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Accidents · NTSB WPR09MA159 · Final report

Pilatus PC-12/45 accident near Butte, Montana, March 22, 2009

On March 22, 2009 at about 8:30 pm local time, a Pilatus PC-12/45, registered N128CM, was substantially damaged in an accident during maneuvering near Butte, Montana (Bert Mooney Airport). It was a personal flight under general aviation rules (Part 91). 14 people were killed. The weather was visual conditions (good weather).

The NTSB's probable cause their words, unchanged

(1) the pilot's failure to ensure that a fuel system icing inhibitor was added to the fuel before the flights on the day of the accident; (2) his failure to take appropriate remedial actions after a low fuel pressure state (resulting from icing within the fuel system) and a lateral fuel imbalance developed, including diverting to a suitable airport before the fuel imbalance became extreme; and (3) a loss of control while the pilot was maneuvering the left wing-heavy airplane near the approach end of the runway.

Source: NTSB aviation accident database, copy made October 12, 2026. Docket and reports at the NTSB.

What the record shows

Date
March 22, 2009 · about 8:30 pm local time · cases in 2009
Place
Butte, Montana · Bert Mooney Airport · cases near this airport · map
Type
Accident
Injuries
14 people were killed.
Weather
visual conditions (good weather)
Aircraft
Pilatus PC-12/45 · all PC-12/45s on the register
Registration
N128CM · registry record · serial 403
Damage
Substantial damage
Flight
Personal flight · general aviation rules (Part 91)

The NTSB's narrative final · quoted from the NTSB record

The Safety Board's full report is available at http://www.ntsb.gov/investigations/reports_aviation.html. The Aircraft Accident Report number is NTSB/AAR-11-05. On March 22, 2009, about 1432 mountain daylight time, a Pilatus PC-12/45, N128CM, was diverting to Bert Mooney Airport (BTM), Butte, Montana, when it crashed about 2,100 feet west of runway 33 at BTM. The pilot and the 13 airplane passengers were fatally injured, and the airplane was substantially damaged by impact forces and a postcrash fire. The airplane was owned by Eagle Cap Leasing of Enterprise, Oregon, and was operating as a personal flight under the provisions of 14 Code of Federal Regulations Part 91. The flight departed Oroville Municipal Airport, Oroville, California, on an instrument flight rules flight plan with a destination of Gallatin Field, Bozeman, Montana. Visual meteorological conditions prevailed at the time of the accident.

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

  1. Aircraft servicing event during prior to flight
  2. Fuel related during enroute (cruise)
  3. Loss of control in flight during maneuvering defining event

The NTSB's findings

  • cause Personnel issues › Action/decision › Action › Lack of action › Pilot
  • cause Aircraft › Aircraft oper/perf/capability › Performance/control parameters › (general) › Not attained/maintained
  • cause Aircraft › Fluids/misc hardware › Fluids › Fuel additive › Not specified other cases naming the fuel system
  • Personnel issues › Task performance › Inspection › Preflight inspection › Pilot
  • Aircraft › Aircraft handling/service › Placards and markings › (general) › Not specified
  • Aircraft › Aircraft systems › Indicating/recording systems › (general) › Not specified other cases naming the instruments and avionics
  • Aircraft › Aircraft systems › Equipment/furnishings › Passenger compartment equip › Incorrect use/operation other cases naming the cabin, seats and restraints

Pilot

  • Certificate: airline transport pilot
  • Ratings: multi-engine land; single-engine land; instrument: airplane
  • Flight time: 8,840 hours in all; 1,759 in this make and model; 35 in the last 90 days; 10 in the last 30 days; 418 on instruments
  • Last flight review: January 9, 2009
  • Medical certificate: Class 2 (with waivers/limitations)
  • Seat: left
  • Injury: fatal

The aircraft

  • Airframe total time: 1,815 hours
  • Last inspection: annual inspection, October 9, 2008
  • Maximum gross weight: 9,921 lb
  • Seats: 10
  • Landing gear: retractable
  • Engine: P & W Canada PT6A-67B (turboprop); 0 hours total
  • Fire on the ground
  • Operator: Eagle Cap Leasing, Inc.

The flight

  • Departed from: KOVE Oroville CA at 7:10 pm
  • Destination: KBZN Bozeman MT
  • Flight plan: IFR
  • Runway 33, 9,001 ft by 150 ft

Weather at the time

  • Light: daylight
  • Wind: from 300° at 8 knots
  • Visibility: 10 statute miles
  • Sky: overcast at 8,000 ft; a few clouds at 4,400 ft
  • Temperature: 45°F (7°C), dew point 27°F (-3°C)
  • Altimeter: 30.00 inHg
  • Observation at 8:53 pm from KBTM

Injuries

FatalSeriousMinorNone
Flight crew1
Passengers13

Documents from the investigation the NTSB's docket: the evidence folder behind the report

78 documents, released by the NTSB on March 21, 2024. View them here, or download them; the NTSB redacts some personal details before release, and this site shows the NTSB's own titles rather than its file names.

#DocumentWhat it is
1 Summary Paragraph Errata PDF, 1 page View Download
2 Operations 2-FACTUAL Report of Group Chairman PDF, 27 pages View Download
3 Errata to Operations 2-FACTUAL Report of Group Chairman PDF, 1 page View Download
4 Operations 2-ATTACHMENT 1-FLIGHT Planning-flight Plans PDF, 5 pages View Download
5 Operations 2-ATTACHMENT 2-EAGLE Cap Leasing Corporation Document PDF, 4 pages View Download
6 Operations 2-ATTACHMENT 3-PC12 Limitations PDF, 7 pages View Download
7 Operations 2-ATTACHMENT 4-EMERGENCY Procedures-fuel System PDF, 3 pages View Download
8 Operations 2-ATTACHMENT 5-WEIGHT and Balance PDF, 17 pages View Download
9 Operations 2-ATTACHMENT 6-PC12 Systems PDF, 38 pages View Download
10 Operations 2-ATTACHMENT 7-FUELING Records PDF, 34 pages View Download
11 Operations 2-ATTACHMENT 8-FUEL Testing Documentation PDF, 3 pages View Download
12 Operations 2-ATTACHMENT 9-INTERVIEW Summaries PDF, 19 pages View Download
13 Operations 2-ATTACHMENT 10-PILOT Training Records PDF, 24 pages View Download
14 Operations 2-ATTACHMENT 11-PILOT'S Summary of Flight Hours and Resume PDF, 3 pages View Download
15 Operations 2-ATTACHMENT 12-VACAVILLE Vcb Airport Manager Statement PDF, 2 pages View Download
16 Operations 2-ATTACHMENT 13-RECORD of Conversation-bill Umberger PDF, 3 pages View Download
17 Operations 2-ATTACHMENT 14-RECORD of Conversation-randy Shares PDF, 2 pages View Download
18 Operations 2-ATTACHMENT 15-RECORD of Conversation-cisco Aguilera PDF, 2 pages View Download
19 Operations 2-ATTACHMENT 16-STATEMENT of Record-ron Cox PDF, 4 pages View Download
20 Operations 2-ATTACHMENT 17-RECORD of Conversation-jim Ott PDF, 2 pages View Download
21 Operations 2-ATTACHMENT 18-MEMO-VACAVILLE Refueling PDF, 2 pages View Download
22 Operations 2-ATTACHMENT 19-ALTERNATE Airport Information PDF, 4 pages View Download
23 Operations 2-ATTACHMENT 20-ALTERNATE Airport Flight Track PDF, 16 pages View Download
24 Operations 2-ATTACHMENT 21-STATEMENT of Record-philip Ensley PDF, 2 pages View Download
25 Operations 2-ATTACHMENT 22-RECORD of Conversation-larry Jacento PDF, 2 pages View Download
26 Operations 2-ATTACHMENT 23-RECORD of Conversation-guy Yocum PDF, 2 pages View Download
27 Operations 2-ATTACHMENT 24-VIDEO Surveillance Review PDF, 3 pages View Download
28 ATC 3-FACTUAL Report of Group Chairman PDF, 15 pages View Download
29 ATC 3-ATTACHMENT 1-ATC Transcripts PDF, 15 pages View Download
30 ATC 3-ATTACHMENT 2-CONTROLLER Statements PDF, 9 pages View Download
31 ATC 3-ATTACHMENT 3 -atc Facility Record of Daily Operation PDF, 1 page View Download
32 ATC 3-ATTACHMENT 4-FLIGHT Progress Strips PDF, 1 page View Download
33 ATC 3-ATTACHMENT 5-FSS Controller Statements PDF, 3 pages View Download
34 ATC 3-ATTACHMENT 6-FSS Record of Daily Operation PDF, 1 page View Download
35 ATC 3-ATTACHMENT 7-FSS Audio Transcripts PDF, 10 pages View Download
36 ATC 3-ATTACHMENT 8-RADAR Ntap Data for Flight from Ove to Btm PDF, 16 pages View Download
37 ATC 3-ATTACHMENT 9-RADAR Ntap Data for Flight from Red to Ove PDF, 11 pages View Download
38 Witness 4-FACTUAL Report of Group Chairman PDF, 39 pages View Download
39 Witness 4-WITNESS 18 Statement Received 09-22-2009 PDF, 2 pages View Download
40 Meteorology 5-FACTUAL Report of Group Chairman PDF, 29 pages View Download
41 Airworthiness Factual Report of Group Chairman PDF, 48 pages View Download
42 Airworthiness Factual Report of Group Chairman-attachment 1-AHRS A Data-text text file View Download
43 Airworthiness Factual Report of Group Chairman-attachment 2-ATTACHMENT 2 Bfu Concise Engineering Report-cacu Data PDF, 7 pages View Download
44 Airworthiness Factual Report of Group Chairman-attachment 3-CACU Data-tabular text file View Download
45 Airworthiness Factual Report of Group Chairman-attachment 4-NON-VOLATILE Memory Data Study PDF, 10 pages View Download
46 Airworthiness Factual Report of Group Chairman-attachment 4-NON-VOLATILE Memory Data Study-errata SHEET-1 PDF, 2 pages View Download
47 Airworthiness Factual Report of Group Chairman-attachment 4-NON-VOLATILE Memory Data Study-addendum 1 PDF, 7 pages View Download
48 Airworthiness Factual Report of Group Chairman-attachment 5-ATTACHMENT 5 Eis Data-tabular text file View Download
49 Airworthiness Group Chairman's Factual Report-addendum 1 PDF, 17 pages View Download
50 Airworthiness Factual Report of Group Chairman-addendum 1-ATTACHMENT 1-EXEMPLAR Single Engine Turbo-propeller Powe PDF, 2 pages View Download
51 Airworthiness Factual Report of Group Chairman-addendum 1-ATTACHMENT 2-COLD Test with Excess Water Report Crane D PDF, 37 pages View Download
52 Airworthiness Factual Report of Group Chairman-addendum 1-ATTACHMENT 3-FLIGHTS 1557 1558 and 1559 Fuel Consumpti PDF, 20 pages View Download
53 Airworthiness Factual Report of Group Chairman-addendum 1-ATTACHMENT 4-PILATUS Service Bulletin 28-008 and Crane S PDF, 11 pages View Download
54 Airworthiness Factual Report of Group Chairman-addendum 2 PDF, 3 pages View Download
55 Airworthiness Factual Report of Group Chairman-addendum 3- PDF, 2 pages View Download
56 Airworthiness Group Chairman's Factual Report-additional INFORMATION_N666M Event Documentation PDF, 18 pages View Download
57 Aircraft Performance 13-AIRPLANE Performance Study PDF, 7 pages View Download
58 Survival Factors 6-SPECIALIST Factual Report PDF, 3 pages View Download
59 Survival Factors 6-ATTACHMENT 1 Fom Section 6 PDF, 2 pages View Download
60 Survival Factors 6-ATTACHMENT 2 Preamble to 1971 Seatbelt Rule PDF, 3 pages View Download
61 Survival Factors 6-ATTACHMENT 3 FAA Legal Interpretation 1990-14 PDF, 2 pages View Download
62 Survival Factors 6-ATTACHMENT 4 FAA Report AM-400-91-2 PDF, 5 pages View Download
63 Materials Laboratory 15-FACTUAL Report 10-005 PDF, 22 pages View Download
64 Pilot-operator Aircraft Accident Report NTSB Form 61201 PDF, 10 pages View Download
65 Comments from Swiss Accredited Representative and Technical Advisors PDF, 5 pages View Download
66 Statement of Party Representatives to NTSB Investigation PDF, 6 pages View Download
67 Retention-release of Wreckage Form PDF, 1 page View Download
68 Toxicological Report PDF, 2 pages View Download
69 Fuel Checklist REV5 PDF, 2 pages View Download
70 Fuel Checklist REV6 PDF, 5 pages View Download
71 NTSB Response to Petition for Reconsideration PDF, 48 pages View Download
72 NTSB - Adopted Board Report - Original PDF, 92 pages View Download
73 NTSB - Adopted Board Report - Revised Pages 4/17/2023 PDF, 8 pages View Download
74 Petition for Reconsideration PDF, 55 pages View Download
75 Petition for Reconsideration - Supplement PDF, 38 pages View Download
76 Petition for Reconsideration - Attachment PDF, 50 pages View Download
77 Party Comments on Petition for Reconsideration - Crane Company PDF, 38 pages View Download
78 Party Comments on Petition for Reconsideration - Pilatus Aircraft Ltd. PDF, 129 pages View Download

The same docket at the NTSB · documents without a copy here are fetched from the NTSB when you open them.

Connections how this case links to the rest of the register

Aircraft
  • N128CM on the register today · the tail number may have moved to another aircraft since
  • Pilatus PC-12 1,445 registered today · the model family and its accident history
  • Pilatus 403 aircraft on the register
  • Engine: P & W Canada PT6A-67B · as the NTSB recorded it
Place

The whole map of how records connect · these connections as data: /graph/accident/WPR09MA159.json.

The bigger picture in Aviation Analytics: accidents over time since 1982, by model, by phase of flight and conditions, by place and on the map.

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 does not name anyone involved, its policy at this time. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.