NTSB Final Report Points to Breakup in Fatal Air Ambulance Crash

Agency releases details of 2023 Pilatus accident in Nevada that killed five.

Meg Godlewski

Thursday, June 05, 2025 at 02:00 PM ET

Verified

Edited By:

Travis Tingle

A Pilatus PC-12 [Credit: Shutterstock]

Key Takeaways:

The NTSB determined the February 2023 fatal air ambulance crash was caused by the pilot's spatial disorientation in night instrument meteorological conditions (IMC) amidst poor weather, leading to an in-flight breakup.
Contributing factors included an "insufficient risk assessment" by the operator, their failure to complete a required pre-flight risk assessment, and a lack of organizational oversight.
The accident crew, who were relatively new in their roles, were not informed that other operators had previously turned down flights due to the severe weather conditions.
Additional contributing factors included the disengagement of the autopilot during the flight and a brain tumor discovered in the pilot during autopsy, which may have contributed to his disorientation.

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The National Transportation Safety Board cites poor weather and “insufficient risk assessment” as causal factors in the February 2023 fatal crash of an air ambulance Pilatus PC-12/15 in Stagecoach, Nevada.

The pilot, two medical crewmembers, and two passengers were killed when the aircraft experienced a midflight breakup shortly after takeoff. The Pilatus was operating in night instrument meteorological conditions (IMC).

According to the 27-page NTSB final report released this week, the flight was a nonemergency transport of a patient from Reno-Tahoe International Airport (KRNO) to Salt Lake City International Airport (KSLC) in Utah.