Tuesday, June 10, 2025

Air Tractor AT-502, N45113, accident occurred on June 5, 2025, near Jonesboro, Arkansas

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed.

https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/200287/pdf

https://registry.faa.gov/AircraftInquiry/Search/NNumberResult?nNumberTxt=N45113

Housley Boyz Flying Service Inc

NTSB CEN25LA200 (the text is not from the preliminary)

On June 5, 2025, at about 1837 local time, an Air Tractor AT-502, N45113, registered to Housley Boyz Flying Service Inc out of Jonesboro, AR, and being operated by Over and Under Flying Service out of Madison, Indiana, sustained substantial damage when it was involved in an accident near Jonesboro, Arkansas. The pilot sustained serious injuries. The airplane was operated as an agricultural flight conducted under the provisions of Title 14 Code of Federal Regulations Part 137.


The FAA reported that the aircraft lost control on takeoff due to a gust of wind.

Yakovlev Yak-50, N150YK, accident occurred on June 7, 2025, at Hayward Executive Airport (HWD/KHWD), Hayward, California

 This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed.

https://registry.faa.gov/AircraftInquiry/Search/NNumberResult?nNumberTxt=N150YK

BPM Yak-50 LLC

NTSB WPR25LA171 (this is not the preliminary)

Figure 1: ADS-B Exchange

On June 7, 2025, at about 1252 local time, a Yakovlev Yak-50, N150YK, registered to BPM Yak-50 LLC out of Wilmington, Delaware, sustained substantial damage when it was involved in an accident at Hayward Executive Airport (HWD/KHWD), Hayward, California. The pilot received minor injuries.. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.


The FAA reported that the airplane experienced engine issues at 30 feet agl, made right 180 turn and crashed on the runway.


According to ADS-B data, the airplane was departing runway 28L and made it about 2,800 ft down the 5,694 ft runway before it conducted a 180 turn from an altitude of 100 ft and crashed next to taxiway E.


According to the FAA registry, the airplane was powered by an Aeromotors M-14PFXDK reciprocating engine.

Lancair 235, N25DB, accident occurred on June 7, 2025, in Pawhuska, Oklahoma

 This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed.

https://registry.faa.gov/AircraftInquiry/Search/NNumberResult?nNumberTxt=N25DB

NTSB CEN25LA201 (this is not the preliminary)

On June 7, 2025, at about 1528 local time, a Lancair 235, N25DB, registered to a private individual out of White Heath, Illinois, sustained substantial damage when it was involved in a gear-up landing in Pawhuska, Oklahoma. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.


Most likely occurred at Pawhuska Municipal Airport (H76), but no ADS-B data or news coverage is available.

Cessna 182P Skylane, N7376N, accident occurred on June 8, 2025, at Mineral Wells Airport (MWL/KMWL), Mineral Wells, Texas

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed.

https://registry.faa.gov/AircraftInquiry/Search/NNumberResult?nNumberTxt=N7376N

LKW Ventures LLC

NTSB CEN25LA199 (this is not the preliminary)

Figure 1: ADS-B Exchange

On June 8, 2025, at about 1640 local time, a Cessna 182P Skylane, N7376N, registered to LKW Ventures LLC out of Montgomery, Texas, sustained substantial damage when it crashed on takeoff from Mineral Wells Airport (MWL/KMWL), Mineral Wells, Texas. The pilot and three passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.


ADS-B data shows that the airplane accelerated to about 70 knots groundspeed on departure from runway 13 when it veered off the right side.


- Weather:

METAR KMWL 082306Z AUTO 17010KT 10SM CLR 33/26 A2977 RMK AO2 LTG DSNT SE AND S T03280256 

METAR KMWL 082353Z AUTO 17007KT 10SM CLR 29/21 A2975 RMK AO2 SLP061 60000 T02940211 10350 20294 58012

Monday, June 09, 2025

Cessna 414, N414BA, fatal accident occurred on June 8, 2025, near San Diego, California:

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed.

https://registry.faa.gov/AircraftInquiry/Search/NNumberResult?nNumberTxt=N414BA

Optimal Health Systems LLC

- History of Flight:

On June 8, 2025, at about 1230 local time, a Cessna 414, N414BA, was destroyed when it impacted the ocean shortly after takeoff from San Diego International Airport (SAN/KSAN), San Diego, California. The pilot and five passengers sustained fatal injuries. The aircraft was registered to Optimal Health Systems LLC out of Pima, Arizona, and being operated by the pilot. The flight originated from KSAN, and was destined to the Phoenix-Sky Harbor International Airport (PHX/KPHX), Phoenix, Arizona.


According to preliminary flight-track history, on June 7, 2025, at about 1138 local time, the airplane departed Safford Regional Airport (SAD/KSAD), Safford, Arizona, on a flight to Phoenix. On the same day, at 1435 local time, the airplane departed Phoenix on a flight to San Diego. The airplane landed in San Diego at 1621. The accident flight was the return trip to Phoenix.


According to preliminary Automatic Dependent Surveillance–Broadcast data, at 1224 local time, the airplane departed runway 27 at KSAN and entered a climbing left turn to an altitude of 1,600 ft. (figure 1)

Figure 1: Flight Path (copyright ADS-B and Google Earth)

According to ATC communications, the KSAN tower asked the pilot to contact Socal departure. The pilot responded "Over to to Socal, 4BA." The pilot then said "Socal Departure, Cessna 414BA is with you at 1,000." The controller responded "N414BA, Socal Departure, radar contact." Then asked the pilot to turn left heading 180. The pilot responded "Left heading 180, 4BA." According to ADS-B data, the airplane did enter a left turn towards 180, but at the same time, it started a gradual descent from 1,600 ft. At 1227:44, the airplane descended to 1,500 ft while maintaining a 180 heading. A few seconds later, at 1227:56, the airplane began a climb to 1,800 ft while turning left towards the east. At about 1228:17, the airplane entered a descending left hand turn, which was followed by the pilot was being asked by the controller about his altitude, he responded "1000', 4BA." The controller immediately issued a low altitude alert and advised the pilot to climb and maintain 4,000 ft. The airplane descended as low as 200 ft.  At one point, the airplane had an average rate of -16,000 feet per minute (fpm). At about 1228:31, after reaching 200 ft, the airplane was able to recover and climb back to 1,500 ft (Figure 2). For the next minute, the flight path appeared to be stable, but at 1229:28, the airplane entered another descending left hand turn. At 1229:41, the airplane reached an altitude of 800 ft before recovering for a second time (Figure 3). It climbed to about 1800 ft, but at 1230:08, it entered a final descending left hand turn before it disappeared from radar over the ocean, about 2 miles west offshore. The last ADS-B return was recorded at 1230:23, the airplane was at 500 ft, 119 knots groundspeed, and descending 6400 feet per minute (fpm). (Figure 4)

Figure 2: First Dive (copyright Flysto)

Figure 3: Second Dive (copyright Flysto)

Figure 4: Last ADS-B Return (copyright Flysto)

After the first dive, the controller asked the pilot if he needed any assistance. The pilot replied "Affirm, if I could get...", the controller asked the pilot "N414BA what seems to be the issue?" The pilot replied "Uhh just struggling right now to maintain heading and climb." The controller then said "N414BA, you're struggling to maintain altitude and headings. Maintain as high as you can for now, at least above 2,000." The pilot replied "Maintain above 2,000', 4BA." The controller then suggested the following "N414BA, The closest airport I can get you to is North Island Airport, which is off to your left in like 1 mile. Do you see that?" The pilot replied "Negative, 4BA." The controller then made another suggestion "N414BA, there is an airport off of your east side, east side, and about three miles is a criss-cross runway. It's North Island and it is your closest airfield." A few seconds later, the pilot sent 4 mayday calls in a panicked voice. This was the last transmission from the plane. The controller then said "N414BA, If you see North Island, you're cleared to land. 4BA, if you see the airport, you are cleared to land." and "4BA, approach... 4BA, low altitude alert. Climb immediately. 4BA, radar contact lost 6 southwest of San Diego airport."


A witness, who was surfing senset cliffs near the accident reported that the airplane "went in at full throttle." Another witness stated "I saw him come down at angle. He wasn't flying straight to the ground. The next time he came out of the clouds, he went straight into the water. Full throttle."


Figure 5 shows the vertical speed profile for the accident flight, highlighted point was during the initial dive to 200 ft.


Figure 6 shows the speed profile for the accident flight.

Figure 5: Vertical Speed Profile (coypright Flysto)

Figure 6: Speed Profile (copyright Flysto)

- Pilot Info:

Non known at the moment.


- Aircraft Info:

(Accident Aircraft, copyright aircraft.com)

The airplane was a 1970 Cessna 414, serial number 414-0047. Two Continental TSIO-520-J engines provided thrust through constant-speed, three-blade, McCauley 3AF32C93-NR propellers, rated at 285 HP. The low-wing airplane was of conventional aluminum construction, was equipped with a retractable tricycle landing gear, and had a pressurized cabin that was configured to seat six people. The airplane was equipped for night operations in IMC conditions.

(Cockpit, copyright aircraft.com)

According to a sale listing of the aircraft, the airframe had accumulated a total service time of 9508.0 hours.


At the time of the listing, the left engine had accumulated a total service time of 3,915.3 hours since new and 1,953.6 hours since being overhauled on March 2008. The left propeller had accumulated 1,779 hours since being overhauled on March 2017. 


At the time of the listing, the right engine had accumulated a total service time of 3669.4 hours since new and 1,072.9 hours since being overhauled on May 2009. The right propeller had accumulated 2,157 hours since being overhauled on March 2017.


The current registered operator, stated that the airplane was sold to a private individual in 2023, which suggests the FAA registry is outdated.


- Wrecakge and Impact Information:

The wreckage has not been located at the time of this writing.


- Airport

San Diego International Airport was located about 2 miles west of San Diego, California. It had one paved landing surface for airplanes which was designated as 9/27. The airport had an air traffic control tower that operated 24-hours a day.


According to the FAA Chart Supplements, runway 9/27 was a 9,401-foot-long and 200-foot-wide, grooved, asphalt, and concrete runway. Runway 27 was equipped with 4-light PAPI system and had 7,591 ft of runway available for landing and 9,401 ft available for takeoff. The runway had an 1,810-foot displaced threshold.


- Weather:

- (1) Brief:

The nearest recorded weather at KNUC, at 1220 (about 10 minutes before the accident), included: winds 300 at 7 knots, 10 miles visibility, an overcast layer (OVC) 1500ft AGL, temperature: 19°C, dewpoint 14°C, and an altimeter setting of 30.00 inches of mercury.


Another nearby weather recording station at KNZY, at 1243 (about 13 minutes after the accident), included: winds 310 at 10 knots, 10 miles visibility, an overcast layer (OVC) 1500ft AGL, temperature: 19°C, dewpoint 14°C, and an altimeter setting of 29.97 inches of mercury.


- (2) METARs:

METAR KSAN 081851Z 28006KT 10SM OVC013 18/14 A3001 RMK AO2 SLP161 T01830144 $

METAR KSAN 081920Z 30007KT 10SM OVC015 19/14 A3000 RMK AO2 T01890144 $

METAR KSAN 081951Z 29007KT 10SM OVC015 19/15 A2999 RMK AO2 SLP156 T01890150 $

METAR KSAN 082026Z 29008KT 10SM OVC015 19/14 A2998 RMK AO2 T01940144 $


METAR KNZY 081852Z 32009KT 10SM OVC010 18/14 A2999 RMK AO2 SLP154 T01780144

METAR KNZY 081943Z 31010KT 10SM OVC015 19/14 A2997 RMK AO2 T01890144

METAR KNZY 081952Z 31009KT 10SM OVC015 19/14 A2997 RMK AO2 SLP149 T01890144

METAR KNZY 082052Z 29009KT 10SM BKN015 19/14 A2996 RMK AO2 SLP144 T01890144 58012


- (3) Area Forecast Discussion:

  • According to the NWS Area Forecast Discussion for San Diego at 900 AM PDT on Sun Jun 8 2025:

Area Forecast Discussion
National Weather Service San Diego CA
900 AM PDT Sun Jun 8 2025

.SYNOPSIS...
The warming trend sets in through midweek, peaking Monday through
Wednesday for inland areas, before a slow cooldown towards the
end of the week. The marine layer becomes shallower through mid
week with night and morning low clouds for the coastal areas and
western valleys.

&&

.DISCUSSION...FOR EXTREME SOUTHWESTERN CALIFORNIA INCLUDING ORANGE...
SAN DIEGO...WESTERN RIVERSIDE AND SOUTHWESTERN SAN BERNARDINO
COUNTIES...

.UPDATE...
No meaningful shift in the forecast from the previous package. The
deep marine layer is quickly eroding from inland areas and will
filter to the coast through the morning. Some light patchy drizzle
was observed this morning, but increasing heights in the coming
days will favor a shallower marine layer with limited drizzle
potential. Still, the marine layer will persist across the coastal
areas each morning, limiting heating while the deserts warm with
the thermal ridge axis displaced to the east. Confidence has
decreased on exceeding 110F in the lower deserts and Coachella
Valley on Tuesday, but conditions remain favorable for
temperatures at least 5-10 degrees above normal for eastern areas
Monday through Wednesday.

.PREVIOUS FORECAST FROM 247 AM...
Marine layer low clouds are slowly making their way into the
Inland Empire with clear skies elsewhere. The marine layer is more
shallow than last night with a cloud deck that is not quite as
thick, limiting the potential for drizzle this morning. Clearing
will be a struggle for the coastal areas, especially in San Diego
County where the gloom is likely to persist through the day.

An upper level ridge of high pressure tries to build in from the
south today, though the closed upper low slowly inches eastwards
towards the Central/So Cal coast. A few degrees of warming is
expected for inland areas, with generally little change closer to
the coast as the persistent marine layer keeps temps down. 00Z
deterministic models, supported by about 70% of the global
ensemble members, show the forecast track of the upper low has
shifted further south as it digs into southeast CA on Monday with
the upper ridge amplifying off the coast. Latest NBM runs have not
caught on to this shift yet, but if it holds it could result in
less warming on Monday than originally thought. The struggle
continues into Tuesday and possibly even Wednesday as there are
hints of a gulf surge into the lower deserts both days. This
added moisture could dampen heating by about 5 degrees in those
areas should the surge occur and moisture doesn`t mix out early in
the day. If the moisture doesn`t materialize, the building ridge
could easily produce temperatures near 110 in the lower deserts.
Confidence is much higher in continued warming for inland areas
Tuesday and Wednesday as the upper ridge strengthens.

An upper level trough slowly amplifies off the West Coast for the
latter half of the week, though the trend has been towards this
trough being positioned further west and forcing a strengthening
upper ridge near the Four Corners region, with So Cal under dry
southwesterly flow wedged between the two. The result is slower
and less noticeable cooling with only subtle changes in the
marine layer depth Thursday through next weekend.

&&

.AVIATION...
081600Z....Coast/Valleys...OVC low clouds with bases 500-1200 ft MSL
have filled in much of the coastal basin. Low clouds will clear
inland areas through 18z, with partial and intermittent clearing for
coastal areas this afternoon. Low clouds slowly push inland again
after 00z Monday. Patchy cig coverage expected to reach portions of
the Inland Empire 09-12Z Mon. Bases tonight into Mon AM are expected
to be 500-1200 ft MSL, with vis restrictions 2-4 SM in patchy FG for
elevated inland valleys.

Mountains/Deserts...Mostly clear skies and unrestricted VIS
through tonight.

  • According to the NWS Area Forecast Discussion for San Diego at 112 PM PDT on Sun Jun 8 2025:
  • Area Forecast Discussion
    National Weather Service San Diego CA
    112 PM PDT Sun Jun 8 2025
    
    .SYNOPSIS...
    A warming trend sets in through midweek, peaking Tuesday and
    Wednesday for inland and desert areas, before a very slight
    cooldown towards the end of the week. Above normal temperatures
    may return by the weekend. The marine layer becomes shallower
    through mid week with night and morning low clouds for the coastal
    areas and western valleys.
    
    &&
    
    .DISCUSSION...FOR EXTREME SOUTHWESTERN CALIFORNIA INCLUDING ORANGE...
    SAN DIEGO...WESTERN RIVERSIDE AND SOUTHWESTERN SAN BERNARDINO
    COUNTIES...
    
    The marine layer made it sufficiently inland this morning but
    continues to burn off quickly with a slightly shallower marine layer
    poised to push inland again tonight, persisting through at least mid
    week. Water vapor imagery currently shows an upper level low moving
    into Central California while high pressure amplifies off the
    coast of Baja. As the low moves into California today, it becomes
    an open trough and sweeps down into western Arizona on Monday,
    limiting the influence of the ridge to the southwest. As such,
    high temperatures on Monday look similar to highs today, with only
    slight warming by a degree or two for the deserts and Coachella
    Valley.
    
    Tuesday through Thursday, the ridge shifts slightly northeast and a
    quick warm up ensues for nearly all locations east of the coasts.
    One noticeable change in the models compared to previous runs is the
    indication of some gulf moisture trying to sneak up into the deserts
    and Coachella Valley on Tuesday and moreso on Wednesday, which
    would severely limit the warming potential there. Should this
    occur, highs in the low deserts and Coachella valley may be cooler
    by around 3-7 degrees compared to the current forecasted highs
    for both Tuesday and Wednesday. At this point, chances of
    exceeding 105F in the Coachella Valley on Tuesday are around 70%
    while the chance for exceeding 110F is around 40%. Elsewhere, the
    shift of the high to the north has encouraged significant heating
    over the previous forecast, with highs for many spots in the
    Inland Empire now expected to be well over 90F, with around a 60%
    chance of hitting or exceeding 95F both Tuesday and Wednesday for
    locations like San Bernardino and Hemet. For the coastal regions,
    a shallower marine layer would support a slightly quicker burn off
    and warmer afternoons, but at this point the moderate onshore
    flow looks to help it persist along the direct coast through at
    least mid week, helping hold temperatures near normal for mid June
    while other locations heat up.
    
    There is still strong agreement between the global models with an
    upper low transversing south along the Canadian coastline, breaking
    down the ridge and zonal flow aloft settles in over the region.
    Newest guidance slows down this low and shifts the high into Baja
    late week and eventually into the Four Corners this weekend, with
    weak ridging over SoCal for the end of the week and stronger
    ridging for the weekend. Currently, ensemble members support this
    pattern compared to the more aggressive troughing, and this would
    prevent much cooling off for inland areas and the deserts through
    the end of the week. Should this pan out, there may be more
    stagnant temperatures or only a slight cooldown into the end of
    the week with a quick warm up this weekend. There remains a lot of
    uncertainty with the placement of the high as well as the
    Canadian low, but have generally adjusted temperatures to match
    this warmer solution in the long term.
    
    &&
    
    .AVIATION...
    082000Z....Coast/Valleys...OVC low clouds with bases 1200-2000 ft
    MSL will linger along the immediate coast through the afternoon with
    only partial and intermittent clearing. Clear skies will prevail in
    the valleys. Low clouds slowly push inland again after 00z Mon.
    Patchy cig coverage expected to reach portions of the Inland Empire
    09-12Z Mon. Bases tonight into Mon AM are expected to be 500-1200 ft
    MSL, with vis restrictions 2-4 SM in patchy FG for elevated inland
    valleys. Low clouds expected to clear to the coast 16-18Z Mon, with
    partial and intermittent clearing expected again along the immediate
    coast Mon afternoon.
    
    Mountains/Deserts...Mostly clear skies and unrestricted VIS
    through Monday.

    - Additional Info:

    NONE

    Sunday, June 08, 2025

    Loss of engine power (total): Cessna 177 Cardinal, N3268T, accident occurred on May 18, 2024, near Selma, Alabama

    https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/194288/pdf

    https://data.ntsb.gov/Docket?ProjectID=194288

    https://registry.faa.gov/AircraftInquiry/Search/NNumberResult?NNumberTxt=3268T

    • Location: Selma, Alabama 
    • Accident Number: ERA24LA222 
    • Date & Time: May 18, 2024, 21:15 Local 
    • Registration: N3268T 
    • Aircraft: Cessna 177 
    • Aircraft Damage: Substantial 
    • Defining Event: Loss of engine power (total) 
    • Injuries: 1 Serious 
    • Flight Conducted Under: Part 91: General aviation - Personal

    On May 18, 2024, at 2115 eastern daylight time, a Cessna 177, N3268T, was substantially damaged when it was involved in an accident near Selma, Alabama. The commercial pilot was seriously injured. The personal flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91.


    The pilot reported that a preflight inspection revealed no anomalies, and he subsequently departed on a night cross-country flight. While in cruise flight at an altitude of 3,500 ft, he noticed a sudden drop in oil pressure, declared an emergency with air traffic control, and diverted to a nearby airport. While enroute to the diversion airport, the engine began running roughly and oil leaked into the cabin. When the pilot was unable to activate the runway lights at the diversion airport he aborted the landing approach and chose to divert to another airport; however, enroute to the second airport, the engine lost total power, and the airplane impacted terrain about 2.5 miles from the runway.


    Postaccident examination of the engine revealed that the No. 4 piston was seized in its cylinder and its connecting rod had separated from the crankshaft. In addition to the crankshaft’s No. 4 throw bearing, main bearings Nos. 2 and 3 also exhibited features consistent with oil starvation. The engine’s oil pump was undamaged and displayed no abnormal operating signatures. An unquantified amount of oil was found on the underside of the airplane’s fuselage, within the engine cowling, and remaining with the engine’s impactdamaged oil sump. Based on the pilot’s initial description that the engine had lost oil pressure during the flight, and the damage signatures observed that were consistent with oil starvation, it is likely that the loss of engine power was due to insufficient lubrication to the engine’s internal components. The reason for the oil starvation could not be determined.


    - Probable Cause: Insufficient lubrication of the engine’s internal components, which resulted in a total loss of engine power.

    Loss of control in flight: Pilatus PC-12/45, N273SM, fatal accident occurred on February 24, 2023, near Stagecoach, Nevada

    https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106784/pdf

    https://data.ntsb.gov/Docket?ProjectID=106784

    https://registry.faa.gov/AircraftInquiry/Search/NNumberResult?nNumberTxt=N273SM

    Guardian Flight LLC dba Care Flight

    • Location: Stagecoach, Nevada 
    • Accident Number: WPR23MA113 
    • Date & Time: February 24, 2023, 21:14 Local 
    • Registration: N273SM Aircraft: Pilatus PC-12/45 
    • Aircraft Damage: Substantial 
    • Defining Event: Loss of control in flight 
    • Injuries: 5 Fatal 
    • Flight Conducted Under: Part 135: Air taxi & commuter - Non-scheduled - Air Medical (Discretionary)

    On February 24, 2023, about 2114 Pacific standard time, a Pilatus PC-12/45, N273SM, was substantially damaged when it was involved in an accident near Stagecoach, Nevada. The pilot, flight paramedic, flight nurse, and two passengers were fatally injured. The airplane was operated by Guardian Flight, LLC dba Care Flight under the provisions of Title 14 Code of Federal Regulations (CFR) Part 135.


    The pilot, two medical crew members, and two passengers departed on the medical transport flight, which was operating on an instrument flight rules (IFR) flight plan in night instrument meteorological conditions (IMC). Onboard data and ADS-B flight track information showed that, between 1 and 3 minutes after takeoff, the autopilot disengaged and then reengaged; however, the airplane continued to fly a course consistent with the published departure procedure. About 11 minutes after takeoff, the airplane turned about 90° right, away from the next waypoint along the departure procedure, and remained on that heading for about 47 seconds. Around this time, the airplane’s autopilot was disengaged again and was not reengaged for the remainder of the flight. Also, about this time, the airplane’s previously consistent climb rate stopped, and the airplane maintained an altitude of about 18,300 ft mean sea level (msl) for about 20 seconds, even though the pilot had been cleared to climb to 25,000 ft msl. The airplane subsequently turned left to a northeasterly heading and climbed to about 19,400 ft msl before entering a descending right turn. Shortly after entering the right turn, the airplane’s rate of descent increased from about 1,800 ft per minute (fpm) to about 13,000 fpm, and the rate of turn increased before ADS-B tracking information was lost at an altitude of about 11,100 ft msl, in the vicinity of the accident site.


    The distribution of the wreckage at the accident site was consistent with a low-altitude in-flight breakup. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation, and data obtained from onboard recording devices showed that the engine was developing power at the time of impact. Postaccident examination of the autopilot, trim servos, and trim actuators did not reveal any evidence of mechanical malfunction or failures that would have precluded normal operation.


    Recorded weather conditions at the departure airport about the time of departure included 1 ¾ statute miles visibility and a cloud ceiling 1,700 ft above ground level (agl). The departure airport and surrounding areas had been impacted by significant winter weather throughout the day of the accident, and the pilot who was on call for the accident operator earlier that day turned down a flight request due to the weather conditions. Another air medical operator, who operated the same make and model airplane as the accident airplane, also turned down a request for a flight in the area due to the low visibility, turbulence, and icing conditions.


    The accident airplane was equipped for flight into known icing conditions. Review of weather information indicated that the airplane was likely operating in IMC above 6,000 ft msl, and likely did not accumulate much, if any, structural icing.  Icing conditions would have been present between 5,000 and 10,000 ft msl. Although turbulence was likely present in the area, there was no evidence to support that the accident airplane encountered hazardous turbulence during the flight.


    The airplane was equipped with several sources of recorded data, including a central advisory and warning system (CAWS) computer. The CAWS computer, which captured autopilot status, among other parameters, was significantly impact damaged and missing one of the memory chips that stored time information; therefore, the two autopilot disengagements could only be identified as occurring in two-minute windows after elapsed takeoff time, with the first about 1 to 3 minutes after takeoff, and the second between about 2 and 4 minutes before the accident. There are several ways in which the autopilot could have been automatically or manually disengaged during the accident flight; however, based on the available CAWS data and examination of the airplane and system components, the reason for the two autopilot disengagements during the accident flight could not be determined.


    Following the second autopilot disengagement, the pilot would have been required to manually maintain control of the airplane while operating in IMC, which increased his susceptibility to spatial disorientation. The airplane’s subsequent flight path was consistent with a phenomenon known as a “graveyard spiral,” a sensory illusion in which a pilot believes they are flying in a wings-level descent; however, the airplane is actually in a descending turn. Attempts to arrest the descent by pulling back on the control yoke have the effect of tightening the turn and losing altitude at an increasing rate until the airplane’s structural limits are exceeded, resulting in an in-flight breakup, or until the airplane impacts the ground. Graveyard spirals are most common at night or in poor weather conditions where no horizon exists to provide a visual reference to correct misleading inner-ear cues.


    Autopsy of the pilot revealed a 3 cm fibroblastic meningioma (tumor) in the right parietal section of the brain. The parietal lobe is one of the four major components of the cerebral cortex and has a primary role in the integration of sensory information, including spatial and navigational information. The parietal lobe is also primarily responsible for the integration of visual and vestibular information. The presence and location of the tumor may have impacted the pilot’s ability to synthesize and respond to sensory interpretation from the conditions under which he was flying; however, it is also possible that the tumor may have been an incidental finding without any significant symptoms, and the pilot’s next of kin indicated no changes in his behavior or health before the accident. Based on the available information, whether the effects of the pilot’s undiagnosed brain tumor contributed to the accident could not be determined.


    The accident pilot was not permanently assigned to the base from which the accident flight departed; rather, he was classified as a “float” pilot, who rotated across the operator’s bases throughout the country. The operator did not have any formal training or mentoring procedures in place to ensure that local area knowledge was passed along to pilots new to a specific operating area; the investigation was unable to establish the pilot’s experience operating in night IMC over mountainous terrain. All three crewmembers of the accident flight were relatively new in their respective roles. The pilot was hired by the operator about five months before the accident, while both clinicians had been assigned to the airplane for about six months. The company’s website highlighted the “Three to say go, one to say no” protocol as a best practice among air ambulance providers that empowers any member of the flight team, for any reason, to raise a safety concern. For rotorcraft flights, the operator required that clinicians with less than one year of experience be paired with clinicians with more than one year of experience, a practice that leveraged the flight team’s collective experience to benefit flight safety. However, fixed-wing operations were not subject to this requirement.


    The operator’s procedures also required company dispatchers to inform flight crews if a flight had been turned down by another operator. Although the weather can change throughout the course of a given day, the fact that other pilots and operators turned down flights due to weather in the area on the day of the accident should have been relayed to both the pilot and medical crew as part of their decision-making process. However, review of communication logs did not indicate that the company’s dispatchers made the accident crew aware of the turndowns earlier on the day of the accident.


    The operator also required that a flight risk assessment be completed before each flight; however, no such assessment was located for the accident flight. Even if a risk assessment had been conducted, the crew’s relative inexperience, and lack of information about the earlier turndowns, increased the likelihood of a knowledge-based error during the risk assessment and decision-making process. That an inexperienced flight crew was permitted to accept the accident flight given the weather conditions and the previous flight turndowns with no additional approval demonstrated an insufficient risk assessment process and lack of organizational oversight. Another fatal accident involving the accident operator occurred 71 days before this accident; the investigation into that accident also revealed the lack of a preflight risk assessment.


    - Probable Cause: The pilot’s loss of control due to spatial disorientation while operating in night instrument meteorological conditions, which resulted in an in-flight breakup. Contributing to the accident was the disengagement of the autopilot for undetermined reasons, as well as the operator’s insufficient flight risk assessment process and lack of organizational oversight.