PILATUS PC-12/45Eagle Cap Leasing, Inc.
Butte, MT, USA · 2009-03-22·N128CM
What happened
NTSB summary, verbatimThe Safety Board's full report is available at http://www.ntsb.gov/investigations/reports_aviation.html. The Aircraft Accident Report number is NTSB/AAR-11-05. On March 22, 2009, about 1432 mountain daylight time, a Pilatus PC-12/45, N128CM, was diverting to Bert Mooney Airport (BTM), Butte, Montana, when it crashed about 2,100 feet west of runway 33 at BTM. The pilot and the 13 airplane passengers were fatally injured, and the airplane was substantially damaged by impact forces and a postcrash fire. The airplane was owned by Eagle Cap Leasing of Enterprise, Oregon, and was operating as a personal flight under the provisions of 14 Code of Federal Regulations Part 91. The flight departed Oroville Municipal Airport, Oroville, California, on an instrument flight rules flight plan with a destination of Gallatin Field, Bozeman, Montana. Visual meteorological conditions prevailed at the time of the accident.
Photographs
1the aircraft, and what the investigators foundPhotographs are NTSB docket attachments — works of the US government, in the public domain. Captions are the Board’s own.
Probable cause
the Board's determination(1) the pilot's failure to ensure that a fuel system icing inhibitor was added to the fuel before the flights on the day of the accident; (2) his failure to take appropriate remedial actions after a low fuel pressure state (resulting from icing within the fuel system) and a lateral fuel imbalance developed, including diverting to a suitable airport before the fuel imbalance became extreme; and (3) a loss of control while the pilot was maneuvering the left wing-heavy airplane near the approach end of the runway.
Occurrence sequence
3 stepsNTSB coding · CICTT taxonomy- 1 · Prior to flightAircraft servicing event
- 2 · Enroute-cruiseFuel related
- 3 · ManeuveringLoss of control in flightdefining event
Findings
6 causal · 1 contributing- CAUSEPersonnel issues › Action/decision › Action › Lack of action — Pilot
- CAUSEAircraft › Aircraft oper/perf/capability › Performance/control parameters — Not attained/maintained
- CAUSEAircraft › Fluids/misc hardware › Fluids › Fuel additive — Not specified
- CAUSEPersonnel issues › Task performance › Inspection › Preflight inspection — Pilot
- CAUSEAircraft › Aircraft handling/service › Placards and markings — Not specified
- CAUSEAircraft › Aircraft systems › Indicating/recording systems — Not specified
- FACTORAircraft › Aircraft systems › Equipment/furnishings › Passenger compartment equip — Incorrect use/operation
Safety recommendations
12 issuedwhat changed because of this accidentTO THE FEDERAL AVIATION ADMINISTRATION: Amend 14 Code of Federal Regulations Part 91 to require separate seats and restraints for every occupant.
TO THE FEDERAL AVIATION ADMINISTRATION: Amend 14 Code of Federal Regulations Part 91 to require each person who is less than 2 years of age to be restrained in a separate seat position by an appropriate child restraint system during takeoff, landing, and turbulence.
TO THE FEDERAL AVIATION ADMINISTRATION: Amend 14 Code of Federal Regulations Parts 121 and 135 to require each person who is less than 2 years of age to be restrained in a separate seat position by an appropriate child restraint system during takeoff, landing, and turbulence.
TO THE FEDERAL AVIATION ADMINISTRATION: Amend certification requirements for aircraft requiring fuel additives, including fuel system icing inhibitors, so that those limitations are highlighted by a warning in the limitations section of the airplane flight manual.
TO THE FEDERAL AVIATION ADMINISTRATION: Require all existing certificated aircraft (both newly manufactured and in-service aircraft) that require fuel additives, including fuel system icing inhibitors, to have those limitations highlighted by a warning in the limitations section of the airplane flight manual.
TO THE FEDERAL AVIATION ADMINISTRATION: Amend aircraft certification fuel placarding requirements so that aircraft requiring fuel additives, including fuel system icing inhibitors, have a fuel filler placard that notes this limitation and refers to the airplane flight manual for specific information about the limitation.
TO THE FEDERAL AVIATION ADMINISTRATION: Require all existing certificated aircraft (both newly manufactured and in-service aircraft) that require fuel additives, including fuel system icing inhibitors, to have a fuel filler placard that notes this limitation and refers to the airplane flight manual for specific information about the limitation.
TO THE FEDERAL AVIATION ADMINISTRATION: Issue guidance on fuel system icing prevention that (1) includes pilot precautions and procedures to avoid fuel system icing problems aboard turbine engine-powered aircraft and (2) describes the possible consequences of failing to use a fuel system icing inhibitor, if required by the airplane flight manual, especially during operations at high altitudes and in cold temperatures.
TO THE EUROPEAN AVIATION SAFETY AGENCY: Amend certification requirements for aircraft requiring fuel additives, including fuel system icing inhibitors, so that those limitations are highlighted by a warning in the limitations section of the airplane flight manual.
TO THE EUROPEAN AVIATION SAFETY AGENCY: Require all existing certificated aircraft (both newly manufactured and in-service aircraft) that require fuel additives, including fuel system icing inhibitors, to have those limitations highlighted by a warning in the limitations section of the airplane flight manual.
TO THE EUROPEAN AVIATION SAFETY AGENCY: Amend aircraft certification fuel placarding requirements so that aircraft requiring fuel additives, including fuel system icing inhibitors, have a fuel filler placard that notes this limitation and refers to the airplane flight manual for specific information about the limitation.
TO THE EUROPEAN AVIATION SAFETY AGENCY: Require all existing certificated aircraft (both newly manufactured and in-service aircraft) that require fuel additives, including fuel system icing inhibitors, to have a fuel filler placard that notes this limitation and refers to the airplane flight manual for specific information about the limitation.
NTSB analysis
from the final reportThe Safety Board's full report is available at http://www.ntsb.gov/investigations/reports_aviation.html. The Aircraft Accident Report number is NTSB/AAR-11-05. On March 22, 2009, about 1432 mountain daylight time, a Pilatus PC-12/45, N128CM, was diverting to Bert Mooney Airport (BTM), Butte, Montana, when it crashed about 2,100 feet west of runway 33 at BTM. The pilot and the 13 airplane passengers were fatally injured, and the airplane was substantially damaged by impact forces and a postcrash fire. The airplane was owned by Eagle Cap Leasing of Enterprise, Oregon, and was operating as a personal flight under the provisions of 14 Code of Federal Regulations Part 91. The flight departed Oroville Municipal Airport, Oroville, California, on an instrument flight rules flight plan with a destination of Gallatin Field, Bozeman, Montana. Visual meteorological conditions prevailed at the time of the accident.