Pilot Debrief

LOCKHEED P2V-7 near Stockton, UT — 2009-04-25

Final reportWPR09GA216
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Date
2009-04-25
Location
Stockton, UT, USA
Aircraft
LOCKHEED P2V-7
Registration
N442NA
Category
Airplane
Highest injury
Fatal
Fatalities
3
Phase of flight
Descent

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.

Contributing factors

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.

NTSB narrative

The multi-engine fire bomber, which was not carrying retardant, was established at its cruise altitude while en route to a fire base where it would be used as part of the effort to fight a local fire. While en route, the flight crew encountered a forecast area of instrument meteorological conditions, whereupon they began a series of descents to lower altitudes in order to stay in visual flight rules (VFR) conditions beneath the clouds. During the last few minutes of their flight, the flight crew had descended to an altitude that was less than 1,300 feet above ground level (agl) over nearly level terrain. As they approached rapidly rising terrain at the end of the broad open valley they had been flying over, they inadvertently entered instrument meteorological conditions (IMC). Soon thereafter, while still in a nearly wings-level attitude, the airplane impacted a ridge about 240 feet below its top. The First Officer, who was flying at the time, had asked the Captain about ten minutes prior to the impact if their altitude was high enough to clear the upcoming terrain, but the Captain did not respond, and the First Officer did not challenge the Captain about the issue. Witnesses in the area reported low clouds with ceilings about 200 feet above ground level with a visibility of one-quarter mile or less, with rain and fog. One of the witnesses reported momentarily viewing the airplane flying "very low," while the others reported only being able to hear the airplane.

Analysis

Primary failure mode
Controlled flight into terrain
First missed decision gate
The crew could have chosen to avoid flying in low visibility conditions.

NTSB coding

Evidence available

  • CVR
  • ADS-B / radar
  • Photos
  • 35 docket documents
View NTSB final reportView NTSB docket

Docket documents35

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