NTSB Factual Report

HISTORY OF FLIGHT

On January 11, 2005, approximately 2145 mountain standard time, a Beech E-90, N41WE, operating as Yampa Valley Air Ambulance, was destroyed when it impacted terrain while flying the VOR/GPS approach to runway 22 at Rawlins Municipal Airport/Harvey Field (RWL), Rawlins, Wyoming. The airline transport pilot (ATP) and two flight nurses were killed, and the flight paramedic was seriously injured. The airplane was owned and operated by Mountain Flight Service, Inc., of Steamboat Springs, Colorado. Night instrument meteorological conditions (IMC) prevailed at the time of the accident. The emergency medical services (EMS) repositioning flight was being conducted on an instrument flight rules flight plan under the provisions of 14 Code of Federal Regulation Part 91. The cross-country flight originated at Steamboat Springs, Colorado, about 2116.

About 2018, St. Anthony Hospital's dispatch in Denver, Colorado, sent a general launch page to Mountain Flight Service's on-call flight and medical crews to transport a patient from Rawlins, Wyoming, to Casper, Wyoming. About 2057, St. Anthony Hospital dispatch sent a general page indicating that N41WE was on the way to Rawlins with an estimated en route time of 30 minutes.

About 2112:04, the Sector 11 controller at Denver Air Route Traffic Control Center (ZDV) cleared the pilot for departure from Steamboat Springs Airport (SBS) to RWL, directing him to "climb and maintain one three thousand." About 2116:40, the pilot of N41WE contacted ZDV, stating "…out of nine thousand for one three thousand." The ZDV controller responded, "…thanks have you in radar, just a moment, climb and maintain one four thousand."

ZDV radar contact was established at 2116:52. Radar data indicate that the airplane took off to the south-southeast from SBS and climbed through an altitude of 9,400 feet mean sea level (msl) on a magnetic heading of 140 degrees. Approximately 5 miles south of SBS, ZDV radar showed the airplane make a climbing 207-degree right turn to a heading of 323 degrees. About 2117, the controller cleared N41WE to 16,000 feet msl and direct to RWL. At 2126:04, the pilot checked in with the ZDV Sector 22 controller and stated he was at 16,000 feet, direct RWL. At 2133:41, the pilot contacted ZDV and informed him, "...for planning purposes we'd like...clearance for the VOR/GPS runway 22 approach into Rawlins." ZDV cleared the pilot direct to the Rawlins VOR and told him to expect clearance for the approach.

About 2134:28, ZDV transmitted to N41WE, "...descent at pilot's discretion, maintain one one thousand, Rawlins altimeter two niner three five." The pilot responded with the altitude and altimeter setting. At 2136:31, ZDV told the pilot of N41WE to "cross Rawlins VOR at or above one one thousand, cleared VOR or GPS runway 22 approach to the Rawlins Airport," and the pilot acknowledged the transmission.

At 2140:14, the pilot reported, "...crossed over VOR at eleven for nine." ZDV told N41WE, "change to advisory approved you can recancel with me ah or through radio, have a good approach." The pilot responded, "With you or through radio…and the radio frequency on the ground at Rawlins is?" ZDV responded, "…I'm showing one twenty-two two." The pilot said, "Roger that same here…thank you." About this time, ZDV radar showed the airplane cross the RWL VOR and turn right to an outbound heading of 044 degrees. About 2142, radar contact with the airplane was lost. At the time radar contact was lost, the airplane was 8 miles east of the Rawlins Airport at 9,200 feet msl. The airplane was flying an approximate heading of 090 degrees, which is consistent with it being midway through the procedure turn inbound for the approach to runway 22.

A ground ambulance driver reported that she was dispatched to the airport to pick up the flight medical crew and take them to the hospital to pick up the patient. She stated that the runway lights were already on when she arrived at the airport and recalled that the time was 2138. She said the airplane was due in a little before 2200. The ambulance driver said she contacted the hospital to inquire about the flight crew and learned that the hospital had not heard anything. She stated that a little after 2200, the runway lights went off. The ambulance driver said she contacted the sheriff's dispatcher by phone, informed them the airplane was late, and inquired if they had heard anything. The dispatcher told her they had heard nothing. At that point, the ambulance driver contacted the emergency room at the hospital. About 2215, they were notified by sheriff's dispatch that the airplane had crashed.

At 2205:44, the Casper Flight Service Station (FSS) contacted the ZDV Sector 22 controller and asked about N41WE's status. The controller informed the FSS of the airplane's approach clearance, and the FSS indicated that the airplane had not arrived at RWL. After the airplane was reported overdue, search and rescue efforts were initiated. The airplane was located approximately 2.5 miles northeast of RWL in mountainous terrain about 0152on January 12, 2005.

The flight to Rawlins was originally scheduled with Wyoming Medical Center in Casper. A pilot for Wyoming Medical Center stated the flight had been pending for several hours. He said the weather was bad and that the pilot on duty before him declined the flight because of the weather, which was below Part 135 minimums. The pilot said he declined the flight initially but later accepted the flight as the weather at Rawlins improved. Before departure, Wyoming Medical Center received a more urgent call, and the mission was changed to Riverton.

PERSONNEL INFORMATION

The 35-year old pilot held an ATP certificate with a multiengine land airplane privileges dated December 22, 2002. The pilot's certificate showed a type rating in the SA-227 airplane and listed commercial privileges in single-engine land airplanes. The pilot also held a first-class medical certificate dated February 21, 2004, with the limitation, "Airman must wear corrective lenses while exercising the privilege of this certificate."

Company records showed the pilot had completed recurrent training in the B-100 King Air on June 19, 2004, and had successfully completed a proficiency check flight given by a Federal Aviation Administration (FAA) check pilot on November 16, 2004. According to company records, the pilot joined the company in June 2003 and, at that time, reported having approximately 3,800 total flying hours. Of that time, the pilot reported having 3,778 hours as pilot-in-command, 2,823 hours multiengine time, 1,000 hours flight time at night, and 200 hours actual instrument flight time.

Company time and duty records showed that since December 2003, the pilot logged 413.9 flying hours in the company's aircraft. The records also showed the pilot had logged 118.3 hours in the previous 90 days to the accident, 54.3 hours in the previous 30 days, and 1.7 hours within the 24 hours prior to the accident.

AIRCRAFT INFORMATION

The airplane was a 1978 Beech E-90 King Air, serial number (S/N) LW 280. The airplane was owned and operated by Mountain Flight Service, Inc., and was used for EMS transport. The airplane's registration was dated June 17, 2003.

The airplane was being maintained by Mountain Aircraft Maintenance, Inc., of Steamboat Springs, Colorado. The airplane was on a continuous maintenance schedule as prescribed by Raytheon Beech, the airplane manufacturer. The airplane underwent a Phase 3 and 4 inspection (required every 200 hours) on November 14, 2004. At the time of the inspection, the airframe time was 8,891.2 hours, the Hobbs time was 525.2 hours, and the airplane's cycles (one landing gear retraction and one landing gear extension) were 8,772.

The airplane's flight log and load manifest was recovered from the accident site. It showed that the airplane left SBS about 2110. The Hobbs out time was listed as 555.3 hours, and the cycles out was listed as 8,815.

METEOROLOGICAL INFORMATION

Several witnesses in the vicinity of the accident site reported surface weather conditions varying from freezing rain to heavy snow. The National Weather Service Surface Analysis chart for 2300, January 11, 2005, showed a north-south stationary front positioned along the front range of the Rocky Mountains beginning at the Wyoming/Montana border and extending south into north-central Colorado. Station plots indicated patchy snow over western Colorado and Wyoming.

The Weather Surveillance Radar-1988, Doppler (WSR-88D) at Riverton, Wyoming, 322 degrees at 95 nautical miles (nm) from the accident site, was the closest weather radar. Assuming standard refraction, the radar beam was centered over the accident location at approximately 16,700 feet msl for the lowest antennae elevation angle of 0.5 degrees. The beam width was approximately 9,600 feet (see the Meteorological Factual Report in the public docket for this accident).

About 2109, 7 minutes before the airplane's departure from SBS, the automated surface observation system (ASOS) at RWL reported the weather as a broken ceiling at 1,100 feet above ground level (agl), 1,800 feet agl broken, and 3,100 feet agl overcast, visibility 2.5 statute miles (sm) with light snow and mist, temperature 33 degrees Fahrenheit (F), dew point 30 degrees F, winds 240 degrees at 3 knots, and altimeter 29.35 inches of mercury (in Hg).

About 2140, the ASOS at RWL reported the weather as few clouds at 500 feet agl, scattered clouds at 900 feet agl, overcast ceiling at 1,500 feet agl, visibility 2 sm with light snow and mist, temperature 32 degrees F, dew point 32 degrees F, winds 250 degrees at 3 knots, and altimeter 29.35 in Hg.

The Man computer Interactive Data Access for the period 1400 to 0000 showed no pilot weather reports (PIREPs) for icing for Wyoming. During the first hour following the accident, six PIREPs were given reporting light to moderate rime and mixed icing from 11,000 feet msl to 16,000 feet msl.

In-flight advisories (AIRMETS) for IMC, mountain obscuration, turbulence, and icing were updated at 1945. AIRMET ZULU indicated that (icing) extended across an area that included the accident airplane's entire route of flight and states, "occasional moderate rime or mixed icing in clouds and precipitation between the freezing level and flight level 220." The freezing level for the area encompassing the route of flight and the accident airport began at the surface.

About 2036, the pilot contacted the Denver FSS and requested current weather conditions in Rawlins, Wyoming, and Casper, Wyoming. The FSS briefer told the pilot the following:

Looks like...a band of moisture...on radar...looks like moderate precipitation just blowing right up your way...Current observations at Rawlins...report winds 210 at 10 with 10-mile visibility, 3,100 scattered, 8,500 overcast, 1 and -1 for temp[erature] and dew point from what I can see on radar it looks like a band of...light to moderate snow shower activity. At the moment it is about half way between Rock Springs and Rawlins, but it is of course spreading to the northeast. Also this band of snow shower activity extending up to just west of the Casper area too, we'll say almost Casper, Rawlins, and west toward Lander and so forth, light to moderate snow showers on the bill at Casper...winds...360 at 6 with 10 miles visibility and ceilings 2,100 overcast, -4 and -7 on the temperature dew point, that's actually up from what they were previously because they had snow occurring. They had been down to about 1,500 overcast 5 miles, light snow. It ended then they improved. But I think we're going to see conditions probably throughout the afternoon or evening just continuing to fluctuate up and down in the snow shower cells, move in and out of the area. Now, forecast for Rawlins, this is a terminal forecast, until 0600Z, gusty winds are in the forecast, winds 240 at 15 gusts to 25 [knots]. It seems like winds blow up there all the time doesn't it?

The briefer went on to say about Rawlins that the forecast was 5 miles visibility in fog or mist and showers in the vicinity, with skies 2,000 scattered and ceilings 4,000 overcast. The pilot then said, "Alright, let's go ahead and file a couple of plans for us." The briefer then asked, "[Do] you want that forecast at Casper or anything or do we need to check NOTAMS [notices to airmen]?" The pilot said that he had been there the night before but told the briefer to go ahead and give him the current Rawlins and Casper NOTAMS. After the briefer provided the NOTAMS, the pilot filed his flight plan. The briefer then said, "Okay, I have got that flight plan. Now we do have some...adverse conditions, some flight precautions and so forth up along that route for occasional mountain or terrain obscurations." The pilot said, "Right, I plan on not being able to even look at terrain." The briefer said, "Okay, IFR, well I mean we are required to give them to you if you want them." The pilot said, "Well, I'll be IFR the whole way. Thank you." The briefer said, "Mountain terrain obscuration, icing, and turbulence." The conversation ended after the pilot responded, "All of that fun stuff."

AIDS TO NAVIGATION

The VOR/GPS approach to runway 22 at RWL requires the pilot to fly a procedure turn maneuver to align the aircraft on the final approach course of 224 degrees. The approach requires the pilot to fly over the VOR, which is collocated on the airport at 9,000 feet msl or higher altitude assigned, then initiate a turn outbound to a 044 degree heading. The pilot is required to remain within 10 nm of the VOR during the maneuvers. Once inbound on the 224-degree course, the pilot can descend to a step-down altitude of 7,780 feet (967 feet above the terrain). On passing 3.5 DME (nm by distance measuring equipment), the pilot can descend to the minimum descent altitude (MDA) of 7,520 feet msl (707 feet above airport elevation). The MDA is based on the airplane's category (the Beech E-90 is a category C airplane) or the approach speed required to maintain for the approach. The pilot tracks inbound until he/she sees the runway environment. If the pilot reaches the VOR and does not see the runway environment, the pilot must execute a missed approach. The weather minimums for the approach are a 707-foot ceiling and 2 miles visibility. The field and touchdown zone elevation for RWL is 6,813 feet.

The FAA navigation facilities branch conducted a flight check of the VOR/GPS approach to runway 22 at RWL on January 12, 2005, starting about 0915 and ending about 0940. The flight check showed no anomalies with the approach or the VOR station.

WRECKAGE AND IMPACT INFORMATION

The accident site was located on the northeast side of a 7,269-foot msl ridgeline approximately 2.5 nm northeast of RWL. The ground scar at the accident site measured 104-feet long and 25-feet wide and ran northeast to southwest along a 225-degree magnetic heading, about 800 feet short of the crest of the ridge near the start of the upward rise. The northeast edge of the ground scar was at an elevation of 7,065 feet msl, and its southwest edge was at an elevation of 7,086 feet msl. Three distinct parallel-running tracks were evident at the northeast edge of the ground scar. Each track was 6 feet apart, approximately 25 inches in width, and ran southwestward for approximately 10 feet 6 inches. Pieces of the airplane's nose gear doors, main gear doors, and belly antennae were embedded about 20 feet southwest of the start of the ground scar.

The airplane's left and right propellers, the left and right main landing gear struts and tires, the nose gear trunnion, and the nose gear strut and tire were located about 270 feet southwest of the beginning of the ground scar. The left propeller assembly was broken torsionally at the flange and rested at an elevation of 7,097 feet msl. The right propeller assembly was located 18 feet northwest of the left propeller assembly and was also broken torsionally at the flange. Both sets of propeller blades showed severe torsional bending, chordwise scrapes and scratches, and nicks in the leading and trailing edges. Both propeller spinners were bent, br

NTSB Probable Cause

The pilot's inadvertent flight into adverse weather [severe icing] conditions, resulting in an aerodynamic stall impact with rising, mountainous terrain during approach. A factor contributing to the accident was the pilot's inadequate planning for the forecasted icing conditions.