Cause of Pilatus PC-12/47E Air Crash in Santa Fe, NEW MEXICO, USA on 9/29/2008





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Final Report on Probabable Cause of Crash

HISTORY OF FLIGHT

On September 29, 2008, at 2216:27 mountain daylight time, a Pilatus PC-12/47E, N606SL, owned and operated by a private pilot, was destroyed when it impacted terrain three nautical miles north of the Santa Fe Municipal Airport (SAF), Santa Fe, New Mexico. A post impact fire ensued. Dark night visual meteorological conditions prevailed at the time of the accident. The personal flight was being conducted under the provisions of Title 14 Code of Federal Regulations Part 91 on an instrument flight rules (IFR) flight plan. The private pilot, the sole occupant on board, was fatally injured. The cross country flight departed Lubbock Preston Smith International Airport (LBB), Lubbock, Texas, approximately 2115 and was en route to SAF.

The pilot's family reported that several days prior to the accident, the pilot had flown the accident airplane to Akron, Ohio, from his home near Santa Fe, to spend the weekend in Akron with friends. On the morning of the accident, the pilot left his hotel at an unknown time and proceeded to the Akron-Canton Regional Airport. According to Federal Aviation Administration (FAA) records, the pilot departed Akron-Canton Regional Airport, Akron, Ohio, at 0717 (0917 Eastern Daylight Time (edt))en route to Teterboro Airport (TEB), Teterboro, New Jersey. He arrived at TEB approximately 0850 (1050 edt). At Teterboro, the pilot contacted Lockheed Martin Flight Service Station (FSS) at 1353 (1553 edt) to file an IFR flight plan. The flight plan filed by the pilot identified TEB as the departure airport and SAF as the destination. The pilot planned six hours en route at flight level (FL) 280. The airplane departed TEB at 1424 (1624 edt). While en route, the pilot diverted to LBB to obtain fuel.

The pilot arrived at LBB at 2021 (2221 edt) and had the airplane refueled. He also spoke with his wife on the telephone, and did not report any problems regarding the airplane or himself. The pilot then departed LBB approximately 2115 (2315 edt).

Approaching Santa Fe, the pilot initiated a descent to 12,000 feet mean sea level (msl) as cleared by Albuquerque Center at 2158:56. The pilot was cleared for the visual approach into SAF at 2212:43 and canceled his flight plan ten seconds later. No further communications with the pilot were recorded.

Radar data, provided by Albuquerque Air Route Traffic Control Center (ZAB) in National Track Analysis Program (NTAP) format, depicted the accident flight approaching SAF. The airplane track progressed from the southeast towards the northwest on a measured magnetic bearing of 290 degrees in a descent. At an approximate altitude of 8,000 feet msl, approximately two nautical miles (nm) northeast of the airport, the track shifted to a magnetic bearing of 320 degrees and continued in a descent. The last radar target was recorded at 2216:27 at an encoded altitude of 7,200 feet msl, 3.2 nautical miles north of the airport on a measured magnetic bearing of 003 degrees from the airport. The airplane's ground speed remained above 200 knots until just prior to impact, when the ground speed slowed to 190 knots.

The National Transportation Safety Board (Safety Board) Investigator in Charge (IIC) interviewed one witness and received written statements from the same witness and one additional witness. The witnesses were located at SAF three miles south of the impact location. According to the witnesses, the airplane approached the airport from the "southeast" and "overflew" the area on a ground track consistent with a traffic pattern for one of the runways. The airplane was visible due to the airplane position lights. The pilot reported over UNICOM that he was five miles from the airport. The runway lights were activated and the level of lighting was adjusted several times following the radio transmission. No other radio calls were made by the pilot. There were no other aircraft in the area at the time of the accident. According to one witness, the airplane initiated a left turn towards the airport at which time the airplane pitched down and descended at a "steep angle." The two witnesses resumed their normal duties, waiting for the airplane to land, unaware that the airplane had crashed. According to one witness, it was standard practice for the pilot to report five miles out in addition to his position on downwind, base, and final for the landing runways. The pilot did not make any of these traffic pattern reports.

PERSONNEL INFORMATION

The pilot, age 54, held a private pilot certificate with airplane single engine land, multi-engine land, and instrument ratings last issued on April 11, 2006. He was issued a third class airman medical certificate on July 27, 2007. The certificate contained the limitation "holder shall wear lenses that correct for distant vision and possess glasses that correct for near vision."

The pilot's family provided the Safety Board IIC a digital copy of the digital logbook that the pilot had maintained on his personal computer. A review of these records revealed the pilot had logged no less than 2,437 hours total flight time; 1,456 hours in turbine aircraft, 86.5 hours in the Pilatus PC-12/47E, 14 hours in a Pilatus simulator, and 85 hours of night flight experience, 2.4 hours of which were in the Pilatus. The last flight in this digital record was logged on September 26, 2008, and the flight totals did not include his flight activity between that time and the accident flight. The pilot satisfactorily completed the Pilatus PC-12 NG initial course at SIMCOM Training Center on July 24, 2008.

AIRCRAFT INFORMATION

The accident airplane, a Pilatus PC-12/47E (serial number 1020), was manufactured in 2008. It was registered with the FAA on a standard airworthiness certificate for normal operations. The airplane was powered by a Pratt & Whitney Canada PT6A-67P turbo propeller engine rated at 1,200 shaft horsepower. The engine was equipped with a four-blade, Hartzell propeller (model number HC-E4A-3D, serial number KX596).

The airplane was registered to Gardner Leasing LLC, operated by the pilot, and was maintained under an annual inspection program. The airplane was new and had been registered on August 26, 2008. According to Safety Board estimates the airplane had flown 100 hours, between the time it was sold to the pilot and the accident, and had an estimated total airframe time of 130 hours. A review of the maintenance records revealed no maintenance had been performed since the sale of the airplane. The last maintenance performed was the installation of a cabin entertainment system. This maintenance was performed by Pilatus Business Aircraft in Broomfield, Colorado. The installation was completed on July 24, 2008, at an airframe total time of 27.6 hours.

METEOROLOGICAL CONDITIONS

The closest official weather observation station was Santa Fe Municipal Airport (SAF), located three nm south of the accident site. The elevation of the weather observation station was 6,348 feet msl. The routine aviation weather report (METAR) for SAF, issued at 2153, reported, winds, 120 degrees at 8 knots, visibility, 10 miles; sky condition, clear below 12,000 feet; temperature 16 degrees Celsius (C); dew point, zero degrees C; altimeter, 30.43 inches.

According to the United States Naval Observatory, Astronomical Applications Department Sun and Moon Data, the moon rose at 0719 on the day of the accident and set at 1847 the same day. The moon phase was "new moon" as of 0212 the day of the accident.

AIRPORT INFORMATION

Santa Fe Municipal Airport is a public airport located in Class D airspace. The airport is located nine miles southwest of Santa Fe, New Mexico, at 35 degrees, 37 minutes, 01.59 seconds north latitude and 106 degrees, 5 minutes, 21.9 seconds west longitude, at a surveyed elevation of 6,348 feet. The airport had three open runways at the time of the accident; runway 2/20 (8,342 feet by 150 feet, asphalt), runway 15/33 (6,307 feet by 100 feet, asphalt), and runway 10/28 (6,300 feet by 75 feet, asphalt). The control tower is open between the hours of 0700 and 2100. When the control tower is closed, the airspace reverts to Class E airspace.

WRECKAGE AND IM

Initial Report

The pilot was approaching his home airport under dark night conditions. He reported that he was five miles from the airport and adjusted the airport lighting several times. He made no further radio calls, though his normal practice was to report his position several times as he proceeded in the landing pattern. The airplane approached the airport from the southeast in a descent, continued past the airport, and adjusted its course slightly to the left. One witness reported observing the airplane enter a left turn, then pitch down, and descend at a steep angle. The airplane impacted terrain in a steep left bank and cart wheeled. An examination of the airframe, airplane systems, and engine revealed no pre-impact anomalies. Flight control continuity was confirmed.

The pilot had flown eight hours and 30 minutes on the day of the accident, crossing two time zones, and had been awake for no less than 17 hours when the accident occurred. The accident occurred at a time of day after midnight in the pilot's departure time zone. Post-accident toxicology testing revealed doxylamine and amphetamine in the pilot's tissues. The pilot had been diagnosed with attention deficit hyperactivity disorder (ADHD) almost five years prior to the accident and had taken prescription amphetamines for the disorder since that diagnosis. The FAA does not medically certify pilots who require medication for the control of ADHD. At the time of the accident, the pilot's blood level of amphetamines may have been falling, and he may have been increasingly fatigued and distracted. The use of doxylamine (an over-the-counter antihistamine, often used as a sleep aid) could suggest that the pilot was having difficulty sleeping.
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2008 - Pilatus NEW MEXICO

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