Butte, Montana
March 22, 2009
NTSB Number: AAR-11-05
NTIS Number: PB2011-910405
Adopted: July 12, 2011
PDF
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.
The National Transportation Safety Board determines that the probable cause of this accident was (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.
The safety issues discussed in this report address fuel system limitations, requirements for fuel filler placards, and guidance on fuel system icing prevention.
As a result of this investigation, the National Transportation Safety Board makes the following recommendations 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. (A-11-70)
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. (A-11-71)
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. (A-11-72)
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. (A-11-73)
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. (A-11-74)
As a result of this investigation, the National Transportation Safety Board makes the following recommendations 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. (A-11-75)
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. (A-11-76)
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. (A-11-77)
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. (A-11-78)
The National Transportation Safety Board issued the following recommendations to the Federal Aviation Administration on August 11, 2010:
Amend 14 Code of Federal Regulations Part 91 to require separate seats and restraints for every occupant. (A-10-121)
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. (A-10-122)
The National Transportation Safety Board issued the following recommendation to the Federal Aviation Administration on March 18, 2010:
Establish and implement standard procedures to document and share control information, such as frequency changes, contact with pilots, and the confirmation of the receipt of weather information, at air traffic control facilities that do not currently have such a procedure. These procedures should provide visual communication of at least the control information that would be communicated by the marking and posting of paper flight-progress strips described in Federal Aviation Administration Order 7110.65, "Air Traffic Control." (A-10-42)
Safety Recommendations A-10-121, which was issued to the Federal Aviation Administration on August 11, 2010, is reclassified "Open - Unacceptable Response" in section 2.5 of this report.
Amend 14 Code of Federal Regulations Part 91 to require separate seats and restraints for every occupant.
