Beech B100 accident near Rapid City, South Dakota, June 15, 2009
On June 15, 2009 at about 10:52 pm local time, a Beech B100, registered N4490M, was involved in an accident during enroute (descent) near Rapid City, South Dakota. It was flown under charter and air-taxi rules (Part 135). 1 person was seriously injured and 4 people had minor injuries. The weather was visual conditions (good weather).
The NTSB's probable cause their words, unchanged
The flight crewmembers’ failure to secure the patient using the available over-the-shoulder restraints and the encounter with clear-air turbulence during cruise descent.
Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.
What the record shows
- Date
- June 15, 2009 · about 10:52 pm local time
- Place
- Rapid City, South Dakota · map
- Type
- Accident
- Injuries
- 1 person was seriously injured and 4 people had minor injuries.
- Weather
- visual conditions (good weather)
- Aircraft
- Beech B100 · all B100s on the register
- Registration
- N4490M · registry record · serial BE-64
- Damage
- Not recorded
- Flight
- Flight · charter and air-taxi rules (Part 135)
The NTSB's narrative final · quoted from the NTSB record
The air-ambulance flight encountered clear-air turbulence during cruise descent. During the turbulence encounter, the patient’s unrestrained upper-torso fell off the aircraft mounted stretcher assembly. After the turbulence had subsided, the patient’s unrestrained head, neck, and upper-torso were laying off the stretcher in the center aisle. His restrained lower body remained attached to the stretcher which was elevated off the cabin floor. The cabin flight crewmembers stabilized the patient’s neck before repositioning him back onto the stretcher. The airplane then made an uneventful landing at its intended destination. The patient suffered a fracture of the C3 cervical vertebra during the turbulence encounter. The stretcher’s available over-the-shoulder restraints were not used because of an interference caused by a flexible lift system that was used to transfer the patient from the ambulance gurney to the aircraft’s stretcher. After the accident the aeromedical transport company discontinued the use of the flexible patient lift system model used during the accident flight and required flight crewmembers to only use lift systems that allowed the use of the aircraft stretcher’s available over-the-shoulder restraints.
The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.
The factual record from the NTSB's investigation tables, in plain English
What happened, in order
- Aircraft loading event during prior to flight
- Clear air turbulence encounter during enroute (descent) defining event
The NTSB's findings
- cause Aircraft › Aircraft systems › Equipment/furnishings › Passenger compartment equip › Incorrect use/operation
- cause Personnel issues › Task performance › Use of equip/info › Use of equip/system › Flight crew
- cause Environmental issues › Conditions/weather/phenomena › Turbulence › Clear air turbulence › Effect on personnel
Pilot
- Certificate: airline transport pilot, flight instructor
- Ratings: multi-engine land; single-engine land; instructor: airplane multi-engine; instructor: airplane single-engine; instructor: instrument airplane; instrument: airplane
- Flight time: 3,305 hours in all; 516 in this make and model; 40 in the last 90 days; 1 in the last 30 days; 3,150 as pilot in command; 890 on instruments
- Last flight review: May 7, 2009
- Medical certificate: Class 2 (without waivers/limitations)
- Seat: left
- Injury: minor injuries
The aircraft
- Airframe total time: 9,898 hours
- Last inspection: approved inspection programme, May 12, 2009
- Maximum gross weight: 11,600 lb
- Seats: 6
- Landing gear: retractable
- Engine 1: Garrett Airesearch TPE-331 (turboprop); 0 hours total
- Engine 2: Garrett Airesearch TPE-331 (turboprop); 0 hours total
- Operator: Air Methods Corporation
The flight
- Departed from: KGRN Gordon NE at 10:19 pm
- Destination: KRAP Rapid City SD
- Flight plan: IFR
- A second pilot was aboard
Weather at the time
- Light: daylight
- Wind: from 360° at 10 knots
- Visibility: 10 statute miles
- Sky: clear
- Temperature: 66°F (19°C), dew point 50°F (10°C)
- Altimeter: 29.73 inHg
- Observation at 10:52 pm from KRAP, 10 miles away
Injuries
| Fatal | Serious | Minor | None | |
|---|---|---|---|---|
| Flight crew | 4 | |||
| Passengers | 1 |
Documents from the investigation the NTSB's docket: the evidence folder behind the report
The docket, the folder of records gathered during an investigation (maintenance records, photographs, witness statements, examinations), has not been read from the NTSB for this case yet; the list appears here once it has. Open the docket at the NTSB.
Everything on this page comes from the NTSB's public records. The narrative, probable cause and findings are the NTSB's own words; the coded tables behind the report are written out in plain English, with pilots' ages, home towns and medical details left out. The documents and photographs are the NTSB's docket, shown as the NTSB released them. This site's own text never names anyone involved. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.