Federal accident investigators have issued a report relating to a plane crash that killed 13 members of a family headed to a Montana ski vacation two years ago. The report says the crash was caused by a pilot who did not use a required anti-ice additive in the fuel and continued to fly despite a deteriorating fuel system. The investigation into the crash of a high-performance Pilatus PC-12 in Butte, Mont., on March 22, 2009, found several examples of the pilot skirting federal flight laws or ignoring the aircraft manufacturer’s guidance for operating the single-engine turboprop, the National Transportation Safety Board found. The pilot was also killed in the crash. NTSB Chairwoman Deborah Hersman had this to say:
To err is human, but we all know that the aviation environment is not forgiving when it comes to mistakes. That is exactly why it is so important to follow procedures, use checklists and always ensure you have a safety margin to offset the potential for human error.
The plane had a total of 10 seats, meaning some of the passengers were on board illegally. The Federal Aviation Administration, which regulates aircraft operations, requires that everyone be belted into a seat on a flight, except children younger than two years of age, who may be held in an adult’s lap. NTSB investigators calculated that the plane was about 600 pounds over its maximum takeoff weight when it left Oroville, Calif. According to Malcolm Brenner, an expert in human errors, it appeared that oversight of the privately-owned plane had gradually become sloppy.
Investigators initially were concerned that the cause of the crash would never be determined. There were no crashproof recorders on the plane, and the heavily damaged wreckage yielded no clues. But NTSB investigator Dennis Diaz found a small set of microchips from the plane’s safety-warning system. The unit was heavily damaged by fire, but the chips were salvaged, and they contained a detailed record of the plane’s history that ultimately solved the case.
It showed that the left tank had become blocked by ice that formed in the fuel lines. As the right tank’s fuel was drained by the engine, the plane became increasingly out of balance and difficult to control. It was later confirmed that the pilot had not used anti-ice additive the two times he refueled the plane the day of the accident. The additive is required when flying in freezing temperatures.
Based on the evidence recovered from the chip, investigators estimated that the fuel imbalance began more than an hour before the accident. The aircraft’s emergency manual tells pilots to land as soon as possible if a fuel imbalance occurs, but the pilot continued past several airports. As the plane approached Butte, with the right-wing fuel tank nearly empty, the pilot attempted a sharp turn, and the plane plunged into a cemetery.
Source: USA Today
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