History of Flight
On February 24, 2023, about 2114 Pacific standard time, a Pilatus PC-12/45, registration N273SM, was substantially damaged when it impacted terrain near Stagecoach, Nevada. The pilot, flight paramedic, flight nurse, and two passengers were fatally injured. Guardian Flight, LLC, doing business as Care Flight, operated the airplane under 14 CFR Part 135.
The flight was a non-emergency patient transport from Reno-Tahoe International Airport (RNO) to Salt Lake City International Airport (SLC) under an instrument flight rules flight plan. The day shift pilot on duty from 0700 to 1900 declined a similar flight request that day due to visibility at RNO. At 1851, Care Flight received a new request, and the accident crew was notified about 1858. The crew received only the destination; no specific patient information was provided before acceptance. The unit was assigned about 1914.
Another air ambulance operator, also flying a PC-12/45, turned down a similar patient transport from RNO to SLC at 1455 due to “snow drifts, high winds, Reno below min[imums].” That operator also declined a later flight due to “low vis, turbulence and icing.” According to Guardian Flight personnel, dispatchers were required to inform pilots if a patient flight request had been turned down by another operator. However, a review of Care Flight's communication log did not indicate the accident pilot was advised of the earlier turndowns.
At about 2020, ground transportation with the medical crew and passengers departed the hospital, arriving at the airplane about 2029. The pilot contacted ground control about 2052 and was instructed to taxi to runway 17L. The ground controller noted the airplane appeared to be “getting lost” and offered assistance. At 2054, the controller cautioned that “the taxiway hasn’t been plowed in a while” and later corrected the pilot’s taxi path. At 2055, the pilot indicated they had the situation under control. The RNO automated weather observation at the time included visibility 1¾ statute miles in light snow and an overcast ceiling at 1,700 ft above ground level.
The flight received an IFR clearance to SLC including the ZEFFR7 departure via the BLKJK transition. The pilot was cleared for takeoff from runway 17L about 2059; ADS-B data showed the airplane airborne about 45 seconds later. About one minute after takeoff, the pilot was handed off to departure control.
The airplane continued south until about 2105:50 near EPOSE waypoint, then turned left to a southeasterly heading at about 12,100 ft msl. At 2108:37, the pilot contacted Oakland Center, reported climbing through 15,400 ft msl, and was instructed to climb to flight level 250 with a caution for light to moderate turbulence. The pilot acknowledged; no further transmissions were received.
The airplane climbed on a southeasterly heading until about 2108:50, when it turned northeast near WITTT waypoint. About 2111:15, it began a right turn before reaching DATTT waypoint. The climb rate stopped, and the airplane maintained about 18,300 ft msl for 20 seconds. It then turned left to a northeasterly heading, climbing to about 19,000 ft msl, then to 19,400 ft msl before entering a descending right turn about 2113:20. The rate of descent increased from about 1,800 fpm to 13,000 fpm, and the turn rate increased. ADS-B contact was lost about 2114:12 at 11,100 ft msl near the accident site.
Pilot Information
The pilot was hired on September 6, 2022, as a float pilot rotating across Guardian Flight bases. He had requested extra shifts and was assigned to the RNO base for a week. According to an assistant chief pilot, the accident pilot had flown two shifts in Ely, Nevada, previously and was familiar with the RNO area. He arrived on Monday, worked a day shift Tuesday, a night shift Wednesday, and the accident occurred on Friday.
Training records showed the pilot began initial PC-12 flight training on October 5, 2022, completing 8.1 hours by October 10. On October 10, 33 of 53 flight subject training areas were graded “satisfactory” and 20 “waived.” Two areas—“autopilot system” and “Nav and Avionics System”—received “unsatisfactory” grades on October 5 and 7 but were graded satisfactory on October 9. The pilot also completed 7.1 hours of simulator training between September 19 and 23, with all grades “proficient” or “normal progress.”
Before Guardian Flight, the pilot flew Cessna 208 for a cargo operator. His most recent 14 CFR 135.293, 135.297, and 135.299 checks were completed on June 9, 2022, with all entries “satisfactory,” though the “Approaches: GPS” item required retraining and retesting. He previously worked for a Part 121 airline from May to August 2021 but was unable to satisfactorily complete the training program due to issues with pre-departure, climb, descent, and approach procedures.
Aircraft Information
The accident airplane was equipped with a Bendix/King KFC 325 Digital Flight Control System (AFCS) with three-axis control. The KFC 325 Pilot’s Guide described that the autopilot monitors operations continuously; if a problem is detected, it disconnects with flashing AP annunciation and an aural tone. In the event of autopilot malfunction, the recommended procedure includes grasping the controls firmly, pressing and holding the autopilot disconnect/trim interrupt pushbutton, pulling the autopilot circuit breaker, and not reengaging. Seven means were available to manually disconnect the autopilot.
The airplane also had a Central Advisory and Warning System (CAWS) with warning, caution, and advisory annunciations. The pneumatic wing deice system consisted of inflatable boots on the leading edges; a green CAWS caption indicated normal operation, while an amber “DE ICE BOOTS” caption signaled a failure.
Meteorological Information
The Current Icing Potential imagery showed a 10 to 20% chance of trace to light icing between 14,000 and 16,000 ft at the time of the accident. A High-Resolution Rapid Refresh (HRRR) model sounding near the accident site at 2100 identified clouds between about 5,000 and 28,000 ft msl, with the freezing level at the surface. Light icing was indicated below about 15,000 ft, moderate icing between about 9,500 and 11,500 ft msl, and potential for severe turbulence between about 11,000-12,000 ft and 15,000-16,500 ft msl. Winds at 15,000 ft msl were from the southeast at about 30 knots.
NCAR-provided HRRR data showed positive liquid water content between 5,000 and 10,000 ft along the flight path. RNO observations recorded overcast ceilings near 6,100 ft msl. GOES-18 infrared imagery at 2111 showed cloud top heights about 24,000 ft msl. No Convective SIGMETs were active, but SIGMET Victor 2 was issued for severe turbulence below 15,000 ft due to strong low-level winds, mountain wave activity, and wind shear.
An airline crew descending into RNO near the accident site reported complete instrument meteorological conditions (IMC) throughout descent, light to moderate turbulence, and light rime ice.
Wreckage and Impact Information
The airplane impacted flat, sagebrush-covered terrain about 0.31 miles northeast of the last ADS-B target. The debris field extended about 0.9 miles southwest of the main wreckage. The main wreckage, including the fuselage, left wing, inboard right wing, vertical stabilizer, and rudder, was oriented upright on a magnetic heading of about 018°. The fuselage was mostly crushed vertically with a large hole above and aft of the rear cargo door. The left wing remained mostly intact and attached; the right inboard wing was also attached but the outboard wing sections were found separated. The right and left horizontal stabilizers were found southwest of the main wreckage. The landing gear were retracted.
Forward fuselage fracture occurred between the firewall and lower windshield edge. The pilot windshield was shattered; the co-pilot windshield outer pane was fractured. There was no oil on the windshields. An area of fuselage impact damage on the right side extended diagonally over the crown, with rubber transfer marks consistent with the wing deice boot. The left wing fuel tank and right fuel tank were breached, with strong odor of jet fuel. The left aileron was attached but rotated beyond normal limits; the left flap was separated. The right aileron and flap were partially separated.