NTSB Factual Report

HISTORY OF FLIGHT

On May 31, 2000, approximately 1728 mountain daylight time, radio and radar contact was lost with a Cessna 414, N5113G, being operated by Lynch Flying Service of Billings, Montana, on a 14 CFR 91 company business flight from Great Falls, Montana, to Billings. The wreckage of N5113G was located the following day, June 1, 2000, at approximately the 7,500-foot level on the southwest flank of 8,309-foot Barker Mountain, approximately 37 nautical miles southeast of Great Falls and 6 nautical miles east of Monarch, Montana. The airplane was destroyed, and all three of the aircraft's occupants (the airline transport pilot-in-command, a prospective-hire commercial pilot undergoing a pre-employment screening flight with Lynch Flying Service, and a Lynch Flying Service pilot being repositioned from Great Falls to Billings and riding aboard the aircraft as a passenger) were found dead at the accident scene. Instrument meteorological conditions were reported at Great Falls at 1656 and 1756, and the flight (which departed Great Falls at 1711) was on an instrument flight rules (IFR) flight plan.

The accident flight was the return flight of a planned round trip from Billings to Great Falls and back. The purpose of the flight was to deliver another Lynch pilot to Great Falls to pick up another Lynch aircraft (a Cessna 402) and fly it back to Billings, and to pick up the pilot who had flown the Cessna 402 into Great Falls and return him to Billings. Additionally, the prospective-hire pilot was brought along on the trip to undergo a pre-employment screening evaluation. The pilot-in-command on the trip was Lynch's director of training (NOTE: Subsequent references to the "pilot" in this report are to the pilot-in-command, unless otherwise indicated.) The pilot who was delivered to Great Falls reported to the NTSB that on the flight to Great Falls, the pilot occupied the left seat, and the prospective hire occupied the right seat and flew the instrument approach into Great Falls. The Lynch pilot who rode to Great Falls also reported that the pilot told him that on the return flight to Billings, he intended to have the prospective hire occupy the left seat with the pilot-in-command in the right seat.

Lynch's chief pilot reported to the NTSB that the pilot utilized the WeatherMation computerized weather briefing service at Lynch during preflight planning. Recordings of FAA air traffic control (ATC) and air traffic services communications disclosed that prior to departing Billings, the pilot also twice contacted the Great Falls FAA automated flight service station (AFSS) and requested weather information. During the first contact, at 1321, the Great Falls AFSS preflight briefer advised the pilot that Great Falls was reporting 1/4 mile visibility in heavy snow and fog, and that an AIRMET advisory was in effect for occasional moderate rime and mixed icing conditions in clouds and in precipitation from 6,000 feet to flight level (FL) 180. The briefer also relayed a pilot report (PIREP) from a Cessna 340 aircraft indicating moderate rime ice at FL 190, along with the area forecast for Montana, the Great Falls terminal aerodrome forecast (TAF), and radar information showing light to moderate (with embedded heavy to very heavy) precipitation over most of the state. The briefer indicated that since the reported weather at Great Falls was worse than had been forecast (the visibility had been forecast to be 6 miles, with occasional visibility down to 2 miles, for that time period), he expected the TAF to be amended. The pilot stated that he "might have to try it", but indicated that he would wait and see if the visibility at Great Falls improved beyond 1/4 mile. He then filed an IFR flight plan for the Billings-Great Falls flight, with an estimated departure time of 1430 from Billings.

During the second contact, at 1516, the Great Falls AFSS briefer advised the pilot (who identified himself to the briefer as "Vince down at Lynch") of a convective SIGMET meteorological advisory for an area of thunderstorms around Billings. The pilot asked about any PIREPs of icing conditions. The briefer relayed PIREPs from Boeing 727 (B-727) and Beech Bonanza aircraft, which reported encountering light rime ice at 12,000 feet over Great Falls, and that at 15,000 feet, one of the aircraft had accumulated 1/2 inch of rime ice. The briefer also relayed to the pilot that he could expect to encounter shower activity almost immediately after departure from Billings, and that the precipitation would change to mixed rain and snow approximately 10 to 20 miles west of Lewistown. The briefer further stated that approaching Great Falls, the precipitation would change to light to moderate, and possibly heavy, snow showers. The pilot then revised his estimated time of departure from Billings to 1530, and also filed an IFR flight plan for the Great Falls-Billings flight. The pilot filed for a return flight departure time from Great Falls of 1700, with a cruising altitude of 17,000 feet.

The flight subsequently departed Billings, and at 1616, while en route to Great Falls, contacted the Great Falls AFSS by radio and relayed a PIREP. During this report, the pilot reported he was 71 miles southeast of Great Falls at 16,000 feet, that he was in and out of instrument meteorological conditions (IMC), that the temperature was -11 degrees C, and that he was not encountering any icing or turbulence. The Great Falls AFSS inflight briefer advised the pilot that the flight was north of the convective SIGMET area and relayed the weather conditions at and around Great Falls, including moderate precipitation south to southeast of Great Falls with upslope conditions prevailing in the vicinity. The briefer then asked the pilot if he needed updates to the AIRMETS for icing, and the pilot replied in the negative, stating that he had them.

Investigators interviewed the line service shift supervisor at Holman Aviation in Great Falls who was on duty at the time the accident airplane arrived. The shift supervisor reported that the aircraft arrived between 1630 and 1700, and remained on the ground for approximately 15 minutes. He stated that when the aircraft arrived, he observed approximately 1 inch of rime ice on the unprotected leading edge areas of the wing and tip tanks, and approximately 3/8 inch of ice on the aircraft's nose (he reported that the wing upper surfaces and deice boots appeared clean.) The shift supervisor stated that he removed a small amount of ice by hand from an area between the boot and the tip tank, and that he pointed out the ice to the crew, who replied with a statement to the effect of, "Yeah, we picked up some ice." The shift supervisor stated that the crew did not request that the aircraft be deiced, and that no deice fluid was applied to the aircraft before departure. The shift supervisor reported that the last time he saw the airplane, ice was still present on the airframe. Holman Aviation's president reported that while the crew was in the facility, he observed them looking at satellite weather in Holman's flight planning room (Holman Aviation subscribes to a weather briefing service provided by DTN, Inc.)

Investigators interviewed the Lynch pilot who rode to Great Falls in the accident aircraft (hereafter referred to as the "Lynch relief pilot".) This pilot reported that on the way in to Great Falls, the aircraft picked up about 1/2 inch of ice which was successfully removed with the deice boots. The Lynch relief pilot also stated that the aircraft was "sloughing ice" on the instrument landing system (ILS) final approach into Great Falls. The Lynch relief pilot stated that when the aircraft landed at Great Falls, the only ice he observed on the aircraft was the chunk the lineman picked off the aircraft, which the lineman handed to him. He stated that this piece was approximately 6 inches long and 1/2 inch thick. The Lynch relief pilot stated that he did not see the accident aircraft deiced before it left. The Lynch relief pilot reported that he blocked out of Great Falls in the Cessna 402 at 1852 (approximately 1 hour and 40 minutes after the accident aircraft's departure), and that no weather delay was involved with his flight. However, he stated that since Great Falls AFSS reported the worst icing conditions to be south and east of Great Falls, he requested a runway 21 departure with a right turnout to a departure heading of 090 degrees until clear of the icing conditions.

FAA ATC information indicated that prior to takeoff, the flight was cleared to the Billings airport as filed via Great Falls direct, climbing to an initial altitude of 12,000 feet with an expected altitude of 15,000 feet 10 minutes after departure. After issuing the flight its clearance, the Great Falls controller called the aircraft and stated that while he did not have any current pilot reports east of the airport, he did have a current pilot report relayed 10 minutes previously (approximately 1700) from a Boeing 727 (B-727) aircraft 30 miles southwest of the Great Falls VORTAC reporting moderate rime ice from 11,000 to 12,000 feet. The pilot replied, "...yah we played with a little ice on the way in but ah we were on top about fourteen or so." The flight was subsequently cleared for takeoff from runway 3, with a right turn to a heading of 120 degrees after takeoff, at 1710:51, and was handed off to Great Falls departure control at 1713:20. Great Falls Departure cleared the flight to resume its own navigation direct to Billings at 1713:36, and cleared the flight to climb to and maintain 15,000 feet at 1717:42. At 1720:14, the departure controller relayed the earlier PIREP from the B-727 of moderate rime ice from 11,000 to 12,000 feet. The pilot replied, "one three golf roger thank you sir." Great Falls Departure handed off the flight to the Salt Lake Air Route Traffic Control Center (ARTCC) at 1724:02.

According to a transcript of the accident aircraft's communications with Salt Lake ARTCC, the flight checked on with Salt Lake Center at 1724:20. Approximately 1 1/2 minutes later, at 1726:00, the pilot reported, "...we're having a little trouble here getting up there we're picking up some ice." Approximately 30 seconds after this call, at 1726:34, the pilot stated he would have to descend back to Great Falls as the aircraft was not getting out of the ice. The controller asked if the pilot could maintain 10,000 feet; the pilot responded, "one three golf requesting vectors back to great falls." The controller cleared the flight direct to Great Falls and asked if the pilot could maintain 9,000 feet; the pilot replied that he could not. The controller then stated that the minimum IFR altitude in that area was 9,000 feet, and that if the pilot was unable to maintain that altitude, to "let me know." The pilot's reply, which was the last transmission from the aircraft (at 1727:32), was, "start a turn back too [sic] great falls keep it moving dave." At 1729:17, the Salt Lake controller attempted unsuccessfully to contact the accident aircraft. The Salt Lake controller also queried the Great Falls approach controller whether the aircraft was on the Great Falls approach control frequency yet; the Great Falls approach controller responded that it was not and that he had lost radar contact with the aircraft. Starting at 1730:00, several airborne aircraft in the area then reported to the Salt Lake controller that they were receiving emergency locator transmitter (ELT) signals.

FAA ATC radar data on the accident aircraft showed the aircraft initiating a right turn after takeoff and proceeding generally southeastbound, directly toward Billings. The aircraft was in a climb until approximately 1722:40, about which point it attained its maximum altitude for the flight of 9,400 feet; it then began a gradual descent while continuing southeastbound. The last positive radar contact with the aircraft on the Great Falls approach radar was at 1727:28, approximately 34.3 nautical miles east and 13.4 nautical miles south (referenced to magnetic) of the Great Falls approach radar, at an altitude of 8,700 feet. After this time, the radar target went into the "coast" mode on Great Falls' approach radar. Radar data from Salt Lake ARTCC showed the aircraft in a right turn from 1727:29 to 1728:29, and descending from 8,800 feet to 8,400 feet. The coordinates of the last three Salt Lake ARTCC radar returns were plotted on a Great Falls Sectional Aeronautical Chart, and all three plots were found to be less than 1/2 nautical mile from the 8,309-foot summit of Barker Mountain, at an altitude of 8,400 to 8,500 feet. The crash site was located approximately 1/2 nautical mile south of the last Salt Lake ARTCC radar position. Further review of the Great Falls sectional chart revealed generally higher, mountainous terrain (to 9,177 feet above sea level) to the south (right) of the aircraft's southeasterly track, and relatively lower, level terrain (less than 5,000 feet above sea level) to the north (left) of the aircraft's track.

Based on the time radio and radar contact was lost, the accident occurred during the hours of daylight at 47 degrees 4.9 minutes North latitude and 110 degrees 41.2 minutes West longitude.

PERSONNEL INFORMATION

The pilot-in-command, who was Lynch's training manager, held an airline transport pilot certificate with airplane multi-engine land rating, and commercial privileges for single-engine land airplanes and helicopters. He held a first-class FAA medical certificate dated April 17, 2000. The pilot's medical certificate carried a limitation requiring the wear of corrective lenses. According to the operator's accident report to the NTSB, the pilot had 8,000 hours total pilot time, including 7,000 hours of pilot-in-command (PIC) time, 2,500 hours as PIC of multi-engine airplanes, 500 hours of actual instrument time, and 100 hours of simulated instrument time. The operator did not furnish any information on the pilot's total time in the Cessna 414.

According to records furnished by Lynch Flying Service, the pilot last successfully accomplished a 14 CFR 135 qualification check in a Cessna 310 aircraft on March 14, 2000. On this check, the pilot demonstrated (among other items) current knowledge of various aircraft (including the Cessna 414) as per 14 CFR 135.293(a), flight competency in the Cessna 310 as per 14 CFR 135.293(b), and IFR proficiency as per 14 CFR 135.297.

The operator reported that the pilot had flown 105 hours (including 15 hours in the Cessna 414) in the last 90 days, 38 hours (including 8.2 hours in the Cessna 414) in the last 30 days, and 1.8 hours in the last 24 hours.

The prospective-hire pilot held a commercial pilot certificate with airplane single-engine land, airplane multiengine land, and instrument airplane ratings, and a flight instructor certificate with airplane single-engine, airplane multiengine, and instrument airplane ratings. He held a first-class FAA medical certificate dated December 17, 1999. According to the prospective-hire's resume and employment application, furnished to the NTSB by Lynch Flying Service, at the time of his employment application to Lynch (dated May 26, 2000), the prospective-hire was a Beech 1900D first officer for Continental Express Airlines, and had been employed in that capacity since June 1999. Lynch's chief pilot reported that the prospective hire told him he was leaving Continental Express due to personal problems with some of the captains at the airline; on his employment application for Lynch, he gave his reason for leaving as "limited flight time." The prospective hire had also been employed as a flight instructor by Embry-Riddle Aeronautical University, Daytona Beach, Florida, from August 1998 to June 1999. The prospective-hire's resume indicated that he had 1,800 hours total pilot time including 1,220 hours as PIC, 490 hours as second-in-command, 750 hours of multiengine time, and 200 hours of actual instrument time. Continental Express records indicated that the pilot successfully completed a Beech 1900 first officer initial simulator proficiency check on August 1, 1999, a Beech 1900 first officer initial aircraft proficiency check on August 6,

NTSB Probable Cause

The failure of the pilot-in-command to ensure adequate airspeed for flight during a forced descent due to airframe icing, resulting in a stall. Factors included: freezing rain conditions, airframe icing, an improper decision by the pilot-in-command to turn toward mountainous terrain (where a turn toward lower and level terrain was a viable option), mountainous terrain, and insufficient altitude available for stall recovery.