Steamboat Springs – Rawlins
Flight / Schedule
Steamboat Springs – Rawlins
Aircraft
Beechcraft 90 King AirRegistration
N41WE
MSN
LW-280
Year of Manufacture
1978
Operator
Mountain Flight ServiceDate
January 11, 2005 at 09:45 PM
Type
CRASHFlight Type
Ambulance
Flight Phase
Landing (descent or approach)
Crash Site
Airport (less than 10 km from airport)
Crash Location
Rawlins Wyoming
Region
North America • United States of America
Coordinates
41.7908°, -107.2392°
Crash Cause
Human factor
Narrative Report
On January 11, 2005 at 09:45 PM, Steamboat Springs – Rawlins experienced a crash involving Beechcraft 90 King Air, operated by Mountain Flight Service, with the event recorded near Rawlins Wyoming.
The flight was categorized as ambulance and the reported phase was landing (descent or approach) at a airport (less than 10 km from airport) crash site.
4 people were known to be on board, 3 fatalities were recorded, 1 survivors were identified or estimated. This corresponds to an estimated fatality rate of 75.0%.
Crew on board: 1, crew fatalities: 1, passengers on board: 3, passenger fatalities: 2, other fatalities: 0.
The listed crash cause is human factor. 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."
Aircraft reference details include registration N41WE, MSN LW-280, year of manufacture 1978.
Geospatial coordinates for this crash are approximately 41.7908°, -107.2392°.
Fatalities
Total
3
Crew
1
Passengers
2
Other
0
Crash Summary
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."
Cause: Human factor
Occupants & Outcome
Crew On Board
1
Passengers On Board
3
Estimated Survivors
1
Fatality Rate
75.0%
Known people on board: 4
Operational Details
Schedule / Flight
Steamboat Springs – Rawlins
Operator
Mountain Flight ServiceFlight Type
Ambulance
Flight Phase
Landing (descent or approach)
Crash Site
Airport (less than 10 km from airport)
Region / Country
North America • United States of America
Aircraft Details
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