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 primarily caused by poor weather (night instrument meteorological conditions) leading to the pilot's spatial disorientation and an in-flight breakup after the autopilot was disengaged.
Key contributing factors included the operator's "insufficient risk assessment process" and lack of organizational oversight, as a required pre-flight risk assessment was not completed for the flight.
The company also failed to inform the relatively new flight crew that other operators had turned down flights in the area due to hazardous winter weather conditions.
An undiagnosed brain tumor in the pilot was noted as a potential contributing factor to his loss of spatial orientation during the flight.

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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.