Steamboat Springs-Bob Adams

The pilot was conducting a solo night cross-country flight in low visibility through mountainous terrain. The pilot was then cleared by an air traffic controller to conduct a RNAV (GPS)-E instrument approach into the destination airport. After passing the final approach fix and before the missed approach point, the pilot, for an unknown reason, executed a left turn, consistent with the missed approach procedure. During the turn toward the holding waypoint, the airplane did not climb. Shortly thereafter, the airplane impacted steep rising terrain The local weather at the time of the accident indicated a cloud ceiling of 1,200 ft above ground level and 1 statute mile visibility, which was below the weather minimums for the approach. Data retrieved from the onboard avionics revealed that although the pilot flew the published route in accordance with the instrument approach procedure, the minimum required altitudes were not adhered to. A review of the ForeFlight weather briefing data indicated that a route weather briefing had been generated by the pilot with the filing of the instrument flight rules (IFR) flight plan. While no weather imagery was reviewed during the period, the pilot had checked METARs for the destination and another nearby airport before departure and viewed the RNAV (GPS)-E approach procedure at the destination airport. A review of the data that was presented to the pilot indicated that visual flight rules conditions prevailed at the destination with light snow in the vicinity at the time it was generated. Based on the preflight weather briefing the pilot obtained, he was likely unaware of the IFR conditions and below minimum weather conditions at the destination until he descended into the area and obtained the current local weather during the flight. It is probable that, based upon the weather and flight track information, as the pilot was on the instrument approach, he became aware of the below minimum weather conditions and elected to initiate the missed approach, as evident by the turn away from the airport similar to the missed approach procedure and the flaps and landing gear being in transition. This investigation was unable to determine why the missed approach procedure was prematurely initiated and why the airplane failed to climb. Additionally, there were no preimpact mechanical malfunctions or anomalies found during a postaccident examination that would have precluded normal operation.

The air ambulance was dispatched from Steamboat Springs, Colorado (SBS), to pick up and transport a patient in serious condition from Rawlins Municipal Airport/Harvey Field (RWL) to Casper, Wyoming. Approaching RWL, the pilot initiated a right turn outbound to maneuver for the final approach course of the VOR/GPS approach to runway 22. On the inbound course to the airport, the airplane impacted mountainous terrain, approximately 2.5 nautical miles east-northeast of the airport. The airplane, configured for landing, struck the terrain wings level, in a 45-degree nose-down dive, consistent with impact following an aerodynamic stall. Approximately 5 minutes before the accident, RWL reported broken ceilings at 1,100 and 1,800 feet above ground level (agl), 3,100 feet agl overcast, visibility 2.5 statute miles 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. Before departing SBS, the pilot received a weather briefing from Denver Flight Service. The briefer told the pilot that there was a band of light to moderate snow shower activity halfway between Rock Springs and Rawlins, spreading to the northeast. The briefer told the pilot there were adverse conditions and flight precautions along his route for occasional mountain or terrain obscurations. The pilot responded that he planned to fly instrument flight rules for the entire flight. The National Weather Service, Surface Analysis 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 most recent AIRMET reported, "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 began at the surface. Witnesses in the vicinity of RWL reported surface weather conditions varying from freezing rain to heavy snow. An examination of the airplane showed clear ice up to 1 ½ inches thick adhering to the vertical stabilizer, the left and right wings, the right main landing gear tire, and the right propeller. The airplane's aerodynamic performance was degraded due to the ice contamination, leading to a stall. An examination of the airplane's systems revealed no anomalies. A human factors review of interviews and other materials showed insufficient evidence that the company placed pressure on the pilot to take the flight; however, the review did not rule out the pilot inducing pressure on himself. FAA Advisory Circular (AC) 135-15, Emergency Medical Services/Airplane (EMS/A) addresses several subject areas not practiced by the operator, including, "Additional considerations when planning IFR flights include the following: (1) Avoid flight in icing weather whenever possible."

The pilot obtained a weather briefing, filed an IFR flight plan, and departed on a nonscheduled domestic cargo flight, carrying 270 pounds of freight. The flight proceeded uneventfully until it was established on the VOR/DME-C approach. Radar data indicates that after turning inbound towards the VORTAC from the DME arc, the airplane began its descent from 10,600 feet to the VOR crossing altitude of 9,200 feet. Enlargement of the radar track showed the airplane correcting slightly to the left as it proceeded inbound to the VORTAC at 9,400 feet. Shortly thereafter, aircraft track and altitude deviated 0.75 miles northwest and 9,700 feet, 0.5 miles southeast and 9,600 feet, and 0.5 miles northwest and 9,400 feet before disappearing from radar. Witnesses said the weather at the time of the accident was 600 foot overcast, 1.5 miles visibility in "misting" rain that became "almost slushy on the ground," and a temperature of 36 degrees Fahrenheit. One weather study indicated "an icing potential greater than 50% and visible moisture" in the accident area. Another report said "icing conditions were likely present in the area of the accident." The airplane was equipped and certified for flight into known icing conditions. The wreckage was found in a closely area. There was no evidence of pre-impact airframe, engine, or propeller malfunction/failure. The pilot was properly certificated, but his flight time in aircraft make/model was only 38 hours. He had previously recorded 16 icing encounters, totaling 11.2 hours in actual meteorological conditions. He recorded no ice encounters and only 1.0 hour of simulated (hooded) instrument time in the Cessna 208. Microscopic examination of annunciator light bulbs revealed the GENERATOR OFF light was illuminated. This condition indicates a generator disconnection due to a line surge, tripped circuit breaker, or inadvertent switch operation. The operator's chief pilot agreed, noting that one of the items on the Before Landing Checklist requires the IGNITION SWITCH be placed in the ON position. The START SWITCH is located next to the IGNITION SWITCH. Inadvertently moving the START SWITCH to the ON position would cause the generator to disconnect and the GENERATOR OFF annunciator light to illuminate. He said this would be distracting to the pilot.

While initiating a cross country flight, the eight place aircraft with nine persons aboard, impacted terrain shortly after takeoff. Ice had been seen on the wings and horizontal stabilizer, and icing conditions were present. The aircraft was over maximum gross weight by a minimum of 258 pounds, and the pilot held an expired student pilot certificate dated august 17, 1984. A copy of a private pilot certificate designating multiengine land and instrument was found in the pilot's personal belongings. Faa officials concluded that it was not a valid certificate. An application for a medical certificate dated may 30, 1991, indicated the pilot had 4,000 hours of flight time. This figure could not be verified. Just prior to takeoff the pilot was observed brushing snow off the wings. Following the accident granular ice was found on the aerodynamic surfaces. The pilot and two passengers were killed while six other occupants were injured.

The flight departed Steamboat Springs-Bob Adams Airport at 1855LT on a scheduled flight to Denver-Stapleton, carrying 20 passengers and a crew of two. After takeoff, while climbing, the crew encountered severe icing conditions and was cleared to return when the flight crashed into a mountain at the 10,530 feet level. Rescuers arrived on scene the following morning. A pilot and a passenger died while 20 other occupants were injured, most of them seriously. According to official observations, the weather at Steamboat Springs about 25 minutes before the accident consisted of an estimated 2,000 feet overcast ceiling and 6 miles visibility in freezing rain. According to surviving passengers, after the accident, snow was falling at the crash site and a strong wind was blowing and gusting from the west.