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NTSB investigation record

DEN07FA140

Completed

Cessna 182R· N6109N

Date
August 20, 2007
Location
Dayton, WY
Conditions
VMC
Record
Published September 2, 2021

Primary finding

Probable cause

the pilot's inability to maintain aircraft control while maneuvering in mountainous terrain due to gusty wind conditions, and lee side turbulence. Contributing to the accident was the pilot's improper in-flight planning and decision making, and his failure to follow operational procedures regarding altitudes flown.

Investigator assessment

Analysis narrative

The accident airplane departed approximately 1530 for a search and rescue mission in the mountains. A witness in the area observed an airplane, matching the description of the accident airplane, flying approximately 400 to 600 feet above the ground. The burning wreckage of the accident airplane was located north of the witnesses position approximately 1800, on the east down sloping face of a vegetated canyon wall. The airplane was destroyed by fire. An examination of the airplane's systems revealed no anomalies. An AIRMET for moderate low-level turbulence was valid for the area. Winds in the area of the accident were recorded gusting to 25 miles per hour. Winds normal to the ridgeline of 20 knots or greater is conducive to leeside turbulence. Mission procedures state that the pilot should adjust the search altitude based upon the winds aloft - 10 knots of wind results in an addition of 1,000 feet to the search altitude and 20 knots of wind results in an addition of 2,000 feet to the search altitude. The pilot reported on his mission planning statement that his search altitude would be 1,000 feet.

Source record

Factual narrative

HISTORY OF FLIGHT On August 20, 2007, approximately 1630 mountain daylight time, a Cessna 182R, N6109N, operated by the Civil Air Patrol as CAPS flight 4940, was destroyed when it impacted terrain 20 miles west of Dayton, Wyoming. A post impact fire ensued. Visual meteorological conditions prevailed. The search and rescue flight was being operated under the provisions of Title 14 Code of Federal Regulations Part 91 without a flight plan. The commercial pilot, a pilot rated passenger (scanner trainee) and one observer were fatally injured. The flight departed Sheridan County Airport (SHR), Sheridan, Wyoming, approximately 1530. According to the Civil Air Patrol (CAP) and the Sheridan County Sheriff's office, the accident airplane departed Cowley, Wyoming, at an undetermined time, in order to pick up two observers in Sheridan, for a missing hiker search and rescue mission in the Big Horn Mountains. One of the observers on the accident flight contacted the United States Forest Service approximately 1430 with regards to the temporary flight restriction (TFR 7/3431 Bone Creek Incident) over the Big Horn Mountains. The intended search area for the Civil Air Patrol mission included the perimeter of the TFR. It was determined that CAPS flight 4940 would not be a factor for the TFR. Communication frequencies and procedures were established with the US Forest Service prior to departure from SHR. According to a US Forest Service pilot, communication with the accident airplane was established approximately 1550. The CAP airplane reported that they were "maneuvering above their search area" and they were at a higher altitude "familiarizing themselves with the terrain." The incident commander for the Garland Gulch fire (part of the Bone Creek Incident) reported observing an airplane, consistent in appearance with the accident airplane, fly "slowly" over his location in a north, northwest direction, towards the Lake and Lick Creek drainages. The witness stated that the airplane was approximately "400 to 600 [feet] above the ground. There was no apparent indication of trouble in performance of the aircraft, nor did it dip its wings or anything else remarkable." He stated that the airplane did not return to his area. At 1756, the search and rescue teams on the ground located the missing hiker. Approximately the same time, an aerial team working on the Bone Creek Incident discovered another fire three miles north of where the hiker was located, along the Lick Creek Canyon. Several water drops were made on the fire and the wreckage of the accident airplane was discovered approximately .75 miles from the ridge of Lick Creek Canyon, on the east wall of the canyon. PERSONNEL INFORMATION The pilot, age 49, held a commercial pilot certificate with an airplane single engine land/sea, multi-engine land/sea, and instrument ratings. He was issued a second class airman medical certificate on January 9, 2007. The certificate contained the limitation "must wear corrective lenses." At the time of application, the pilot reported 1,749 hours total time; 105 hours of which were logged within the previous 6 months. The pilot's personal logbook was not recovered. According to the CAP, the pilot joined the CAP in April of 2001. His Mountain Flying Certification with the CAP was successfully completed on August 10, 2007. According to the CAP Pilot Data Summary sheet dated May 12, 2007, the pilot reported he had logged 1,803 hours total time, 1,541 of which were in single engine airplanes. The pilot reported that his last flight review was conducted on February 27, 2007. His last annual checkride and Mission Check Pilot checkride with the CAP were both conducted on May 12, 2007. The pilot rated passenger, age 53, held a commercial pilot certificate with an airplane single engine land, rotorcraft helicopter, and instrument helicopter ratings. He was issued a second class airman medical certificate in August of 2006. The certificate contained no limitations. According to the CAP, he completed his entry level training on April 20, 2007, and was a scanner trainee. The observer had joined the CAP in November of 2003. According to the CAP, she was trained as a mission observer, mission scanner, and skills evaluator. AIRCRAFT INFORMATION The accident airplane, a Cessna 182R (serial number 18267787), was manufactured in 1981. It was registered with the Federal Aviation Administration (FAA) on a standard airworthiness certificate for normal operations. The airplane was powered by a Teledyne Continental Motors O-470 U engine rated at 230 horsepower at 2,400 rpm. The engine was equipped with a two-blade, McCauley propeller. The airplane was registered to and operated by the Civil Air Patrol, and was maintained under an annual inspection program. The maintenance records were in the airplane at the time of the accident and were destroyed. According to the Civil Air Patrol records, the last recorded maintenance performed was an oil change and filter inspection on April 13, 2007, at an aircraft total time of 3,537.9 hours. The last 100-hour/annual inspection was completed on September 14, 2006, at an aircraft total time of 3,492.6 hours. METEOROLOGICAL INFORMATION Aviation area forecasts were issued for Wyoming by the Aviation Weather Center, the day of the accident. The area forecast for northwestern Wyoming was as follows: sky condition, scattered at 15,000 feet; winds out of the west, gusting to 25 knots. The area forecast for northeastern Wyoming was as follows: sky condition, clear; occasional visibility 3 to 5 statute miles in smoke. The terminal forecast for Sheridan for the time period closest to the accident flight was as follows: winds 340 at 4 knots; visibility, 4 statute miles, smoke; sky condition, few clouds at 10,000 feet, scattered at 20,000 feet. The winds aloft forecasts were issued for the accident airplanes route of flight for Billings (BIL), Montana, (75 miles north, northwest of the accident site) and Crazy Woman (CZI), Wyoming (85 miles southeast of the accident site.) The forecast from 1100 to 1500 was as follows: BIL - 9,000 feet, 280 degrees at 29 knots, 12,000 feet, 280 degrees at 35 knots; CZI - 9,000 feet, 270 degrees at 17 knots, 12,000 feet, 280 degrees at 38 knots. The forecast from 1500 to 2400 was as follows: BIL - 9,000 feet, 280 degrees at 22 knots, 12,000 feet, 250 degrees at 22 knots; CZI - 9,000 feet, 260 degrees at 14 knots, 12,000 feet, 260 degrees at 23 knots. Airman's Meteorological Information (AIRMET) for turbulence (TANGO) was issued for areas in Idaho, Montana, and Wyoming, including the accident airplane's route of flight. AIRMET TANGO covered an area from 50 nautical miles (nm) north, northwest of Williston, North Dakota, to 50 nm west, southwest of Rapid City, South Dakota, to 50 nm east, northeast of Salt Lake City, Utah, to Jackson, Wyoming, to 40 nm south of Cranbrook, Canada. The AIRMET stated to expect moderate turbulence below 14,000 feet. There were no AIRMETS for icing, instrument flight rules, or mountain obscuration for the accident airplane's route of flight. The spot forecast for the Garland Gulch Fire, issued by the National Weather Service in Billings, Montana, forecasted winds west, to northwest at 10 to 15 mph, with gusts to 25 mph for the slopes and valleys. Ridgetop winds were forecast to be out of the west at 25 to 40 miles per hour. The closest official aviation weather observation station was Sheridan County Airport (SHR), Sheridan, Wyoming, located 35 nm east of the accident site. The elevation of the weather observation station was 4,021 feet mean sea level (msl). The routine aviation weather report (METAR) for SHR, issued at 1553, reported, winds, calm; visibility, 3 statute miles, haze; temperature 23 degrees Celsius (C); dewpoint, 03 degrees C; altimeter, 29.94 inches. Two fire weather observation stations were located within 10 miles of the accident site. The Boyd Ri

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