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Crash in Butte Raises Thorny Questions

By Robert Goyer / Published: Mar 23, 2009

The question on everybody's mind is: Just what happened to the Pilatus PC12 that crashed on Sunday while bound for Bozeman (but diverting to Butte)? The crash killed 14 people, including the pilot, six other adults, and seven children.

You've probably read the details elsewhere, but here are the basics: The airplane flew from Redlands (located in the eastern part of the Los Angeles Basin) to Vacaville, California, then on to nearby Oroville, where it picked up passengers and headed out for Bozeman. The families aboard were reportedly heading out for a ski vacation at an exclusive ski club near there. The flight should have taken about three hours.

When the airplane was nearing Butte, the pilot told controllers that he was changing his destination from Bozeman (around 80 miles away) to Butte. This is a common enough exchange--the pilot didn't offer a reason for the diversion (or simply change of plans) and the controllers didn't ask. If anything unusual was going on with the airplane, the pilot didn't mention it to controllers.

Though speculation abounds, just what happened next is a mystery. After the pilot changed frequencies, presumably to unicom at the uncontrolled field at Butte, Bert Mooney Airport, the airplane crashed, just short of the runway, apparently in an extreme nose down attitude, into a cemetery. All 14 aboard surely died instantly.

With this crash, as with the Buffalo crash of a Q400 last month, ice is a leading suspect. Unlike in Buffalo, the PC12, if it encountered icing conditions at all, encountered them for a short period of time, and the pilot spoke with controllers after he reported having the airport in sight. But ice could explain the loss of control at low altitude without, as in Buffalo, the pilot having made any reports of control issues.

There was a post crash fire, though speculation abounds over what that means in terms of fuel remaining. One blogger pointed out that it doesn't take much of a flame to ignite a fire in pine trees, which can be seen burning in post crash photographs. Did the pilot divert because he was low on fuel? Did the crash result due to fuel exhaustion? If so, the NTSB might be able determine that, by examining the post crash fire and the patterns of the flames, among other things.

Weight and balance issues are at the forefront of the investigation, too. And everyone has been pointing out that the PC12 is certified almost always for a maximum of 11 occupants, 10 passengers and the single pilot. With 14 aboard, there were almost certainly at least three too many occupants for the number of belts available.

While some in the FAA might like to think so, airplanes don't crash because they violate FAA regulations. However, CG issues are a possibility that the NTSB is looking at closely. How was the airplane loaded? Where were the bags? How much baggage weight was there? With that many people going on a ski vacation, one might safely assume there were a lot of bags. The PC12 has both a stick shaker and a stick pusher, and the PC12 lands slowly, at just above the normal 61-knot stall speed for singles--it gets credit for the pusher and shaker, and its extremely crashworthy seats. So, while the airplane will still stall, and spin, the airplane is designed to make that as unlikely a scenario as possible. 

Then again, if there were CG issues, most likely a too far aft CG condition, all bets are off in terms of control. A question that has been asked a lot is, will the CG shift aft dramatically as the PC12 burns fuel? The answer is, no, not dramatically. Could it have been a factor still? At this point, it's impossible to rule it out. That's impossible to say right now. In fact, it's impossible to say much authoritatively at all. The NTSB is trying to find out how much fuel the airplane took on and where, the number and weight of bags and passenger loading, seating arrangements and weights. 

Which leads to another question: Was the PC12 over gross? Depending on how much fuel the pilot loaded, the answer could be "yes" or "no." The PC12 has a long range and big tanks, so it can still fly a three hour flight without full fuel. The question remains though: Might a pilot who was willing to put 14 people into an airplane certified for 11 be willing to bend other rules too? That's a question investigators will try to answer as well. It's probably moot. By the time the airplane arrived near Butte, it had burned off around three hours of fuel. If it had been over weight for takeoff, it mostly likely wasn't by that point. 

And surely the NTSB will be looking at pilot incapacitation as a possible cause. Could it be that the pilot didn't report any problem with the airplane because there was no problem with the airplane? Incapacitation can happen to any of us, and the onset can be subtle. It's also one of the hardest things for investigators to determine, especially in a crash as violent as Sundays and especially when there's a post crash fire, as there was.

Or maybe there was a problem with the airplane. There was reportedly no flight data recorder or cockpit voice recorder on board, nor would one expect there to be, but the NTSB might be able to retrieve some valuable data from the engine monitoring system or the navigators, if that data is recoverable after the crash. Tracking down a mechanical problem, if there was one--and the PC12 has what appears to be an excellent safety record--would be a tough chore, but it's been done before.

In an accident as tragic as this one is and as mysterious as it's shaping up to be, any bit of evidence is critical. Because everyone wants to know what happened and why. Whether we ever learn those answers is an open question at this early stage of the investigation.

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typepad's picture

Perhaps it would be helpful if outlets such as Flying were to contact the general media to discourage speculation as to the causes of this and other crashes before enough facts are known. Press reports seem to be siezing on "14 people in an airplane designed for 10" in a way of calling just deserts, but it seems highly unlikely (to me at least) that the plane was over weight by the time it neared landing.

Most major media outlets like sensational stories, especially those featuring someone to blame.

typepad's picture

Unfortunately, what makes the reporting even more ambiguous is the lack of knowledge of the source. They do much more harm in trying to scare the public than report the so called facts.

typepad's picture

Maybe the plane got hit by a small meteor on approach. Who knows?

typepad's picture

I’m thinking the adults would be fore as to keep the children out of the pilots hair and to aid in use of the toilet behind the right seat.
I have always thought diversions should be requested with reason over the radios.
ATC should quickly ask if the pilot does not relay a quick and simple reason.
That’s my two pennies.

typepad's picture

There has been no mention of the pilots qualifications? If the media is to do any thing constructive they should look like they have done some further investigations, instead of their usual ambiguous style and lack of detail reporting.

typepad's picture

Would be great to understand the reports of no flaps on approach. If that is true this a very thorny question.

typepad's picture

We must all remember, the Media is not interested in the facts of any story to any degree. Their job is to sell advertising and listener count for their bottom line. Sensationalisn and nonfactual accounts which enhance a story are unfortunately standard procedure in the Media world...we see it everywhere.

typepad's picture

Some "authority" on Fox news questioned the judgment of a pilot who would fly an airplane with just one engine over the Rocky Mountains. Aviation need a whole bunch of public relations damage control given all the crashes.

typepad's picture

Case in point...

typepad's picture

Simple pilot error seems to be the most likely possible answer. We are all prone to making mistakes, Lord knows, and even hundreds of hours of instruction and flight time cannot rule out the one possibility, maybe as in this case, that we make the error which is fatal. I do agree with Tonwa nevertheless - diversions should always be explained, if not justified. Ted Tunniclliffe - student pilot - Avignon, France.

typepad's picture

This is a terrible loss for the families, general aviation and the reputation of a great airplane. Unfortunately some take chances that others have to pay for in many ways.

typepad's picture

I remember a flight I had once in a C-340. After a flight of some hours I realized in short final that I had to push the yoke forward. Apparently the tailheavy situation went unnoticed during cruise and descent but as airspeed decreased it became a problem. I was able, then, to save the situation by landing with excessive speed. Had I not increased speed after becoming aware of the problem we might have crashed in final - exactly as the Pilatus at Butte.

typepad's picture

uncooridinated turn at low altitude.

witnesses say he was in a steep turn.....

I'd bet money on it !

happens everyday to even the best pilots.

typepad's picture

Ihave been flying the PC12 for over 10 years and it appears that this was a low slow turn to final with the possibility of many other contributing factors. I consider this aircraft the safest aircraft I have ever flown.

typepad's picture

Is there a record of fuel taken on, and where it occurred? If icing had been encountered might he have left the flaps up as recommended in most icing scenarios during landing? Were SLDs encountered along the route? Also, if he was low on fuel maybe this was the reason for the diversion and flaps up in anticipation of an impending flame out (better glide capability) which might have, in fact, occurred a distance from the runway. PC-12 flap extension time is very lengthy, and this, in my opinion is key. Why were they not extended?

typepad's picture

I owned and piloted a PC-12,Serial #288 for 4yrs. I have around 1500 hrs in the PC12. I would bet that the pilot suffered a heart attack or something physical that caused the crash. My old PC12 is based out in San Diego area tail number 64WF year model 2000, does anyone have any info on the serial # of the plane that crashed? Based on the fire, i am sure that fuel exhaustion wasn't an issue.

typepad's picture

This pilot was a Air Force veteran flyer. No one gets any better training, and very few of us can even qualify to get it! Now is NOT the time to question the pilot, or the integrity of the plane. Investigators will find clues that will point to causal factors.

typepad's picture

Single pilot IFR, as we know, has the most risk and the highest workload, but even with two pilots in the cockpit things don't always work out so well. Look at Colgan 3407 for an example. However if this poor guy had become incapacitated another pilot would have possibly saved the day. I have heard controllers asking for reasons for diverting, in fact one guy said "for the tape" which made a lot of sense. As pilots we are always faced with changing situations, but to have a little more stored information would be so helpful in these cases.

typepad's picture

Most of professional pilots know that you should avoid extending flaps for landing if you suspect tailplane icing.
Adding flaps with ice on the tail can result in a tailplane stall in short order. Recovery at low altitude may not be possible in time.
The pilot was reportedly a 65 year old ex-military pilot.
I'm sure he was a seasoned pilot with lots of experience.
Maybe he picked up some ice in a very short amount of time and
decided to land without flaps. Maybe the plane experienced a tailplane stall even without flaps extended. The NTSB has it's work cut out on this one.
On the Buffalo crash they at least had flight data recoderes to work with.

typepad's picture

We flew out of Bozeman on our Citation two days prior. The airport is in a wide valley with a good approach, with weather rarely an issue for arrivals. Diversion was likely due to icing buildup in the mountains, or why divert? May have stalled while heavy on on the steep turn to final.

Putting 14 on a plane for certified for 11 (forget the weight, its about seat belts) tells you something about the pilot, naval aviator or not. If fuel starvation was the issue, then the pilot was completely irresponsible.

Ross Dworman
CE 500 Captain

typepad's picture

Adding to Russ D's comment about the pilot's evident attitude towards seat belts and his military background: the military selects people with outstanding physical and mental ability - but the training and mind set is to complete the mission - sometimes at all costs -rather than tell the commander "...it can't be done" or "it can't be done safely." That may get you a medal (perhaps posthumously) in combat, but it is not a good fit with civilian aviation. Some ex military aviators overcome this very well and are outstanding in the civilian world; others do not. I'm not saying this could have been a cause - we don't know now, and may never. However, perhaps pilots who have flown with this guy, or given him training or checkrides, may be able to illuminate this aspect of his personality.

typepad's picture

The departing CA airport was 190 msl. Butte is 5500 msl. Could the density altitude difference hide a weight & balance problem until just before landing?

typepad's picture

I'm a high time professional pilot, and flight instructor. There is a reason why the airlines put two pilots in the cockpit. I think that if you are flying your precious family members such as children that you have to give them every chance to grow up, and live a full life, and that means puting two professional pilots up there. Like a few people are speculating the pilot could have had a heart attack or just anything physical, like a case of hypoxia which happened to me once about twenty five years ago, agrravated by taking too many aspirins that same day, which I was allegeric to but didn't know it. I was alone, and ATC talked me into getting the cessna 411 safely on the grond at night after crossing the smoky mountains. I was only about thirty three at the time, and this guy was sixty five with no back up. This is sad, and so un called for. We as americans enjoy our freedom to fly our private planes, as one of only a few countries do, but I think we should take flying airplanes more serious. Hire a flight instructor, and buy him a ticket back home. If people can afford such an expensive aircraft then they can pay the flight instuctor.

typepad's picture

Someone as an eyewitness reported that the plane was making a steep turn to final. I'm think that it was an accelerated stall.

typepad's picture

The uncertanity of this tragedy as it relates to cause, we may never know! With certanity,and consideration of the payload alone and type of aircraft,two pilots,two heads in the cock-pit should have been imparitive.

typepad's picture

Did the pilot notice that the CG were going to be a problem
should too much fuel be burned from the tanks. Depending on
the CG location, excessive fuel burn can put you out of CG.
Maybe the pilot realizing this, made the diversion to put
on more fuel so as to prevent getting out of CG. Just something
else to think about.

typepad's picture

Steep turns to final . . .
No flaps . . .
Diversion. . .
There are many very good reasons for all of the above, it is unfortunate that AT THIS TIME we do knot know what those reasons were. When I hear things like, you need to people in the cockpit, single engine over the rockies!!! I wonder where the man with the red flag in front of an automobile went?
Please speculate silently until there are some facts to debate.

typepad's picture

After flying around for 52 years, I've come to the conclusion that, especially flying under IFR, two heads watching and challenging each other during flight preparation, loading, fuel management, etc. most often results in better decisions. We may never know the exact cause of this tragedy and shouldn't speculate. However, we do know that two heads are better than one and there probably was no valid reason to trust 14 people's lives and a million dollar plus plane to one 65 year old dude on a winter IFR flight regardless of his experience.

Richard Somers (age 71)

typepad's picture

Reports of crash 500 feet from runway are misleading. Look at Google Maps. The crash locaton (cemetary) is next to the runway, but mid-field. Unlikely the pilot was turning to final. Instead, it appears he was turning downwind for a landing to the north, but made his turn unusually low and close to the field. Flight track on FlightAware seems to confirm a heading toward mid-field rather than some point south for a base entry or straight-in approach. Lots in interesting theories on cause, but the plane did not drop out of the sky on short final as news reports seem to suggest.

typepad's picture

If I may add my two cents: Wouldn't it be logical to assume that since three of the children were of very young age, the pilot had doubled up the six children unto the three available seats? Also possible, three of the adults had children on their laps for landing. If over-max gross was not an issue, wouldn't these seating arrangement conform to a proper CG? And whats more: Wouldn't it also help counter equipment load aft ?

typepad's picture

A friend of ours knows the owner of the PC-12 (who was not on the plane) and the pilot, Bud Summerfield. In fact, Bud has flown her many times in a Cessna 210, commuting to jobsites. Although not a pilot, she has extensive experience as a passenger in GA aircraft. She felt that Bud was extremely safety conscious, even teaching her how to use the radios in case of an emergency. She also stated that Bud said he was feeling fatigued by some of these long flights, and he was going to request a co-pilot for future trips after this one. The Redlands community has been hit very hard by this tragedy.

typepad's picture

The Pilatus in question was serial number 403, reg N128CM. What about the children on board moving in a group in the cabin causing a CG issue just before landing. Was a passenger occupying the right seat up front? I understand from reports that he took on fuel at his stop in Oroville from the FBO Table Mountain aviation.

typepad's picture

Bozeman, Butte, Billings – all cities in Montana. More than once flight plans have been filed for one while intending another. Was Bozeman the real destination or was it Butte all along, maybe a check with hotel reservations or rental cars could shed some light.
A quick check of FAR 91.107(3)(i) indicates not all passengers require a seat or a seat belt, which may be the case here.

typepad's picture

I beleive a CG issue coupled with a steep turn brought the aircraft down. The pilot may have been feeling ill and felt the need to get down fast. No flaps though is strange.

typepad's picture

Another note from my friend who knew the pilot: Bud had flown this trip many times in this aircraft with this family. Undoutedly he knew the fuel required and had a feel for the weight/balance/CG situation. As pilots, we should all be aware of our tendency to underplan routine flights.

typepad's picture

Have been in a situation in a friends plane when passengers became sick and requested the pilot to land immediately (fortunately an airport was nearby). With so many children on board, why has no one mentioned the possibility of some of the children becoming airsick when the plane was nearing its destination and descending from a higher altitude, possibly encountering some turbulence? Nothing worse than little kids sick in an airplane..would want to make a quick landing at the nearest airfield........and Butte apparently on the flight path and pilot attempting to make a quick diversion to get down to pattern altitude.....and if there was ice, too steep a banked turn to get down asap. Whatever the reason, a sad event.

typepad's picture

Got to add my 1.5 cent. As a Butian, the location of the crash site and the Guidoni's recount, I'll wager pilot medical distress. Bud came over the south rim of the valley set up for a direct in on 33. Dropped in over just to the west of Red Mountain, over the reservior, decending. Got to call traffic-got to come right- got to fly the airplane. Concentrating and fighting for line up- kept drifting left. No flaps. No gear. Now low, slow and way left mid-field, slumps foreward and left. No steep turns on final, no CG problems, no icing. Just a pilot trying his best to get his charges on the ground safely against an unyielding threat. Out prayers go out to all.

typepad's picture

Ross: This guy wasn't in the NAVY he was in the AIR FARCE!

typepad's picture

The point of diversion was about 30 mins (150 miles) out of Bozeman. From Oroville to Bozeman the track of the flight, at the point of diversion to Butte, was only slightly closer than to Bozeman. In a real emergency, Boise or Idaho Falls would have been much closer. I don’t believe the diversion was caused by an emergency.
Let’s not be too quick to judge the pilot. He was on the flight, and knew all the circumstances, not us.

typepad's picture

Although the media, including the Flying article above, refers to the crash site as being 'just short of the runway', looking at a map (http://maps.google.com/maps?hl=en&tab=wl) it looks like the cemetary is West of the airport & both runways run more like North/South. A plane crashing in the cemetary would not have been on final or even base, but more likely midfield on downwind. If on the other hand, he -was- flying directly toward the airport, it must have been to overfly the field & enter a downwind on the other side. Either way, this was not a base-to-final turn or even a downwind-to-base turn. And it doesn't look like any kind of emergency either-- Any pilot in a hurry coming from the SW would have chosen a base or straight-in entry. As for the concern about no flaps being deployed-- Do PC-12 pilots always have flaps out on the downwind? In my plane (not a PC-12), at this point, I have gear down but no flaps.

typepad's picture

I need to respond to Barry B. who wrote the following about military pilots, "...but the training and mind set is to complete the mission - sometimes at all costs -rather than tell the commander "...it can't be done" or "it can't be done safely." I have 2800 hours in military helicopters and my crews and I have been credited with more than 10 civilian lives saved in various missions over 20+ years. Helping others when they need you is pretty strong motivation and makes for high morale. At the same time, I have never experienced anything but full support from my leadership when I declined a mission for weather or for maintenance reasons. Granted, I wasn't ever dropping bombs on targets, but sometimes we had to say "sorry" to a request to search for overdue hikers or boaters or missing aircraft or to pick up injured motorists in the boonies after an accident. Nobody wanted to "go" more than we did, but the safety emphasis in my military career has been first-rate at every assignment. (I will acknowledge that exceeding the number of passengers allowed for in the aircraft in the absense of life & death situations was not condoned and was not something this guy learned in the Air Force.)

typepad's picture

Sad situation all around. could only be a few reasons for divert, ie health, ice, fuel. I thought the PC12 has boots on wings and tail? Stall at low speed and high bank certainly explains a nose low impact, but someone said he was already turned onto final? 14 in a plane with 11 belts could mean toddlers or infants sat on laps as in airliners. Too many questions to speculate with any accuracy, but if the cause(s) are determined it should be a very good case study for all pilots. We should honor the victims by making ourselves better pilots.

typepad's picture

I posted the comment that is up 3 from this one about the location of the crash in relation to runways at Butte. I looked again & see there is a cemetary NW of the airport as well, the Mountain View Cemetary that would be under the final approach to one of the runways. But the cemetary mentioned in news reports is Holy Cross-- The one I was referring to. Anyone know more? Maybe the reports have the two mixed up & the plane really was on short final.

typepad's picture

I've been flying the PC-12 professionally over 9 years with over 3000 hours in type. I've also been flying as single pilot in most of the PC-12's I've flown. Living in Denver, I experience a wide varieties of weather, including icing. The only time I've had any issue with ice the airplane could not handle was SLD. This stuff is scary and the de-ice system won't get rid of it. If the airplane had any appreciable amount of SLD and the pilot put any flaps in on approach, it's Buffalo all over. The PC-12 is certainly a capable airplane and probably the safest in the industry.

typepad's picture

It's time to practice what we preach about not speculating about the cause(s) of an air crash. The NTSB takes over a year to 'do it right' and the crash scenario or 'probable cause' is usually more complex and obscure than most sidewalk superintendents could ever imagine. Ice? Balance? Incapacitation? Child in the copilot seat? We can only guess and that helps no one. Leave it to the NTSB please.

typepad's picture

After reading [Flying's] . . . comments and all comments, many excellent questions are raised concerning fuel, CG, approach, and incapcitation.

There is another whole area I question, the psychological environment, i.e., who was in the right seat? or who was in aisle? Was there a child or a young person with questions or movements distracting?

Distractions disturb our normal "flow" of sequencing. Even with two or three pilots in the sterile environment can be distracted as history shows. Focus and strict checklist adherence will prevent many accidents.

typepad's picture

Speculation by pilots is not that much different than speculation by sensation seeking journalists. The truth is that the only person(s) who really know what happened are no longer around to tell their story.
As for 14 souls on a plane certified for 11, it seems the story stated that seven of them were small children. Even airlines allow infants to travel in their parents' arms. Not saying that its wise, but it is permitted.
By the way, a second pilot would have placed 15 persons aboard.

typepad's picture

Were any of the passengers pilots as well and sitting right seat (or left seat)? Was the diversion made to allow that person an opportunity to fly/land the plane, possibly a 'practice' or 'demonstration' landing? Were the flaps inadvertantly retracted? The speculation can only continue, but there is distraction of some nature responsible for this accident.

typepad's picture

Two issues are rising from reading about the accident as well as the posted comments:
How old someone should get,NOT to be allowed to cary all those souls on bord?
Why did they get on bord?

typepad's picture

If the pilot had overflown the airport and checked for wind direction (2 windsocks, midfield & south end), would have noticed the winds (as reported) from the northwest. He most likely would have made a steep teardrop turn to enter left downwind. That turn would have put him over the northwest corner of the airport. Exactly where that cemetery is located (as seen on Google Earth). Any icing or out-of-CG condition could/would have made that turn fatal.

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