# NTSB CHI02FA284: Pilatus PC-12/45, N451ES, Westphalia, MO, September 14, 2002 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: September 14, 2002, 15:55 local (20:55 UTC) - Place: Westphalia, MO - Coordinates: 38.372222, -92.029724 - Nearby events: https://openairdocs.org/map.md?lat=38.3722&lon=-92.0297&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report October 28, 2004 - Report: Approved by Office Director - Parties: Pratt & Whitney Canada, Federal Aviation Administration - St. Louis FSDO, Pilatus Aircraft, Ltd., Pilatus Business Aircraft - NTSB case key (mKey): 55741 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI02FA284 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/55741/pdf - Page: https://openairdocs.org/ntsb/CHI02FA284 ## Probable cause The pilot's spatial disorientation while turning in a cruise climb in instrument meteorological conditions, which resulted in the pilot's loss of aircraft control, and his failure to recover from a resultant tight descending spiral. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, climb - to cruise - aircraft control - not maintained, pilot in command (cause) - spatial disorientation, pilot in command (cause) - weather condition - clouds (contributing factor) - remedial action - inadequate, pilot in command - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground - Explosion, other ## Analysis The turbo-prop airplane departed controlled flight after initiating an ATC directed turn during cruise climb. The airplane subsequently entered a rapidly descending spiral turn, impacting the terrain and exploding. A witness reported hearing an "unusually loud" engine sound prior to seeing the airplane in a nose-low descent. The witness stated the airplane was "heading straight down, and did between a quarter and half of turn, but was not spinning wildly." The witness reported the airplane disappeared behind a nearby ridgeline and was followed by a "loud sound, and an immediate large cloud of black smoke." Aircraft radar track data showed the airplane heading to the northeast, while climbing to a maximum altitude of 13,800 feet msl. The airplane then entered an increasingly tighter, right descending turn. The calculated descent rate was 7,000 feet/min. Instrument flight rules (IFR) conditions prevailed at altitude and marginal visual flight rules (MVFR) conditions prevailed at the accident site. The instrument-rated pilot received a weather briefing prior to departure. During the briefing the pilot was told of building thunderstorm activity near the departure airport and along the route of flight. The pilot told the briefer he was going to depart shortly to keep ahead of the approaching weather. A witness at the departure airport reported that the passenger was concerned about flying in "bad weather" and the pilot told the passenger that the weather was only going to get worse and that they "needed to go to get ahead of it." A two-dimensional reconstruction determined that all primary airframe structural components, flight control surfaces, powerplant components, and propeller blades were present. Flight control continuity could not be established due to the extensive damage to all components. Inspection of the recovered flight control components did not exhibit any evidence of pre-impact malfunction. The standby attitude indicator gyro and its case showed evidence of rotational damage, consistent with the gyro rotating at the time of impact. Both solid-state Attitude & Heading Reference System (AHRS) units were destroyed during the accident, and as a result no information was available. ## Factual narrative HISTORY OF FLIGHT On September 14, 2002, at 1555 central daylight time (cdt), a Pilatus PC-12/45, N451ES, piloted by a commercial pilot, was destroyed after colliding with terrain near Westphalia, Missouri. The airplane departed controlled flight during a climbing turn while enroute to cruise altitude. Instrument flight rules (IFR) conditions prevailed at altitude and marginal visual flight rules (MVFR) conditions prevailed at the accident site. The business flight was operating under provisions of 14 CFR Part 91 while on an IFR flight plan. The pilot and his passenger were fatally injured. The flight departed Lee C. Fine Memorial Airport (AIZ), Lake Ozark, Missouri, at 1540 and was en route to South Bend Regional Airport (SBN), South Bend, Indiana. An employee of a fixed base operator (FBO) at AIZ overheard a conversation between the pilot of N451ES and his passenger prior to their departure. The FBO employee reported that the passenger was concerned about flying in "bad weather" and the pilot replied that the weather was only going to get worse and that they "needed to go to get ahead of it." The FBO employee stated that the pilot did not purchase any fuel prior to departing. The FBO employee reported that she made a written notation that N451ES departed at 1540. According to information provided by the Federal Aviation Administration (FAA) Kansas City Air Route Traffic Control Center (ARTCC), the pilot of N451ES established radio contact at 1545:20 (hhmm:ss) and reported climbing to 7,000 feet above mean sea level (msl). ARTCC instructed N451ES to continue the climb to flight level 230 (23,000 feet). At 1552:09, ARTCC instructed N451ES to turn 20-degrees right and N451ES acknowledged the vector at 1552:14. No additional communications were received from N451ES. At 1555:33, ARTCC informed N451ES that he was not receiving a transponder beacon return and instructed the pilot to reset the transponder code. Between 1555:49 and 1558:36, ARTCC attempted to reestablish radio contact with N451ES without success. A transcription of the voice communications between ARTCC and N451ES is included with the docket material associated with this factual report. Aircraft radar track data for the period before and after the reported accident time was obtained from FAA Air Traffic Control (ATC). The obtained data indicated a single aircraft transmitting a discrete transponder beacon code (1135) had departed from AIZ approximately 1543. A plot of the radar track data showed the airplane heading towards the northeast, while climbing to a maximum altitude of 13,800 feet msl. At 1553:19, the airplane entered an increasingly tighter, right descending turn. The aircraft descended from 13,700 feet msl to 11,600 feet msl between 1553:47 and 1554:05. The calculated descent rate for this time period was 7,000 feet/min. The last discrete radar return was received at 1554:23. Plots of the radar track data, along with a copy of the source data, are included with the docket material associated with this factual report. Two people on Willibrand Lake witnessed the accident. One witness reported hearing the airplane first, then seeing the top profile of the airplane with the nose pointed straight down. The witness stated that he thought the airplane's altitude was approximately 2,500 feet to 3,000 feet. The witness reported the airplane completed a 1/2-turn towards the left showing the right side of the airplane during the nose-down descent. The witness stated he heard the airplane's engine "screaming loud" as the airplane descended below a ridgeline, followed a few seconds later with the sound of an impact. The other witness reported that an "unusually loud" sound initially drew her attention to the airplane. The witness stated the airplane was approximately 1/2 mile above the ground, about 1 to 1/2 miles from her position. The witness reported the airplane was in a nose-low descent with the top of the airplane visible. The witness stated the airplane was "heading straight down, and did between a quarter and half of a turn, but was not spinning wildly." The witness reported the airplane disappeared behind a nearby ridgeline and was followed by a "loud sound, and an immediate large cloud of black smoke." Witness statements are included with the docket material associated with this factual report. DAMAGE TO AIRCRAFT The airplane was destroyed by impact forces and explosion/fire. PERSONNEL INFORMATION According to FAA records, the pilot held a commercial pilot certificate with airplane single-engine land, airplane multiengine land, and instrument airplane ratings. The pilot also held a certified flight instructor certificate with airplane single-engine, airplane multiengine, and instrument airplane ratings. FAA records show the pilot's last medical examination was completed on September 5, 2002, when he was issued a first-class medical certificate with no restrictions or limitations. A FAA inspector reviewed the pilot's flight logbooks and total flight times were calculated as of the last logbook entry, dated September 9, 2002. The pilot had a total flight experience of 1,645.2 hours, of which 1,091.8 hours were in single-engine airplanes and 553.4 hours were in multiengine airplanes. The pilot had logged 206.5 hours in turboprop airplanes, of which 63.5 hours were in single-engine turboprop airplanes and 143.0 hours were in multiengine turboprop airplanes. The pilot had accumulated 109.3 hours in actual instrument conditions and 45.9 hours in simulated instrument conditions. The logbooks showed the pilot had flown 702.3 hours during the past year, 136.8 hours during the prior 90 days and 39.4 hours during previous 30 days. The pilot's first flight in a Pilatus PC-12/45 was logged on August 3, 2002, and he had logged 58.0 hours in the PC-12/45 as of the last logbook entry. On August 6, 2002, the pilot reported his flight times to the insurance company that provided coverage for the accident airplane. The pilot reported having 3,100 hours total flight experience, of which 2,800 hours were as pilot-in-command (PIC). He reported having 1,900 hours in single-engine airplanes and 1,200 hours in multiengine airplanes. He also reported having 600 hours in a turboprop airplanes and 100 hours in turbojet airplanes. He stated that he had accumulated 900 hours during the previous 12 months and 190 hours during the prior 90 days. The pilot reported his instrument experience included 250 hours in actual instrument conditions and 160 hours in simulated instrument conditions. The pilot reported the following flight times to the FAA when applying for previous medical certificates (total flight hours : hours during prior six months): September 05, 2002 (2,200 : 500) July 13, 2001 ( 960 : 100) July 24, 2000 ( 550 : 75) April 09, 1998 ( 12 : 12) The pilot obtained ground, simulator, and flight instruction from SimCom Training Centers, Orlando, Florida, between July 29, 2002, and August 4, 2002. According to the pilot's training records, he received 3.0 hours of instruction in the PC-12/45 airplane and 7.5 hours of instruction in a PC-12/45 flight training device. Portions of the pilot's flight records are included with the docket information associated with this factual report. AIRCRAFT INFORMATION The accident airplane was a Pilatus PC-12/45, serial number 425. The PC-12/45 is a single engine, turboprop, low-wing airplane. The PC-12/45 is equipped with a retractable tricycle landing gear and is powered by a single turboshaft engine. The fuselage and empennage is an all-metal semimonocoque design. The accident airplane was configured to seat six passengers and had two cockpit seats. The PC-12/45 has a certified maximum takeoff weight of 9,921 lbs and a maximum useful load of 4,454 lbs. The accident airplane was issued a standard airworthiness certificate on November 16, 2001. ## Aircraft - Registration: [N451ES](https://openairdocs.org/deregistered/N451ES-2012-11-13), registration cancelled 2012-11-13, S/N 425, built 2001 (OpenAirDocs) - Reported make and model: Pilatus PC-12/45 - Registry model: [Pilatus PC-12/45](https://openairdocs.org/model/pilatus-pc-12-45) (registry code 7090551) (OpenAirDocs) - Registry engine: [Pratt & Whitney Canada PT6A-67B](https://openairdocs.org/engine/pratt-whitney-canada-pt6a-67b) (registry code 52158, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 425 - Airframe hours: 505.4 - Engines: Pratt & Whitney Canada PT6A-67B 1200 horsepower turbo prop - Damage: Destroyed - Flight: Business, Part 91 - Registered owner: Pilatus Partners Ltd. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 26, 2002 - Departed: AIZ, Lake Ozark, MO - Destination: SBN, South Bend, IN - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 32; injuries: fatal; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; toxicology performed; flight hours: 1,645 total, 58 in this make and model, 137 in the last 90 days, 39 in the last 30 days ## Weather - Conditions: Instrument (IMC), Day - Wind: 310° at 8 knots - Visibility: 3 statute miles - Lowest ceiling: 2,100 ft broken - Temperature: 72 °F, dew point 70 °F - Altimeter: 29.92 inHg - Observed at: JEF, 14 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20020914024819A](https://openairdocs.org/incident/20020914024819A), Sep 14, 2002: Pilats PC1245, West Phalia, MO, Destroyed, 2 fatal. (-23) N451ES, was destroyed during a collision with the terrain near wesphalia, MO. Visual meteorological conditions (VMC) prevailed at the crash site at the… From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.