entry into a stall/spin. Factors contributing to the accident were the pilot's improper in-flight planning and decision-making and his failure to use proper stall/spin recovery techniques.