NTSB Factual Report

HISTORY OF FLIGHT

On April 25, 2009, about 1004 mountain daylight time (MDT), a Lockheed P2V-7 Neptune, N442NA, impacted the terrain about one and one-half mile north of Stockton, Utah. The two airline transport pilots and their passenger were killed in the accident, and the airplane was substantially damaged by the impact sequence. The airplane was owned and operated by Neptune Aviation Services, and dispatched as the result of the issuance of a Resource Order (Aircraft) issued by the National Interagency Coordination Center (NICC). The Title 14 Code of Federal Regulations Part 91 Public Use repositioning flight, which departed Missoula, Montana, about two hours prior to the accident, was en route to Alamogordo, New Mexico. At the time of the accident, the airplane was flying in an area of low ceilings and restricted visibility. No flight plan had been filed with the Federal Aviation Administration, but a company flight plan was on file with NICC.

According to United States Department of Agriculture Forest Service (USDAFS) records, Neptune P2V-7, N442NA (designated Tanker 42), along with its assigned crew, began its yearly Mandatory Availability Period (MAP) under the 2009 National Exclusive Use Airtanker Service Contract (Contract # AG-024B-C-08-9279) on 15 April, 2009. At that time the airplane was assigned to the Missoula Airtanker Base at Missoula International Airport, Missoula, Montana, but was physically located on the ramp adjacent to Neptune Aviation Services on the northeast side of Missoula International Airport. The airplane and crew were assigned to the Klamath Falls, Oregon, Administrative Base for contract management oversight only. The airplane and crew were assigned a basic coverage schedule of six days ON and one day OFF (Monday), with a nine-hour per day Standby period, with the potential of an additional government-assigned extended standby, not to exceed 14 hours total standby per day. During the 160-day MAP Tanker 42 was to be made available for the exclusive use of the government, and although assigned to a specific Administrative Base, was to be available and capable of being dispatched nationwide.

On April 22, 2009, while on Standby at the Missoula Airtanker Base, Tanker 42 was launched under the authority of Resource Order MT-LNF-19, issued by the National Interagency Coordination Center (NICC), in order to fight the Obrien Creek Fire located about five miles west of Missoula International Airport. The crew flew three sorties that day, with a total elapsed time of 1.10 hours.

On April 23 and April 24 the airplane and crew did not fly. On April 24, about 1730 MDT, Neptune Aviation Services was notified via telephone by NICC that a Resource Order was being issued to dispatch Tanker 42 on an empty (not carrying retardant) repositioning flight to the Alamogordo Airtanker Base in Alamogordo, New Mexico. That phone call was followed up by a faxed copy of Resource Order NM-N5S-000198. According to the Resource Order, upon arriving in Alamogordo, the firefighting sorties of Tanker 42 were to be assigned/launched under the authority of the New Mexico Area Dispatch Center (NM-ADC), an Expanded Dispatch, for the purposes of fighting the Four Mile Fire, which was located about eight miles southeast of Dunken, New Mexico.

At 2140 MDT on April 24, 2009, the Tanker 42 First Officer attempted to file a VFR flight plan using the Direct Users Access Terminal (DUAT) system. The flight plan route that he input into the DUAT system was from Missoula, Montana (KMSO), to Pocatello, Idaho (KPIH), to Grand Junction, Colorado (KGJT), to Albuquerque, New Mexico (KABQ), to Alamogordo, New Mexico (KALM), at a filed altitude of 13,500 feet. The flight plan was rejected by the DUAT system, because the DUAT system did not recognize the aircraft type/special equipment entry of Lockheed P2G, and the session ended.

The next morning (April 25), at 0601, the First Officer of Tanker 42 contacted the Federal Aviation Administration's Automated Flight Service Station (AFSS) to obtain a weather briefing. A that time he indicated the flight would be "IFR" (conducted under Instrument Flight Rules), and that the route of flight for which he needed weather was from Missoula, Montana (KMSO), to Alamogordo, New Mexico (KALM), by way of Cedar City, Utah (KCDC), and Albuquerque, New Mexico (KABQ). While he was on the phone with the AFSS briefer, the First Officer also successfully entered the DUAT system at 0605 in order to acquire a "Plain Low Altitude Weather Briefing."

The AFSS briefer provided the synopsis, and indicated that AIRMETs for icing conditions extended over northern Utah from the freezing level to 20,000 feet and an AIRMET for mountain obscuration was current for the region. After providing the weather conditions en route, the briefer asked the First Officer what levels he wanted the winds aloft data for, and the First Officer indicated for 12,000 and 18,000 feet. The AFSS briefer asked again if the First Officer planned on going VFR or IFR, and the First Officer responded with, "...we're filed for IFR". They then discussed in general terms the low pressure system and associated front that was stalled over the area and discussed the radar echoes in the vicinity of Salt Lake City. The co-pilot acknowledged he knew about the echoes, and indicated he had observed them on the TV. The briefer reviewed the NOTAMs (Notice to Airmen) for the region, and the briefing concluded at 0623 MDT.

The routing selected by the First Officer for the DUAT briefing was through Pocatello, Idaho (KPIH), to Grand Junction, Colorado (KGJT), to Albuquerque, New Mexico (KABQ), then to Alamogordo, New Mexico (KALM), at 13,500 feet. That briefing also included the full series of AIRMETs for IFR and mountain obscuration, moderate turbulence below 15,000 feet, and icing conditions over the area. No METARs or TAFs for Utah were included in the DUAT briefing due to the selected routing specified. The only other weather data provided besides the AIRMETs that extended over Utah was the winds and temperature aloft forecast (FD) for Salt Lake City. The forecast data for Salt Lake City at 6,000 feet was wind from 220° at 22 knot with a temperature of +5° C. At 9,000 feet wind from 220° at 24 knots and -3° C. At 12,000 feet from 230° at 38 knots at -17° C, and at 18,000 feet from 240° at 52 knots at -29° C. The document also included 5 1/2 pages of NOTAMs.

The First Officer did not file an FAA flight plan during either the AFSS session or the DUAT session, and there was no record of a VFR or IFR FAA flight plan for N442NA on file on the day of the flight (April 25, 2009).

The flight departed Missoula International Airport at 0803 on April 25. According to recorded data recovered from the onboard automatic flight following (AFF) system and the Garmin global positioning system (GPS) unit, after the initial VFR departure, the crew climbed to the southeast. About 0814, when the airplane was approximately 10 miles east of Stevensville, Montana, the crew leveled off at 11,500 feet mean sea level (MSL). At that time the data indicated that the crew turned slightly right, and maintained headings between 160 and 172 degrees until approximately 0932. About 0932, when the airplane was about four miles west of Malad City, Idaho, and about 12 miles north of the Idaho/Utah border, the crew turned right to a heading of about 180 degrees, while remaining at 11,500 feet. About four minutes later, when the airplane was about four miles south of the Idaho/Utah border, the crew turned further right to about 190 degrees, and began to descend out of 11,500 feet. About four minutes after that (around 0940), while descending through about 7,600 feet MSL, the crew turned further right to a heading of about 220 degrees, and they contacted the next sector of Salt Lake Air Route Traffic Control Center (ARTCC), from whom they were receiving VFR traffic advisories. According to ARTCC audio recordings, at that time the crew of Tanker 42 advised Salt Lake Center that they were departing 11,500 feet in order to "remain VFR." In response, Salt Lake Center advised Tanker 42 to "maintain VFR," and then gave them the current Salt Lake altimeter setting of 29.78. Then about 0942, while descending through about 7,500 feet, the crew turned further right to about 240 degrees.

About 0947, on the same frequency that Tanker 42 was on, the Salt Lake Center controller advised a Delta Airlines flight to expect light mixed icing and light turbulence during the arrival procedure for Salt Lake International Airport. Immediately following that transmission, the Salt Lake Center controller handed Tanker 42 off to the next sector controller by advising them to contact Salt Lake Center on 128.55. Tanker 42 acknowledged that call, and then contacted the next sector controller, advising him that Tanker 42 was "level 6,500." About one minute after Tanker 42 made contact with the new sector, that sector controller began the process of handing Tanker 42 off to the next sector (Lake 641). During the pre-handoff discussion, the current controller advised the Lake 641 controller that, "We've got a Tanker 42. He is VFR. It looks like he is trying to skirt some weather. He's just at the Gunnison gate now at 6,500."

The receiving controller advised the handoff controller that that airspace was actually controlled by a different controller (Heart Sector 41), so the handoff controller contacted the Heart 41 controller to start the handoff process again. During the initial briefing with the Heart 41 controller, the handoff controller stated that Tanker 42 was just on the sector boundary, and was VFR at 6,500 feet. He then said that, "It looks like he is trying to pick his way through that weather." He then asked the receiving controller if he would be able to "...see him out there." The Heart 41 controller asked where Tanker 42 "was going," and the handoff controller said, "He's trying to go down towards Albuquerque." The Heart 41 controller responded that he probably would not be able to see Tanker 42 for about 20 to 30 miles, and the handoff controller then asked if he (the Heart 41 controller) wanted him to just terminate Tanker 42 for now. The Heart 41 controller then said that would be fine.

About 0950, the handoff controller advised Tanker 42 that "Radar service is terminated," because Salt Lake Approach would not be able to "see you" for about 20 miles. The controller then advised Tanker 42 to attempt to contact Salt Lake Approach in about 20 miles on frequency 124.9, and advised Tanker 42 to, "...squawk VFR now." The controller then further stated that Salt Lake Approach would give Tanker 42 a new transponder code after they made contact. Tanker 42's acknowledgment of that transmission was the last known contact with any FAA in-flight resource or controller.

At the time of this last transmission, the crew had turned back to the left to a heading of about 165 degrees, and the airplane was over the middle of The Great Salt Lake, about 30 miles west of Ogden, Utah, and level at about 6,500 feet. About two minutes later, the airplane was down to about 6,000 feet (about 1,800 feet above the surface of the lake), and it stayed near that altitude until reaching the south end of the lake about 0959. By the time the airplane was about five miles south of the lake, near Grantsville, Utah, the crew had descended to about 5,800 feet, which was about 1,400 feet above ground level (agl), and turned left about 10 degrees. By 10:02:40, the airplane was about six and one-half miles west of Tooele, Utah, down to about 5,670 feet, heading about 141 degrees, at an airspeed of 208 knots. According to recorded data from onboard accelerometers, within about six seconds after crossing over State Highway 38 (and the railroad tracks that run parallel to it), at almost exactly 10:04, the airplane impacted the grassy northwest 20-degree upslope of a 5,867 foot-high ridge at an elevation of about 5,630 feet.

LOCALIZED WEATHER

The NWS National Surface Analysis Chart for 0900 MDT depicted a low pressure system with a central pressure of 1001-hectopascals (hPa) over southwestern Utah with a cold front extending southward and a warm to stationary front extending east-northeastward across northern Utah immediately south of the accident site into northwestern Colorado to another low pressure center at 1000-hPa.

The closest weather reporting facility was at Bolinder Field - Tooele Valley Airport (KTVY), which is located about seven and one-half miles north of the accident site, at an elevation of 4,321 feet msl (about 1,310 feet lower than the point of impact). The 0955 recorded Automated Weather Observation System (AWOS-3) for KTVY (about 10 minutes before the accident) indicated wind from 330° at 9 knots, visibility 10 miles in moderate drizzle, ceiling broken at 1,500 feet, overcast at 1,900 feet, both temperature and dew point at 6° Celsius, and an altimeter setting of 29.80 inches of Mercury.

The KTVY weather observation at 1055 MDT, about 50 minutes after the accident, reported wind from 330° at 12 knots, visibility 4 miles in mist, scattered clouds at 800 feet, ceiling broken at 1,300 feet, broken at 2,000 feet, with both temperature and dew point at 5° Celsius, and an altimeter setting of 29.81 inches of Mercury.

There were three witnesses located within one mile of the accident site who heard the airplane just prior to the impact. One witness had a momentary view of the airplane, and described it as flying "very low" from the northwest to the southeast. All of the witnesses reported low clouds with ceilings about 200 feet above the ground at their respective locations (all were at an elevation that put them about between 430 to 480 feet lower than the initial impact site). All three witnesses reported or described a visibility of one-quarter mile or less, with rain and fog. Although all of the witnesses could clearly see the accident site from their respective locations once the ceiling had risen later in the day, none of them could see it at the time of the accident. The two witnesses who heard the impact, and looked in the direction where the noise came from, were not able to see the glow of the post-crash fire.

The Sheriff's deputies who responded to the emergency calls said that the area where they gathered on Highway 38 (about 430 feet below the accident site) was obscured by low clouds and horizontal visibilities down to 200 feet. The Sheriff further indicated that because of the limited visibility, it took his crew more than three hours to find the wreckage, even though it was located about one-half mile from the highway and witnesses were able to point in the direction where it was ultimately found.

One of the witnesses, who was working at a landfill located about seven-tenth of a mile northwest of the impact site, noted that to the west of where he was working, in the general direction of the lower flat terrain where the airplane came from, the clouds were a little higher and the visibility was unlimited.

PERSONNEL DATA

The Pilot-In-Command (Captain), age 66, held an Airline Transport Pilot certificate for airplane multi-engine land, and a second class airman medical issued February 17, 2009, with the limitation that he shall wear glasses for near vision while exercising the privileges of his certificate. According to the operator's records, the Captain had accumulated about 7,335 hours of flying time, 916 of which was in the Neptune P2V. Of his total hours, 5,155 were in multi-engine airplanes, and 2,227 were in single-engine airplanes. He held an instrument rating for airplanes, and had logged 150 hours of simulated instrument time, and 396 hours of actual instrument time. In the 90 days prior to the accident, he had accumulated nine hours of flying time in airplanes, all of which were in the Neptune P2V. The Captains last FAR Part 61.58 proficiency check ride was successfully completed on February 8, 2009, and his Neptune Aviation Services ground training was successfully competed on February 27, 2009. His most recent United Sates Department of Agriculture Forest Service Pilot Qualification and Approval Record was dated February 28, 2009. He completed the Crew Resource Management Skills port

NTSB Probable Cause

The flight crew's failure to maintain terrain clearance during low altitude flight in low ceiling and visibility conditions. Contributing to the accident was the flight crew's failure to adequately monitor their location with respect to the rising terrain environment ahead, and, their lack of crew resource management communication as a crew.