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Board Meeting - Aircraft Accident Report - Aviation Accident Report – Pilatus PC-12/45, N128CM, Butte, Montana, March 22, 2009 - Chairman's Opening and Closing Remarks
Deborah A. P. Hersman
National Transportation Safety Board (NTSB), Aviation Accident Report – Pilatus PC-12/45, N128CM, Butte, Montana, March 22, 2009, Washington, DC

Now, we'll begin with the second item on today's agenda – the accident report on the March 22, 2009, crash of a Pilatus PC-12/45 airplane at Butte, Montana.

For those of you just joining us for this portion of today's meeting, let me re-introduce myself and my colleagues on the Board. I am Debbie Hersman, Chairman of the National Transportation Safety Board, and to my right are Vice Chairman Chris Hart and Member Mark Rosekind, and to my left are Member Robert Sumwalt and Member Earl Weener.

On behalf of the Board members and the entire NTSB staff, I offer our deepest condolences to the family and friends of the fourteen individuals – adults and children – who lost their lives in this accident. We recognize that your lives were forever changed when the crash occurred, and that nothing can replace the loss of a loved one. We now have the opportunity and the obligation to take every step possible to ensure that the lessons of this tragedy are well-learned and the circumstances are not repeated.

Over the past several weeks, the Board Members have read the proposed report and individually met with NTSB staff. Today, however, is the first time that all of the Board Members are meeting together to discuss it.

Staff will make presentations on the major issues of the accident investigation. The presentations will be followed by questions from the Board Members. We will then consider the conclusions, probable cause, and safety recommendations. Because these are the Board's actual deliberations on the report, it may be revised as a result of actions taken during this meeting. Approximately 30 minutes after we conclude, an abstract of this report will be posted on the NTSB's website.

I would like to express the Board's gratitude to the many groups and individuals who helped with the Safety Board's investigation, including those who responded on-scene immediately after the accident. In particular, I'd like to thank the FAA's Montana Flight Standards District Office (FSDO) and the Butte-Silver Bow first responders and law enforcement officers.

Our role at the NTSB is investigatory — our professionals find out what happened so that we can recommend how to prevent similar tragedies from happening in the future. Our role is to follow the facts and see where they lead us.

This accident investigation was truly a case of tracking down clues to solve a mystery. Here's what we learned in the early stages of the investigation. We knew that the plane, a Pilatus PC-12, that took off from Oroville, California with a destination of Bozeman, Montana, was on its third flight of the day. We knew that the airplane was properly certified, equipped, and maintained. The recovered components showed no evidence of pre-impact structural, engine, or system failures. The pilot was properly certificated and qualified. Our investigators found no evidence of any conditions that might have adversely affected the pilot's performance on the day of the accident.

There were no onboard recorders, and none were required. But, because there were no recorders, our investigators initially lacked critical information about what happened on that deadly third leg between California and Montana. For months, our team was uncertain that they would be able to learn enough information to connect all of the dots.

But, this is where help arrived from our international colleagues. Over the years, the NTSB has assisted in a number of foreign investigations. The favor was certainly returned in this investigation. I want to recognize and thank the German Federal Bureau of Aircraft Accidents Investigation, and the Aircraft Accident Investigation Bureau of Switzerland for their pivotal guidance and support. By facilitating data recovery from the aircraft monitoring system, they helped us connect many of the dots in this investigation.

Fourteen people – the pilot plus six adults and seven children – were on board the airplane, even though no more than nine passengers were permitted per the airplane's flight manual and only nine were listed on the flight plan filed by the pilot. Our investigation revealed that the additional passengers on board the airplane were not a factor in the accident. However, this aspect of the investigation raises a troubling, and recurring, safety issue about one passenger per seat.

The NTSB is focusing on child passenger safety this year. Perhaps one of the most obvious ways to protect our youngest passengers is to make sure they enjoy the same level of safety as their parents. Since 1990, the NTSB has recommended that all occupants be restrained during takeoff, landing and turbulent conditions, and that all infants and small children be restrained in an approved child restraint system appropriate to their size. Yet, for general aviation airplanes, the FAA still allows multiple occupants to share a restraint system designed and tested for only one person.

The NTSB re-stated our concerns about this issue as a result of this accident. Unfortunately, the FAA, in its recent Notice of proposed clarification for general aviation, emphasizes that proper restraint for children relies on the "good judgment of the pilot, who should be intimately aware of the capabilities and structural requirements of the aircraft that he or she is operating." That guidance falls short of providing clarity for the aviation community. Further, it seems counter-intuitive that manufacturers are required to meet specific standards under Part 23 for restraint design and installation. But once the aircraft leaves the production facility and is in service, the standards are negated by permitting improper use of the restraints by more than one person per seating position.

We also learned that the pilot neglected to follow the airplane flight manual's requirement to add a fuel system icing inhibitor — commonly known by its brand name "Prist" — to the fuel. This additive is used to prevent ice from accumulating in the fuel system, which can block the flow of fuel to the engines. The pilot didn't put it in himself, nor did he direct anyone who fueled the airplane to do so. That decision set in motion a series of consequences that culminated in the deadly crash.

To err is human, but we all know that the aviation environment is not forgiving when it comes to mistakes. That is exactly why it is so important to follow procedures, use checklists, and always ensure you have a safety margin - to offset the potential for human error.

Dr. Mayer, will you please introduce the staff.