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ASN Wikibase Occurrence # 59012
Last updated: 5 May 2021
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Date:22-MAR-2009
Time:14:30
Type:Silhouette image of generic PC12 model; specific model in this crash may look slightly different
Pilatus PC-12/45
Owner/operator:Eagle Cap Leasing, Inc.
Registration: N128CM
MSN: 403
Fatalities:Fatalities: 14 / Occupants: 14
Other fatalities:0
Aircraft damage: Written off (damaged beyond repair)
Category:Accident
Location:near Butte-Bert Mooney Airport, MT -   United States of America
Phase: Approach
Nature:Private
Departure airport:Oroville, CA (KOVE)
Destination airport:Bozeman, MT (KBZN)
Investigating agency: NTSB
Narrative:
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. 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.

On March 21, 2009 (the day before the accident), the pilot had the airplane fueled with 222 gallons of Jet A fuel at Redlands Municipal Airport (REI), California, where the airplane was based.
During a postaccident interview, the fueling station manager stated that the pilot did not request that a fuel system icing inhibitor (FSII) be added. (All jet fuels contain trace amounts of water, and a FSII lowers the freezing point of water to -40º C to prevent the water from turning into ice crystals, which can block a fuel line or filter.)
The Pilatus PC-12 Airplane Flight Manual (AFM), section 2, Limitations, dated March 30, 2001, stated that an "anti-icing additive [FSII] must be used for all flight operations in ambient [outside air] temperatures below 0º C." On a standard day, the temperature is 0° C at 7,500 feet, so most PC-12 flights would require the use of a FSII.
About 19:46 Pacific daylight time (PDT) on the day before the accident, the pilot filed three flight plans for the next day with an automated flight service station. The pilot listed BZN as the destination airport for the final flight leg and BTM as the alternate airport for that flight leg. On March 22, 2009, the pilot departed REI for Nut Tree Airport (VCB), Vacaville, California, about 07:42 PDT and arrived at VCB about 09:30 PDT.
Fuel records indicated that the airplane had been refueled with about 128 gallons of Jet A fuel after the airplane’s arrival at VCB. The fuel dispensed at the VCB self-service fueling island was not premixed with a FSII, and the fuel pump did not contain provisions for injecting a FSII during fueling. VCB personnel found no evidence to suggest that the pilot had used any other method to add a FSII to the fuel either before or during the fueling.
The airplane departed VCB about 10:20 PDT with nine passengers (four adults and five children) and the pilot on board, although the flight plan indicated that four passengers and the pilot would be on board during that flight leg. The airplane arrived at OVE about 10:33 PDT.
At OVE, four passengers (two adults and two children) boarded the airplane, resulting in a total of 13 passengers (six adults and seven children, who ranged in age from 1 to 9 years).
The flight plan indicated that eight passengers and the pilot would be on board the airplane during the final flight leg. The accident airplane was configured with two pilot seats and eight passenger seats. Because each flight on the day of the accident was a single-pilot operation, one seat in the cockpit could be used by a passenger. The airplane departed OVE for BZN about 12:10 (11:10 PDT).
The IFR flight plan indicated that the airplane would have 3 hours 30 minutes of fuel on board with an estimated en route time of 2 hours 30 minutes.
About 12:28, a controller at the Oakland Air Route Traffic Control Center (ARTCC) cleared the airplane direct to BZN; about 1244, the pilot made initial contact with a controller at the Salt Lake ARTCC.
At 13:59, the pilot contacted the Salt Lake ARTCC sector 6 radar controller. At that time, the airplane was operating at flight level (FL) 250, as assigned by air traffic control (ATC). Radar data showed that, at 14:02, the pilot changed the airplane’s route of flight and turned to the left toward BTM without ATC clearance. At 14:03, the pilot contacted the controller to request a change in destination to BTM but did not provide a reason for the requested divert. The controller did not question the pilot’s request. The controller then cleared the airplane direct to BTM and instructed the pilot to maintain FL250. The pilot acknowledged the clearance at 14:03. Radar data showed that the airplane began a descent from FL250 at 14:04. About 25 seconds later, the pilot contacted the controller to request a lower altitude. The controller issued the altimeter setting for BTM and cleared the airplane to descend at the pilot’s discretion to an altitude of 14,000 feet mean sea level (which was just above the 13,100-foot minimum IFR altitude for the area). The pilot acknowledged the clearance.
At 14:05, the pilot transmitted a second request to change the flight’s destination to BTM. The controller told the pilot that he had previously cleared the airplane to BTM, and the pilot responded by stating that the airplane was descending to 14,000 feet. At 14:06, the controller instructed the pilot to "advise receipt of Butte Montana weather and notams." The pilot responded, "wilco."
The ATC transcript showed that the pilot did not report receipt of BTM weather and NOTAM information and that the controller did not follow up with the pilot to ensure that he had received this information.
At 14:22, the next sector 6 controller to handle the accident airplane cleared the airplane to descend and maintain 13,000 feet and advised the pilot of the airplane’s position relative to BTM. The controller also instructed the pilot to report when he had the airport in sight for a visual approach. The pilot acknowledged the controller’s instruction. At 14:24, the pilot requested a lower altitude, and the controller cleared the airplane to descend and maintain 12,200 feet, which was the minimum IFR altitude at that point in the approach. The pilot acknowledged this clearance.
Radar data showed that the airplane descended below 12,200 feet at 14:26 and continued descending. About 14:27 (2 hours 17 minutes into the flight), the CAWS system provided a caution to the pilot indicating that a low fuel condition existed in the right fuel tank.
At 14:28, the pilot reported that he had the airport in sight and canceled his IFR clearance. Radar data about that time showed that the airplane was 8 miles southwest of BTM at an altitude of 11,100 feet. At 14:28, the controller acknowledged the pilot’s IFR clearance cancellation, instructed him to squawk visual flight rules (VFR) transponder code 1200, and advised him that no known or observed traffic existed between the airplane and the airport. The pilot did not acknowledge this transmission, and no further communications occurred between the pilot and ATC.
Radar data showed that the airplane continued to squawk the previously assigned discrete transponder code as the airplane continued toward the airport. BTM has no ATC tower, but an employee at a BTM fixed-base operator (FBO), who was monitoring the common traffic advisory frequency when the accident airplane was approaching the airport, heard the pilot indicate that the airplane would be landing on runway 33. The last recorded radar target, at 14:30:25, showed that the airplane was at an altitude of 9,100 feet (3,550 feet above ground level) and about 1.8 miles southwest of the runway 33 threshold.
The airplane impacted the ground about 2,100 feet west of the runway 33 centerline. Witnesses to the accident reported that the airplane was approaching runway 33 at a higher altitude than other airplanes that land at the airport. The witnesses also reported that the airplane had entered a steep left turn at an estimated altitude of 300 feet agl and that the nose of the airplane then pitched down suddenly.
CAWS data, along with radar data and assumptions about fuel burn indicated a left-wing-heavy fuel condition before the accident occurred.


Probable Cause: (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.

Sources:

NTSB: https://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20090322X90442&key=1
http://www.ntsb.gov/news/events/2011/butte_mt/synopsis.html
http://edition.cnn.com/2009/US/03/23/montana.plane.crash/
https://flightaware.com/live/flight/N128CM

http://www.ntsb.gov/ntsb/brief.asp?ev_id=20090322X90442&key=1

Accident investigation:
cover
  
Investigating agency: NTSB
Status: Investigation completed
Duration: 2 years and 3 months
Download report: Final report
Location

Safety recommendations:

Safety recommendation A-10-121 issued 11 August 2010 by NTSB to FAA
Safety recommendation A-10-122 issued 11 August 2010 by NTSB to FAA
Safety recommendation A-10-123 issued 11 August 2010 by NTSB to FAA
Safety recommendation A-11-70 issued 26 July 2011 by NTSB to FAA
Safety recommendation A-11-71 issued 26 July 2011 by NTSB to FAA
Safety recommendation A-11-72 issued 26 July 2011 by NTSB to FAA
Safety recommendation A-11-73 issued 26 July 2011 by NTSB to FAA
Safety recommendation A-11-74 issued 26 July 2011 by NTSB to FAA
Safety recommendation A-11-75 issued 26 July 2011 by NTSB to EASA
Safety recommendation A-11-76 issued 26 July 2011 by NTSB to EASA
Safety recommendation A-11-77 issued 26 July 2011 by NTSB to EASA
Safety recommendation A-11-78 issued 26 July 2011 by NTSB to EASA


Images:

Photo of N128CM courtesy AirHistory.net


Springfield - Abraham Lincoln Capital (KSPI / SPI)
9 June 2006; (c) R.A.Scholefield


Photo: NTSB

Revision history:

Date/timeContributorUpdates
22-Mar-2009 23:33 slowkid Added
23-Mar-2009 00:02 harro Updated
23-Mar-2009 00:57 slowkid Updated
23-Mar-2009 23:31 angels one five Updated
25-Mar-2009 08:01 angels one five Updated
11-Apr-2009 07:23 MarkStephenson Updated
03-Feb-2010 23:34 TB Updated [Other fatalities, Source]
13-Jul-2011 03:44 harro Updated [Time, Location, Nature, Departure airport, Destination airport, Source, Narrative]
21-Dec-2016 19:25 ASN Update Bot Updated [Time, Damage, Category, Investigating agency]
01-Dec-2017 12:15 ASN Update Bot Updated [Operator, Other fatalities, Departure airport, Destination airport, Source, Narrative]
01-Dec-2019 10:54 harro Updated [Other fatalities, Source, Narrative, Accident report, ]
06-Jan-2021 09:32 The2ndBaron Updated [Damage, Accident report]
06-Jan-2021 11:42 harro Updated [Source, Narrative, Photo]

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