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 that poor weather, the pilot's spatial disorientation in night instrument meteorological conditions (IMC), and the operator's insufficient risk assessment and organizational oversight caused the February 2023 fatal air ambulance crash.
Key contributing factors included the operator's failure to complete a required pre-flight risk assessment, not informing the inexperienced crew of previous weather-related flight turndowns, and allowing them to fly in severe conditions without additional oversight.
The pilot became spatially disoriented after attempting to hand-fly the aircraft when the autopilot disengaged, leading to an in-flight breakup; an undiagnosed brain tumor may have also 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.