N273SM

HISTORY OF FLIGHTOn February 24, 2023, about 2114 Pacific standard time, a Pilatus PC-12/45, N273SM, was substantially damaged when it was involved in an accident near Stagecoach, Nevada. The pilot, flight paramedic, flight nurse, and two passengers were fatally injured. The airplane was operated by Guardian Flight, LLC dba Care Flight under the provisions of Title 14 Code of Federal Regulations (CFR) Part 135.

The flight was a non-emergency transport of a patient from Reno-Tahoe International Airport (RNO), Reno, Nevada, about 2100 on an instrument flight rules (IFR) flight plan, to Salt Lake City International Airport (SLC), Salt Lake City, Utah.

According to the Guardian Flight pilot on duty from 0700-1900 on the day of the accident, he had received a flight request but declined the flight due to visibility at RNO. The day shift pilot said that the visibility was “down all day,” and that he notified the oncoming (accident) pilot about it. At 1851, Care Flight received a request for transport of the patient again, and the accident crew received notification about 1858. The notification only included the destination, and the crew did not receive any specific patient information before accepting the flight. The unit was assigned about 1914.

Another air ambulance operator, who also operated a PC-12/45, received a request to transport a patient from RNO to SLC. The operator turned down the flight at 1455 due to “snow drifts, high winds, Reno below min[imums].” Additionally, that operator had another flight request to transport a patient from Northeastern Nevada Regional Hospital located in Elko, Nevada, to Renown Regional Medical Center, Reno, Nevada, at 2241, which was also turned down due to “low vis, turbulence and icing.”

According to Guardian Flight, LLC personnel, dispatchers were required to inform pilots if the same patient flight request had been turned down by another operator. Care Flight personnel reported that the flight crew and medical crew would be made aware of a turndown by another transport unit for the same patient flight request. A review of the communication log produced by Care Flight did not indicate that the accident pilot was advised of the earlier turndown by Care Flight, nor the turndown by another air ambulance transport company.

About 2020, the ground transportation unit, which consisted of two paramedics, the accident flight medic, the accident flight nurse, and the two accident flight passengers, departed the hospital for the airport and arrived at the airplane about 2029. The pilot contacted the RNO ground controller about 2052 and was instructed to taxi to runway 17L. About 1 minute later, the ground controller observed the accident airplane “getting lost” while exiting the ramp and asked the pilot if he needed assistance locating the exit. At 2054, the ground controller informed the accident pilot to “use caution the taxiway hasn’t been plowed in a while.” The controller subsequently instructed the pilot, “right turn now, you’re past the centerline of the taxiway.” About 2055, the pilot advised the controller they “have it now.” The RNO automated weather observation about this time included 1 ¾ statute miles visibility in light snow with an overcast cloud ceiling at 1,700 ft above ground level.

The flight was issued an instrument flight rules clearance to SLC that included the ZEFFR7 standard instrument departure procedure from RNO via the BLKJK transition (see figure 1). BLKJK was a GPS waypoint located about 20 nautical miles (nm) east of RNO. The pilot was cleared for takeoff from runway 17L about 2059, and ADS-B data showed the airplane was airborne about 45 seconds later. About 1 minute later, the pilot was given a frequency change and instructed to contact departure control, which the pilot acknowledged.

Figure 1. ZEFFR7 Standard Instrument Departure Procedure (Source: Jeppesen)

The airplane continued on a southerly heading until about 2105:50, in the vicinity of the EPOSE waypoint, when it turned left to a southeasterly heading, at an altitude about 12,100 ft msl. At 2108:37, the pilot contacted the Oakland Air Route Traffic Control Center as instructed by departure control and reported that he was climbing through 15,400 ft mean sea level (msl). The controller instructed the pilot to climb and maintain flight level 250 (25,000 ft msl) and issued a caution for light to moderate turbulence. The pilot acknowledged the altitude assignment shortly thereafter; no additional radio transmissions were received from the accident pilot. The airplane continued to climb on a southeasterly heading until about 2108:50, when it turned northeast in the vicinity of the WITTT waypoint.

About 2111:15, the airplane began a right turn before reaching the DATTT waypoint, which was the next waypoint along the departure procedure. About this time, the airplane’s previously consistent climb rate stopped, with the airplane continuing at an altitude of about 18,300 ft msl for about 20 seconds. The ADS-B data showed that the airplane remained on this heading for about 47 seconds and climbed to about 19,000 ft msl before turning left to a northeasterly heading. The airplane continued on a northeasterly heading and climbed to about 19,400 ft msl before entering a descending right turn about 2113:20. About 2113:30, the airplane’s rate of descent increased from about 1,800 ft per minute (fpm) to 13,000 fpm, and the rate of turn increased. The airplane remained in a descending right turn until ADS-B contact was lost about 2114:12 at an altitude of 11,100 ft msl in the vicinity of the accident site. Figure 2 shows the airplane’s ADS-B flight track.

Figure 2: ADS-B flight track data with waypoint, accident site, and radio communication reference points annotated. PERSONNEL INFORMATIONThe pilot was hired on September 6, 2022, as a float pilot who rotated across Guardian Flight’s bases throughout the country. The accident pilot had requested extra shifts, and was originally given an assignment out of Yuma, Arizona; however, due to staffing issues, he was assigned to the RNO base for a week rotation. According to an assistant chief pilot who oversaw the float pilot program, the accident pilot had previously flown two shifts in Ely, Nevada, with one of those shifts within the 4 to 6 weeks before the accident. The assistant chief pilot reported that the accident pilot was familiar and comfortable with the RNO area. The accident pilot arrived on Monday, began with a day shift on Tuesday, and then a night shift on Wednesday before the accident occurred on Friday.

The following information about the pilot’s training was provided by a representative of Guardian Flight, LLC:

A review of the pilot’s training record from the operator indicated that he began his initial PC-12 flight training on October 5, 2022, and concluded on October 10, 2022, for a total of 8.1 hours. On the flight dated October 10, 2022, of the 53 flight subject training areas, 33 subject areas were graded “S” or “satisfactory” and 20 were graded “W” or “waived.” Of those 53 flight subject training areas, one was titled “autopilot system” and another was titled “Nav and Avionics System”; on two previous separate flights (October 5th and 7th), the pilot received a grade of “U” or “unsatisfactory” for those areas and subsequently graded satisfactory on October 9, 2022.

Training records also indicated that, between September 19, 2022, and September 23, 2022, the pilot received a total of 7.1 hours of simulator training. All grades were marked as either a “1” or a “2.” A grade of “1” was considered “Proficient” and a grade of “2” was considered “Normal Progress.”

Before being hired by the accident operator, the pilot worked as a Cessna 208 pilot for a cargo operator based in Michigan. A review of training records indicated that the pilot was initially hired by that operator on November 14, 2021. His most recent CFR 135.293, 135.297, 135.299 checks were completed on June 9, 2022, during his employment with that operator. Of the 30 entries, all indicated “Satisfactory”; however, the entry for item #24 “Approaches: GPS” indicated that the first attempt was unsatisfactory, and the second attempt was satisfactory. The remarks stated: “Retrain and retested items #24 GPS. Satisfactory.”

The accident pilot was employed from May 10, 2021, until August 12, 2021, by a Part 121 airline. The airline reported that the accident pilot was unable to satisfactorily complete the training program. The reasons provided were pre-departure, climb, descent, and approach procedures. AIRCRAFT INFORMATIONAutopilot

The accident airplane was equipped with a Bendix/King KFC 325 Digital Flight Control System (AFCS). The KFC 325 Digital AFCS had three axis controls for pitch, roll, and yaw. The Bendix/King Digital Flight Control System Pilot’s Guide provided, in part, the following information about the KFC 325 flight control system:

The KFC 325 monitors autopilot operations continuously through sensors that monitor the aircraft's pitch attitude and acceleration, as well as servo motor operation. If monitors in the KFC 325 detect a problem, the autopilot will disconnect, illuminate a flashing AP annunciation, and provide an aural disconnect tone. If an autotrim failure is detected, the TRIM annunciator on the mode controller illuminates and the trim fail tone sounds. If a manual electric trim failure is detected, the TRIM annunciator illuminates and the trim fail tone sounds. The malfunction continues until the pilot takes action to stop it.

In event of autopilot or flight director malfunction pay primary attention to basic aircraft control prior to attempting to diagnose the exact nature or cause of system failure. Once aircraft control is assured, the crew may attempt to reengage the affected autopilot or flight director mode by pressing the related mode pushbutton.

Autopilot Emergencies

The KFC 325 Pilot’s Guide stated, in part, in the event of an a...