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 fatal air ambulance crash was caused by the pilot's spatial disorientation in night Instrument Meteorological Conditions (IMC), leading to a graveyard spiral and mid-flight breakup.
Key contributing factors included the operator's insufficient flight risk assessment process, the failure to complete a required preflight risk assessment for the mission, and a lack of organizational oversight.
The relatively inexperienced flight crew was not informed that other operators had turned down flights in the severe winter weather, and the aircraft's autopilot was disengaged multiple times during the flight.
A post-mortem brain tumor discovery in the pilot was noted as a potential factor contributing to his spatial 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.