AAI_Project_Final_Draft

Departure of Controlled Flight
Pilatus PC‐12/47, N330SF
Lake Wales, Florida
October 28, 2012
Accident Report
NTSB/AAR-12/11
PB2012-910409

NTSB Aircraft Accident Report
ii
NTSB/AAR-12/11
PB2012-910409
Notation 8102A
Adopted November 27, 2012
Aircraft Accident Report
Departure of Controlled Flight
Pilatus PC-12/47, N330SF
Lake Wales, Florida
October 28, 2012

iii
Aircraft Accident Report written by:
Alex Lakes
Pit Probst
Rebekah Haba
Robin Buhler
Taylor Smith
Tovin Hewitt

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National Transportation Safety Board. 2012. Departed controlled Flight, Pilatus PC-12/47,
N330SF, Lake Wales, Florida. October 28, 2012. NTSB/AAR-12/11. Washington, DC.
Abstract: This accident report discusses the October 28, 2012, accident in which a
Pilatus PC-12/47, N330SF, was flying direct Gainesville (GNV) from Fort Pierce, Florida, when
it crashed near Lake Wales. The airplane was substantially damaged. The certificated private
pilot, a flight nurse, and four passengers were fatally injured. The fourth passenger was found
1.31 miles southwest of the crash site. The safety issues discussed in this report address flight
crews actions in response to adverse weather conditions, aircraft in-flight break up, and the
condition of the pilot during the flight. Safety recommendations concerning these issues are
addressed to the Federal Aviation Administration (FAA) and the company operating the flight,
American Air Ambulance Service.

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Contents
Abbreviations.................................................................................................................................. 7
Executive Summary........................................................................................................................ 9
1.0 Factual Information................................................................................................................... 1
1.1 History of the Flight.............................................................................................................. 1
1.2 Injuries to Persons................................................................................................................. 4
1.3 Damage to Airplane.............................................................................................................. 4
1.4 Other Damage....................................................................................................................... 4
1.5 Personnel Information........................................................................................................... 4
1.5.1 The Left-Seat Occupant................................................................................................. 4
1.5.2 72-Hour History............................................................................................................. 5
1.5.3 Witness Statement.......................................................................................................... 5
1.5.4 Background Witness Statement..................................................................................... 6
1.6 Aircraft Information.............................................................................................................. 6
1.6.1 Aircraft History.............................................................................................................. 6
1.6.2 Aircraft Fuel................................................................................................................... 7
1.6.3 Engine and Propeller...................................................................................................... 8
1.6.4 Instruments..................................................................................................................... 9
1.6.5 Airframe and Flight Controls....................................................................................... 10
1.6.6 Impact Information ...................................................................................................... 11
1.7 Weather Conditions ............................................................................................................ 11
1.7.1 Airport Weather ........................................................................................................... 12
1.7.2 Instrument Meteorological Conditions ........................................................................ 13
1.8 Aids to Navigation.............................................................................................................. 13
1.9 Communications ................................................................................................................. 13
1.10 Airport Information........................................................................................................... 13
1.10.1 St. Lucie County International Airport ...................................................................... 13
1.10.2 Gainesville Regional Airport ..................................................................................... 14
1.10.3 Airport Services ......................................................................................................... 14
1.10.4 Air Traffic Control..................................................................................................... 14
1.10.5 Air Traffic Communication ....................................................................................... 15
1.10.6 Radar Data ................................................................................................................. 15
1.11 Survival Aspects ............................................................................................................... 15

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1.12 Medical and Pathological Information.............................................................................. 15
1.13 Flight Operations .............................................................................................................. 15
2.0 Analysis................................................................................................................................... 17
2.1 General Analysis................................................................................................................. 17
2.2 The Accident Sequence....................................................................................................... 17
2.2.1 Possible Result of Flight Path...................................................................................... 18
2.3 Pilot Injuries........................................................................................................................ 18
2.4 The Effects of Controlled Substances on the Flight Crew.................................................. 18
2.4.1 Effects of Paroxetine.................................................................................................... 18
2.4.2 Effects of Alcohol........................................................................................................ 19
2.4.3 Combined Effects of Paroxetine and Alcohol ............................................................. 19
2.5 Flight Crew Currency Requirements .................................................................................. 19
2.5.1 CFR Part 61.113........................................................................................................... 20
2.5.2 CFR Part 135.243......................................................................................................... 20
2.5.3 CFR Part 135.4............................................................................................................. 21
2.6 Fuel Analysis ...................................................................................................................... 21
2.7 Engine Analysis .................................................................................................................. 21
2.8 Instrument Analysis ............................................................................................................ 22
2.9 Weather Analysis................................................................................................................ 22
2.10 Flight Operations Analysis ............................................................................................... 23
3.0 Conclusions............................................................................................................................. 24
3.1 Findings............................................................................................................................... 24
3.2 Probable Cause.................................................................................................................... 25
4.0 Recommendations................................................................................................................... 26
5.0 Appendices.............................................................................................................................. 27
Appendix A – Aircraft Accident Diagram................................................................................ 27
Appendix B – IFR flight Plan................................................................................................... 28
Appendix C – Record of Interview........................................................................................... 29
Appendix D – Background Statements..................................................................................... 30
Appendix E – Fort Pierce/St. Lucie County Intl (FPR) Airport Diagram ................................ 33
Appendix F – Gainesville Regional (GNV) Airport Diagram.................................................. 34
Appendix G – Aircraft Specifications....................................................................................... 35

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Abbreviations
AHRS Altitude and Heading Reference System
AOA Angle of Attack
ARTCC Air Route Traffic Control Center
ARSR Air Route Surveillance Radar
ATC Air Traffic Control
ATCT Air Traffic Control Tower
ATP Airline Transport Pilot
BKN ‘Broken’ 5-7 Oktas
CACU Caution Advisory Control Unit
CFR Code of Federal Regulations
CVR Cockpit Voice Recorder
DU Display Unit
EDT Eastern Daylight Time
EFIS Electronic Flight Instrument System
FAA Federal Aviation Administration
FBO Fixed-Base Operator
FDR Flight Data Recorder
FEW ‘Few’ 1-2 Oktas
FL Flight level
FPR St. Lucie County International Airport
FSDO Flight Standards District Office
FSI Flight Safety International
GNV Gainesville Regional Airport
IAW Initial Airworthiness/In accordance with
IFR Instrument Flight Rules
IFSD In-Flight Shut Downs
IHAS Integrated Hazard Awareness System
IMC Instrument meteorological conditions
KIAS knots indicated airspeed
KX07 Lake Wales Municipal Airport
MSL Mean Sea Level
MCS Mesoscale Convective System
MFD Multi-function display

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MVFR Marginal Visual Flight Rules
NTSB National Transportation Safety Board
NWS National Weather Service
OVC ‘Overcast’ 8 Oktas (Complete Coverage)
PIC Pilot in Command
PWC Pratt & Whitney Canada
RGB Reduction Gear Box
RPM Revolution per Minute
SCT Scattered 3-4 Oktas
SDA Service Difficulty Advisory
SIGMET Significant Meteorological Information

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Executive Summary
On October 28, 2012, about 1720 eastern daylight time, a Pilatus PC 12/47, operated by
American Air Ambulance Service departed controlled flight near Lake Wales, Florida and
crashed in a nearby field. The pilot, flight nurse and four passengers were killed in the crash; the
fourth passenger was found dead 1.31 miles southwest of the crash site. The aircraft was
destroyed on impact. Day instrument meteorological conditions with thunderstorms in the area
prevailed at the time of the accident.
The National Transportation Safety Board determined that the probable cause of the
accident was the pilot’s unfitness to operate the aircraft because of alcohol and drug use, which
caused him to be unable to make sound cockpit decisions. Contributing factors include (1) the
company’s failure to enforce pilot qualifications and certifications, (2) the pilot’s stressed state
before the flight, (3) his attitude towards hazardous weather flying, (4) his flight into instrument
meteorological conditions with embedded thunderstorms.
Safety issues addressed in this report include employee certification policies of American
Air Ambulance Service, communication between American Air Ambulance Service and the
FAA, FAA inspection and oversight of pilot certifications and the improvement of weather
briefings to increase pilot usage and comprehension.

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1.0 Factual Information
1.1 History of the Flight
On Sunday, October 28th
at approximately 17201
eastern daylight time, a Pilatus PC
12/47, N330SF, registered to and operated by American Air Ambulance Service, departed
controlled flight near Lake Wales, Florida. Instrument meteorological conditions prevailed at the
altitude and location of the departure from controlled flight, and an instrument flight rules (IFR)
flight plan was filed under 14 Code of Federal Regulations (CFR) Part 135 flight from St. Lucie
County International Airport (FPR), Fort Pierce, Florida, to Gainesville Regional Airport (GNV),
Gainesville, Florida.2
The airplane was substantially damaged. The certificated private pilot, a flight nurse, and
four passengers were fatally injured. The fourth passenger was found 1.31 miles southwest of the
crash site. The flight originated from FPR at about 1650.
Ramp personnel at FPR stated that when N330SF taxied out, there were six souls on
board: pilot, flight nurse, and four passengers. One of the passengers was in critical condition as
a result of a motorcycle accident and was being flown to Shands Hospital in Gainesville.
According to the Federal Aviation Administration (FAA) air traffic control information,
after departure, air traffic control communications were transferred to Miami Air Route Traffic
Control Center (Miami Center). While in contact with that facility, about 1650, the flight was
cleared to flight level (FL) 150. At about 1700, the controller cleared the flight to FL180, which
the pilot acknowledged. At about 1702 the controller advised the pilot of a large area of
precipitation northwest of Lakeland, with moderate, heavy and extreme echoes. The controller
asked the pilot to look at it and to advise what direction he needed to deviate, then suggested
deviation right of course until north of the adverse weather. The pilot responded that he agreed,
and the controller asked the pilot what heading from his position would keep the airplane clear,
and the pilot responded 320 degrees. The controller cleared the pilot to fly heading 320 degrees,
and to deviate right of course when necessary and, when able, proceed direct to Seminole, which
he acknowledged.
1
Unless otherwise indicated, all times are Eastern Daylight Time, based on a 24-hour clock.
2
The public docket for this accident (National Transportation Safety Board identification number CHI07MA160) is
available online at http://dmssvr/dms/public/search.

2
There was no further recorded communication between the pilot and Miami Center.
According to radar data, between 1702:37, and 1705:25, the airplane proceeded in a west-
northwesterly direction, and climbed from 15,000 feet to 17,000 feet, then maintained that
altitude for the next 45 seconds; however, a change in direction to the right was noted. Between
1708:37, and 1710:49, the airplane descended from 17,000 feet to 16,100 feet, and turned to the
right, and between 1712:49, and 1716:01, the airplane descended from 16,000 feet to 13,500 feet,
and continued the right turn. Between 1717:01 and 1718:37, the airplane descended from 15,000
feet to 8,500 feet, and turned to a southerly heading. Between 1720:07 and 1723:06, the airplane
turned left and proceeded on a northeasterly heading. At, 1725:55, the final secondary return was
recorded at 1,300 feet as the airplane continued on a northeasterly heading.
The pilot of a nearby airplane reported to FAA air traffic control and the NTSB that he
heard a Mayday call about 2 minutes before hearing the sound of an emergency locator
transmitter (ELT) signal.

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Figure 1. The accident airplane’s estimated route of flight based on air traffic position reports
and radar data.

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1.2 Injuries to Persons
The PIC, flight nurse, and four passengers were fatally injured.
Injuries Flight Crew Cabin Crew Passengers Other Total
Fatal 1 1 4* 0 6
Serious 0 0 0 0 0
Minor 0 0 0 0 0
None 0 0 0 0 0
Total 1 1 4 0 6
*The body of one passenger was located 1.31 miles southwest of the wreckage site.
1.3 Damage to Airplane
The airplane was substantially damaged by impact forces and post crash fire.
1.4 Other Damage
No other damage was reported.
1.5 Personnel Information
1.5.1 The Left-Seat Occupant
The pilot, age 57, held a private pilot certificate with ratings for airplane single and multi-
engine land, and instrument airplane. The private pilot certificate with airplane single engine
land rating was issued June 15, 2001, and the instrument rating was added to his private pilot
certificate on August 2, 2004. The multi-engine land rating was added on July 15, 2008. He was
last issued a third class medical certificate with no limitations on May 1, 2012.
According to the Vice President and General Counsel for Flight Safety International, the
pilot received training at their Orlando facility in a PC-12 airplane in 2008, 2009 and 2010. He
received training at their Savannah, Georgia, facility in a PC-12 airplane in August 2011.
A review of the records associated with the training in August 2011, revealed four flights
totaling 8.0 hours, conducted during the course of 3 days. The stick pusher system, Attitude and
Heading Reference System (AHRS), Electronic Flight Instrument System (EFIS) and flight
instruments review during the ground instruction each consisted of 25 minutes coverage. Failure
of the AHRS and unusual attitude recovery were each covered during separate flights; the result
for both was listed as satisfactory.

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Review of a pilot logbook that begins with an entry dated March 10, 2012, and a carry
forward time of approximately 469 hours, to the last entry dated October 8, 2012, revealed he
logged a total time of approximately 1,873 hours, of which approximately 1,050 were in turbine
powered aircraft. His first logged flight in the accident make and model airplane occurred on
December 18, 2008; he recorded accumulating approximately 820 hours in the accident make
and model airplane. Of the 820 hours in the accident make and model airplane, approximately
800 were as pilot-in-command. His last logged instrument proficiency check performed by Flight
Safety International occurred on January 22, 2012, and his last logged instrument flight was on
August 2, 2012. Recent instrument experience could not be determined based on entries in his
pilot logbook, though he did fly to Elizabeth City, NC in September of 2012.
1.5.2 72-Hour History
According to the wife of the pilot, most of October 26 was spent shopping for a
Halloween party the following week. She also stated they went to a movie later that evening.
She stated that Saturday, October 27 was spent visiting family in Miami and shopping at
Aventura Mall, followed by dinner. Guests of the restaurant are offered a bottle of wine with
their meal; the pilot’s wife stated that he refused because he was on call.
The day of the accident, October 28, started at 0730 with the pilot and his wife going for
breakfast. She stated that her husband was in a good mood because he was looking forward to
watching football that afternoon. She said he was a little worried on Saturday and Sunday
because he was on call and was hoping he would not be called. They got home around 1000,
where he began watching football on television, eating popcorn and drinking Coke Zero. She
stated that she offered him some beer, but he refused and said she was tempting him when she
knew he was on call. She stated that his phone rang at 1430, and he hurried to get his flight
equipment and was upset because he was going to miss the rest of the football game. She said he
told her something about a motorcycle accident and flying to Gainesville. Later she said he
called her from the airport, saying he would call her from Gainesville. She asked him about the
weather and he replied that the Pilatus was built to deal with a little weather (See appendix D for
complete statement).
1.5.3 Witness Statement
An eyewitness was contacted in relation to the accident involving American Air
Ambulance Service, Pilatus PC 12/47, N330SF on October 28, 2012. She stated that she lived
just under a mile from the property where the aircraft came to rest. She stated that she had
witnessed the accident, but did not know of anyone else who had. She stated that just prior to the
accident she was working on her classic Camaro in her garage. She stated that the weather was
nice earlier in the day, but had turned bad in the past few hours. She stated that there was a huge
thunderstorm in the area during the accident and that it was cloudy and windy, but no rain had
fallen yet. She stated that as she worked on her Camaro she heard a “loud boom” that she
thought was thunder; when she looked at the sky she saw a plane “dropping and spinning with no

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horizontal movement.” As she stated “horizontal movement” she held a model aircraft and
showed level flight. She stated that she did not notice any lights on the aircraft, fire coming from
the aircraft or parts/debris falling from the aircraft. However, she did notice a “huge, dark black
cloud of smoke coming from the back of the aircraft,” but she could not tell the exact location
where the cloud was coming from. She stated that the aircraft went behind the trees and she did
not see or hear the impact. She stated that she grabbed her ABC fire extinguisher and ran to the
crash site, where she was the first one on scene. She stated that she attempted to extinguish the
fire, which was located in the front of the aircraft, to no avail. She stated that the tail section was
completely separated from the aircraft from just behind the wings and that she noticed openings
in the fuselage that did not appear to be doors or windows; she stated that it was difficult to
describe. She stated that she did not hear anything coming from the aircraft, nor did she see
human bodies or remains. She stated that once firefighters arrived on scene she was cleared from
the area and that she had no further information.
1.5.4 Background Witness Statement
According to the fiancé of the flight nurse involved in the accident, she had expressed
concerns multiple times, concerning the pilot’s fitness to fly because of alcohol use.
1.6 Aircraft Information
1.6.1 Aircraft History
The aircraft, a 2007 built Pilatus PC-12/47 with the serial number 787 was registered
N330SF. It was equipped for medevac flights and was registered to and operated by American
Air Ambulance Service. The aircraft was equipped with a Pratt & Whitney PT6A-67B 1,000
maximum continuous horsepower engine and equipped with a five-bladed MT-Propeller. The
maintenance records revealed the aircraft was last inspected in accordance with an annual
inspection on February 14, 2012. The manufacturer’s maintenance manual states that at the time
of the annual inspection, the accident aircraft had accumulated 300.4 hours of total time. At the
time of the accident, the airframe had 496 hours and 188 cycles. The last pitot static and
altimeter testing were conducted on October 30, 2011 in accordance with (IAW) 14 CFR Part
91.411, and the last transponder test in accordance with 14 CFR Part 91.413. The pilot’s
altimeter was tested to 35,000 feet. The Flight Manual states the maximum operating altitude at
30,000 feet mean sea level and indicated airspeed at 236 knots. The aircraft was equipped with a
stall warning stick pusher system which utilizes angle of attack (AOA) vanes installed on the
leading edges of both wings.
The aircraft was equipped with Honeywell 5” EFIS 50 Pilot and Co-Pilot Displays which
display the aircraft attitude, heading, and other flight-related information.

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The BFG WX-500 Stormscope3
detects electrical discharges associated with
thunderstorms within a 200nm radius of the aircraft. This information is then sent to an external
multifunction display (MFD) which plots the location of the associated thunderstorms. This
information is updated every 2 seconds. The WSI Inflight Sat Weather4
provides the U.S.
Doppler Radar picture with an update every 5 minutes. The aircraft was also equipped with the
Honeywell RDR 2000 Weather Radar5
which is able to examine angle of cell's leading edge to
determine direction of movement, check "radar tops," and clearly distinguish between ground
and weather returns. It is fully stabilized to +/- 30 degrees combined pitch and roll. Four levels of
color with switchable ranges of 10, 20, 40, 80, 160 and 240 nm are available. The Horizontal
scan angle can be set to 100 degrees, vertical scan of 60 degrees. The output is 4.0 kw (rated) and
3.5 kw (nominal). The full equipment list installed in the accident aircraft can be found in the
appendix section.
1.6.2 Aircraft Fuel
The aircraft uses Jet A jet fuel. The tanks have a maximum capacity of 402 gallons. In
accordance with 14 CFR FAR 91.167, the calculated minimum fuel probably carried by the
aircraft was 70 gallons. The smell of fuel noticeable by the first responders indicates there was
still fuel left in the tanks at the time of impact.
14 CFR FAR 91.167 Fuel requirements for flight in IFR conditions.
(a) No person may operate a civil aircraft in IFR conditions unless it carries enough fuel
(considering weather reports and forecasts and weather conditions) to—
(1) Complete the flight to the first airport of intended landing;
(2) Except as provided in paragraph (b) of this section, fly from that airport to the
alternate airport; and
(3) Fly after that for 45 minutes at normal cruising speed or, for helicopters, fly after that
for 30 minutes at normal cruising speed.
_____________________________________________________________________________________________________
3
As described in the WX 500 Stormscope Series II Weather Mapping Sensor User’s
Guide
4
As described in the WSI Inflight Sat Weather Brochure
5
As described on the Honeywell Aerospace Website Product description

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1.6.3 Engine and Propeller
The aircraft was equipped with a Pratt & Whitney Canada (PWC) PT6A-67B engine. At
the time of the accident, the engine had accumulated 496 total flight hours, and review of the
maintenance records revealed the aircraft was last inspected 195.6 flight hours before the
accident, in accordance with an annual inspection, using the manufacturer’s maintenance
manual, on February 14, 2012.
The PT6A-67B is a 1,000 maximum continuous horsepower engine, equipped with a
reduction gearbox to reduce output shaft rpm that drives the five-bladed MT-Propeller.
Examination of the engine revealed severe damage of the reduction and accessory
gearboxes. Heavy circumferential rubbing and machining were noted to the compressor rotor,
compressor turbine vane ring, compressor turbine, 1st stage power turbine shroud, and to the 1st
stage power. The reduction gearbox propeller shaft coupling webs were fractured in torsion and
there were trace amounts of metal debris released into the first-stage sun and planet gears.
In July 2008, Transport Canada issued a Service Difficulty Advisory (SDA) regarding
RGB carrier bolts. The SDA advised:
During the last several years, there have been over twenty reported fatigue fractures of
the Reduction Gearbox (RGB) 1st stage carrier bolts. All but one of these incidents occurred
following overhaul. At least five of the bolt failures caused in-flight shutdowns (IFSD).
The aircrafts five MT-Propeller blades are part of the auto feather system6
, which will
automatically turn the propeller blades parallel to the line of the aircraft to reduce drag when
there is a loss of engine power.

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Examination of the propeller revealed three of the five propeller blades were liberated
from the propeller hub. The piston/cylinder assembly was separated from the propeller hub. The
mounting flange portion of the propeller hub remained attached to the propeller shaft. Numerous
missing parts were not recovered including components consisting of the beta mechanism, blade
counterweights, blade pitch change brackets, three of the four blade preload plates, blade
bearings, and spinner assembly.
Examination of the five propeller blades revealed that one blade exhibited a slight aft
bend and also was bent forward slightly at mid blade. The leading edge was twisted towards low
pitch. The second blade was bent aft approximately 70 degrees, exhibited multiple wavy bends,
and the outer 1/3 of the blade was separated. The trailing edge of the blade was extensively
deformed. The third blade was bent aft approximately 45 degrees at 1/4 radius and the leading
edge was twisted towards low pitch. Extensive trailing edge deformation and tearing was noted
with rotational scoring noted on the non-cambered side of the blade. The fourth blade was bent
forward approximately 30 degrees with a large radius bend, and rotational scoring was noted on
the cambered side of the blade. The fifth blade was bent aft approximately 45 degrees. The
trailing edge exhibited extensive damage and the leading edge was twisted towards low pitch.
1.6.4 Instruments
The aircraft was equipped with a glass cockpit, automatic flight control and multiple
weather radar systems. The following instruments were recovered at the crash site and all
sustained crush damage:
• WSI Inflight Sat Weather • RVSM equipped and Certified
• Dual LCR-92 AHRS • Honeywell KFC 325 Autopilot
• 406 Mhz ELT • Honeywell RDR 2000 Weather Radar
• BFG WX-500 Stormscope • Honeywell KN 63 DME
• Honeywell KMD 850 MFD • Honeywell KR 87 ADF
• Dual Garmin GTX 330D Transponders • Honeywell KRA 405B Radar Altimeter
• Emergency Power System • Honeywell KNI 582 RMI
• Garmin GMA 347 Audio Panel with 6-
Place Intercom
_________________________
6
As described in the Pilatus PC-12 brochure
• Garmin GNS 430A /530A
Nav/Com/GPS

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• Honeywell KMH 980 Hazard
Avoidance System (TCAS 1, TAWS B)
• Honeywell 5” EFIS 50 Pilot and Co-
Pilot Displays
• Honeywell HF 950 High Frequency
Radio
The aircraft was not equipped, or required to be, equipped with a CVR or FDR. However,
the aircraft was equipped with instruments that record flight data. The Honeywell Integrated
Hazard Awareness System7
(IHAS), provides aircraft positioning, weather avoidance, traffic
advisories and terrain awareness information and stores it in non-volatile memory on flash
memory chips; examination of the IHAS revealed that the flash memory chips were separated.
The aircraft was equipped with a Caution Advisory Control Unit (CACU), which records all
cautions and warnings that are triggered and displayed in the aircraft and stores it in non-volatile
memory. The circuit board for the CACU was located; however, the two chips were separated
and not recovered. The circuit board in the area of the missing chips was bent and distorted.
The aircraft was equipped with Electronic Flight Instrument System (EFIS), glass
cockpit. Complete disassembly inspection of both symbol generators (data processors) was
performed. The inspections revealed no burnt or heat signatures to any of the observed
components or circuit boards. Fuses of the ADI low voltage power supply circuit board for both
symbol generators tested satisfactory electrically. Dark discoloration on components adjacent to
electrolytic capacitors was noted for both symbol generators. Disassembly inspection of the
Display Units (DU) was performed. No arcing or burn signatures were noted on any of the high
or low voltage supplies.
1.6.5 Airframe and Flight Controls
Preliminary examination of the accident site revealed the wreckage consisting of the
fuselage and sections of both wings came to rest upright in an open field. The separated
components consisting of sections of both wings, the horizontal stabilizer, and elevator were
located approximately 1.15 miles SE of the main wreckage field. The inboard and outboard flap
actuators for both wings were located and depicted a flaps retracted position The left aileron trim
tab actuator, rudder trim tab actuator, and horizontal stabilizer trim actuator were located and
were found to be positioned 1 degree trailing edge tab down (wing down), 2.5 degrees trailing
edge tab left (tail left), and 0.9 degree stabilizer leading edge down (tail down), respectively. The
aileron trim setting was within 1 degree of neutral, the rudder trim setting was 17 percent of the
available nose-right trim and the pitch trim setting was 12 percent of the available nose-up trim.
The vertical stabilizer separated at the rudder pulley bulkhead, and the leading edge was crushed
aft to the rear spar. The rudder remained attached to the vertical stabilizer at the bottom hinge,
and was bent to the right, and the rudder trim tab remained attached to the rudder. Damage was
noted to the front and rear spars. The full span of the left and right elevator primary flight control
surfaces were accounted for.
________________________
7
As described in the Honeywell IHAS brochure

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The cockpit was intact but did suffer damage, due to a post impact fire. The cargo door,
passenger entry door, and the emergency exit window were located at the accident site.
Examination of the stick pusher control cables revealed the elevator primary cable with
attached stick pusher bridle cable clamps was fractured approximately 4 feet 10 inches from the
forward clamp. The forward clamp was bent mid-span, and the bridle cable was sheared at the
clamp. The forward clamp had all securing hardware in place. Several wire strands of the
forward clamp were broken just forward of the clamp. The bridle cable at the forward clamp
extended 2.6 centimeters (cm) forward of the clamp. The aft clamp had all securing hardware
installed. The bridle cable extended 3 cm past the clamp. The bridle cable was fractured 8.5 cm
forward of the clamp. The primary cable was bent aft of the aft edge of the clamp. The bridle
cable was bent up. The primary cable between the forward and aft bridle cable clamps was
kinked.
Examination of the autopilot system control components revealed pitch servo capstan
damage. The pitch capstan was separated from the motor, but the yaw servo bridle cable was
wrapped around the capstan and it remained connected to the primary flight control cable. The
bridle cable ball was in the drum slot. The carbon graphite clutch disks were broken in many
pieces.
1.6.6 Impact Information
The aircraft crashed into a heavily wooded area of Polk County. The main accident site
was located at 27°48’11.08” N and 81°29’38.18” W. The elevation at the main accident site was
84 feet. Examination of the accident site revealed the airplane’s heading at the initial impact was
approximately 053 degrees magnetic, while the energy path of wreckage debris was oriented on
a magnetic heading of 287 degrees.
1.7 Weather Conditions
On the day of the accident, National Weather Service (NWS) surface analysis charts
showed a deep low-pressure system and associated cold fronts moving across the central parts of
Florida, producing an area of IFR and marginal visual flight rules (MVFR) conditions with rain
and thunderstorms. Radar heights of the indicated flight path and accident site were scanned. The
0.5- degree (4,000 to 12,000 feet) elevation scan depicted large clusters of intense to extreme
echoes moving in a southerly path into central Florida. Cumulonimbus clouds associated with the
squall line were depicted by the Geostationary Operations Environmental Satellite number 12
(GOES 12), ranging from northeastern Alabama, into northern central Florida. The Mesoscale
Convective System8
(MCS) moved in a southerly pattern with expected destabilization of the
area due to surface heating, by which is enhancing the threat of organized supercell
thunderstorms. These thunderstorms are likely to produce, hail, high winds, strong downdrafts,
tornados, microburst, and tend to last several hours. A convective Significant Meteorological
Information9
(SIGMET) was issued at approximately 1655 EDT warning of an area of embedded

12
thunderstorms over areas of central Florida. Lightning detection recognized 55 cloud to ground
lightning strike within 15 statute miles from the scene of the accident.
1.7.1 Airport Weather
October 28, 2012, at approximately 2050z, N330SF departed controlled flight near Lake
Wales, Florida. IMC prevailed at the altitude and location of the departure from controlled flight
and an IFR flight plan was filed for the 14 CFR 135 flight FPR to GNV.
Area METARS10
from the approximate time of the accident:
FEW = 'Few' = 1-2 oktas11
SCT = 'Scattered' = 3-4 oktas
BKN = 'Broken' = 5-7 oktas
OVC = ‘Overcast' = 8 oktas (complete cloud coverage)
KFPR 282053Z 31017KT 2SM HZ BKN005 OVC065 24/20 A2989 RMK A02
St. Lucie County International Airport (KFPR) – October 28, 2012 2053z– Winds from 310 at
17knots –Visibility: 2 Statute Miles – Weather: Hazy – Cloud Coverage: Ceiling 500ft Broken,
6,500ft Overcast – Temperature 24 Celsius (75 Fahrenheit), Dew Point 20 Celsius (68
Fahrenheit) -- Remarks: section Precipitation Data Sensor Available
KLAL 282153Z 32011G32KT 2SM VCTS BKN008 OVC016 22/21 A2969 RMK A01
Lakeland Linder Regional Airport (KLAL) – October 28, 2012 2153z – Visibility 2 Statute
Miles – Winds from 320 at 11 knots gusting 32 knots –– Thunderstorms in the vicinity – Cloud
Coverage: Ceiling 800ft Broken, 1,600ft Overcast – Temperature 22 Celsius (72 Fahrenheit),
Dew Point 21 Celsius (70 Fahrenheit) – Altimeter 2969 – Remarks: No Precipitation Data Sensor
Available.
KGNV 283153Z 33019G34KT 1SM +TSRA BKN005 OVC 010 21/21 A2967 RMK A02
Gainesville Regional Airport (GNV) -- October 28 2012 2153Z—Winds 330 At 19 Knots
Gusting 34 Knots – Visibility 1 Statute mile – Thunderstorms and Heavy Rain – Cloud
Coverage: Broken 500ft, Overcast 1,000ft—Temperature and Dew Point 21 Celsius (70
Fahrenheit) Remarks: Precipitation Data Sensor Available
________________________
8
MCS, is a complex of thunderstorms or a squall line that becomes organized on a scale larger than the individual
thunderstorms but smaller than extratropical cyclones (I.E.hurricane), and normally persists for several hours or
more.
9
Significant Meteorological Information is a weather advisory concerning the safety of all aircraft.
10
METAR is a format for reporting weather information, predominantly used by pilots to complete a part of a pre-
flight weather briefing
11
Cloud coverage is reported by the number of “oktas”(eighths) of the sky that is occupied by clouds.

13
1.7.2 Instrument Meteorological Conditions
IFR and MVFR conditions did exist in the vicinity of the aircraft and the surrounding
areas at the time of the accident. KX07 was an airport in close proximity to the crash site. The
valid METAR from KX07 reported 2 SM visibility with thunderstorms in the vicinity. KGNV
also showed signs of IFR conditions reporting less than 3 SM visibility, a ceiling approximately
1,000ft and heavy rain and thunderstorms. The low pressure system was heading in a southerly
direction towards the accident aircraft in question.
Category Visibility Ceiling
VFR > 5 mi > 3,000 ft
Marginal VFR Between 3 and 5 mi Between 1,000 and 3,000 ft
IFR 1 mi or more but less than 3 mi 500 ft or more but less than 1,000 ft
Low IFR < 1 mi < 500 ft
1.8 Aids to Navigation
No problems with any navigational aids were reported.
1.9 Communications
No communications problems were reported
1.10 Airport Information
1.10.1 St. Lucie County International Airport
FPR is located at 3000 Curtis King Blvd, Fort Pierce, Florida
FPR is a public/civil airport that operates three runways: Runway 10R/28L is 6,492 feet
long and 150 feet wide. Runway 10L/29R is 4,000 feet long and 75 feet wide. Runway 14/32 is
4,755 feet long and 100 feet wide. All three runways have asphalt runways in good condition.
The airport is serviced by an ATC Tower, which handles approaches and departures. The
aircrafts pilot took off from active runway 10R at the time of the crash.
FPR Runway 10R has an elevation of 23 feet and is surrounded by flat open land. 400
feet from the end of the runway there is an 8-foot fence; there are a numerous number of birds
and other wildlife on and around the airport. Trees are 600 feet from the end of runway 10R

14
1.10.2 Gainesville Regional Airport
GNV airport is located at 3880 NE Ave, Gainesville, Florida
GNV is a public/civil airport that operates two runways: Runway 11/29 is 7,504 feet long
and 150 feet wide. Runway 11/29 has a grooved asphalt surface is good condition. Runway 7/25
is 4,158 feet long and 100 feet wide. Runway 7/25 has a grooved asphalt surface in fair
condition. The airport is serviced by an ATC Tower, which handles approaches and departures.
Jacksonville Center is the ARTCC for this facility.
1.10.3 Airport Services
St. Lucie County International Airport
Fuel available: 100LL JET-A
Parking: hangars and tie downs
Airframe service: MAJOR
Power plant service: MAJOR
Bottled oxygen: NONE
Bulk oxygen: HIGH/LOW
Gainesville Regional Airport
Fuel available: 100 JET-A
Parking: hangars and tie downs
Airframe service: MAJOR
Power plant service: MAJOR
Bottled oxygen: HIGH
Bulk oxygen: HIGH
1.10.4 Air Traffic Control
Miami Air Route Traffic Control Center (ARTCC) is divided into 36 sectors, which
operate 24 hours a day 7 days a week, controlling approximately 2.95 million cubic miles of
airspace sharing boundaries with Houston Center, Jacksonville Center, New York Center, San
Juan CERAP, Turks & Caicos, the Bahamas, the Dominican Republic, Haiti, and Cuba Area
Control Centers. The Miami ARTCC was responsible for providing ATC services for the Pilatus
PC 12/47 upon leaving St. Lucie County International Airport. The ARTCC is equipped with a
surveillance weather radar system. Air Route Surveillance Radar12
(ARSR) provides controllers
with the ability to vector aircraft around weather.
_________________________
12
Weather radar echoes are measured in decibels, with light precipitation measuring less than 30 decibels and
moderate precipitation measuring between 30 and 40 decibels. The weather information along the airplane’s route
of flight about the time of the accident showed no intensities measuring more than 30 decibels. Because en route
radar systems presented weather information only in three intensities—moderate, heavy, and extreme—the light
precipitation measuring less than 30 decibels would not have been displayed on the ARTCC’s radar system.

15
1.10.5 Air Traffic Communication
While in contact with Miami center at 1650 the flight was cleared to FL 150 by Miami
controllers. At 1700 the controller cleared the flight to FL 180. At 1702 the controller advised the
pilot of a large area of precipitation northwest of Lakeland, with heavy and extreme radar
returns. The controller asks the pilot to acknowledge and advise a heading to deviate around the
weather. The pilot responded with a heading of 320 degrees. The controller clears the pilot to fly
heading 320 degrees and deviate right of the course when necessary, and proceed direct
Seminole when able. There was no further recorded communication from Miami Center.
1.10.6 Radar Data
Between 1702:37, and 1705:25, the airplane proceeded in a west-northwesterly direction,
and climbed from 15,000 feet to 17,000 feet, then maintained that altitude for the next 45
seconds; however, a change in direction to the right was noted. Between 1708:37, and 1710:49,
the airplane descended from 17,000 feet to 16,100 feet, and turned to the right, and between
1712:49, and 1716:01, the airplane descended from 16,000 feet to 13,500 feet, and continued the
right turn. Between 1717:01 and 1718:37, the airplane descended from 15,000 feet to 8,500 feet,
and turned to a southerly heading. Between 1720:07 and 1723:06, the airplane turned left and
proceeded on a northeasterly heading. At, 1725:55, the final secondary return was recorded at
1,300 feet as the airplane continued on a northeasterly heading.
1.11 Survival Aspects
The accident was not survivable due to impact forces.
1.12 Medical and Pathological Information
The FAA’s Civil Aerospace Medical Institute performed toxicology tests on the pilot,
which tested negative for a wide range of drugs; however, Paroxetine, an anti-depressant, was
found in the pilot’s blood, liver and kidneys. The pilot’s blood alcohol concentration was found
to be .17.
The Polk County medical examiner’s office performed the autopsy and found the cause
of death to be severe trauma to the head causing a concussion and subsequent bleeding. Multiple
fractures to his thumbs, right ankle and wrists were also found.
1.13 Flight Operations
The aircraft was registered and operated by American Air Ambulance Service. The
Gainesville based company was founded in 2002 and specializes in providing on-demand air
ambulance charter services under 14 CFR Part 135, as authorized by the FAA. The fleet contains
five Pilatus PC-12/ 47 similar to the accident airplane with the registrations N331SF, N332SF,

16
N333SF, N334SF, and N335SF. The company has a dispatch and flight operations center at the
Gainesville airport. The maintenance and pilot training are contracted out to Flight Safety
International. The company has a number of pilots and nurses on reserve at any moment. They
are ready to launch within half an hour after the initial notice was given. The crews rotate
through these duty cycles numerous times during the month so that adequate rest is provided.

17
2.0 Analysis
2.1 General Analysis
The investigation found that the pilot was not properly certificated and qualified in
accordance with Federal Aviation Regulations. Through toxicological testing the, investigation
found alcohol and Paroxetine in the blood of the pilot. The pilot’s business medical records did
not note the use of Paroxetine and he himself had not notified his employer of his medical
condition. These conditions would have adversely affected the pilot’s performance on the day of
the accident. Furthermore, the investigation found that the airplane was last inspected in
accordance with an annual inspection, using the manufacturer’s maintenance manual. The
accident plane was operating under IFR conditions; the plane was properly equipped to handle
these conditions, and the pilot was properly trained in accordance with FAA regulations.
The accident was not survivable for any of the occupants because they were subjected to
impact forces exceeding that of the human limit.
No evidence was found that would indicate a failure of the accident airplane’s power
plants, navigation systems, and electrical systems.
One passenger was ejected from the aircraft to rest 1.31 miles from the crash site. The
height from which she fell was unknown, but autopsy revealed her injures were consistent of a
sudden impact that would exceed the G-load tolerance of a normal human being.
This analysis discusses the possible accident sequence and scenarios, including harsh
weather conditions, the airplanes rapid change of direction and decent, ground impact, the pilot’s
condition during flight, the pilot’s decision-making up to the impact, fuel planning, and aircraft
break up leading to the crash.
2.2 The Accident Sequence
The first deviation from normal flight occurred on the climb from 15,000 feet to 18,000
feet. The pilot was notified by ATC, regarding thunderstorms that might interfere with the
planned flight path of the aircraft. ATC authorized the pilot to make the necessary course
deviations for weather avoidance. Shortly thereafter, the pilot notified ATC that a 320 degree
heading would be sufficient to avoid the weather. The controller authorized this deviation and
allowed the pilot to deviate further to the right of his course as necessary. This was the last
communication of pilot intentions to ATC.
According to radar data, the aircraft appeared to continue its climb from 15,000 to 17,000
feet, between 1702:37 and 1705:25. The pilot maintained 17,000 feet for 45 seconds and
deviated course to the right. The first signs of irregular operations occurred between 1708:37 and
1710:49. The airplane began a descent from 17,000 feet to 16,100 feet and continued its right

18
turn. From 1712:49 to 1716:01, the aircraft continued its descent from 15,000 to 8,500 feet,
halting its right turn on a southerly heading. From 1720:07 to 1723:06, the aircraft began a left
turn to a northeasterly heading. The last radar return, at 1725:55, indicated the aircraft was at
1,300 feet, continuing its heading to the northeast.
2.2.1 Possible Result of Flight Path
It appears from meteorological data that the aircraft was flying in an area with multiple
embedded thunderstorm cells. It is a high possibility that the pilot was flying through instrument
conditions, became disoriented from drug and alcohol use, and inadvertently flew directly into a
cell, causing the aircraft to depart controlled flight. In the process of recovering control of the
aircraft, it is possible the pilot overstressed the tail and wings of the aircraft, causing the tail and
sections of the wings to break off. Impact with the ground followed this breakup.
2.3 Pilot Injuries
The pilot’s fractured wrists and thumbs indicate that he was operating the controls of the
aircraft.
2.4 The Effects of Controlled Substances on the Flight Crew
2.4.1 Effects of Paroxetine
Paroxetine, also known as Paxil or Pexeva, is used to treat depression, panic disorders
and other anxiety and stress disorders. It can be used to treat other disorders such as headaches
and male sexual problems and is also used in conjunction with other medication to treat bipolar
disorder. This drug has many possible side effects, such as dizziness, confusion or blurred vision,
which could affect a pilot’s ability to operate an aircraft in a safe manner. If the accident pilot
was experiencing any of these effects, it could explain the erratic flight path and subsequent loss
of control, due to his inability to make sound decisions while under the influence of this drug13
.
2.4.1.1 FAA Anti-depressant Regulations
Currently, the FAA does not allow a pilot to obtain a medical certificate while taking
anti-depressant medication, unless a pilot applies for a special issuance certificate. However, the
special issuance certificate is only issued on a case-by-case basis to pilots who are taking
Fluoxetine, Sertraline, Citalopram or Escitalopram, if they have been treated successfully for at
least 12 months. Paroxetine is not an approved medication for a special issuance medical
certificate and, therefore, would disqualify a pilot from obtaining a certificate. As a result, the
accident pilot, despite being issued a medical certificate, was not fit to fly, as he was in violation
of FAA regulations regarding anti-depressant usage.
_________________
13
Drug information obtained from the US National Library of Medicine.

19
2.4.2 Effects of Alcohol
Males of similar size to the pilot would require about 8 12 ounce bottles of beer per hour
to reach a blood alcohol content of .17. Blood alcohol content this high can cause disorientation,
confusion, dizziness, and exaggerated emotional states with disturbed vision. The pilot’s
perception of color and depth may have been highly degraded. It is also highly possible that he
had a lack of muscular coordination. The pilot may have had higher alcohol content before the
accident, as alcohol is metabolized in the body. It is unclear when the pilot may have ceased
drinking, suggesting the possibility of the pilot beginning to feel the negative after effects of his
drinking, including drowsiness, nausea and dizziness.
2.4.3 Combined Effects of Paroxetine and Alcohol
While it varies by individual, the consequences of heavy drinking, while taking
Paroxetine, can be exacerbated. This combination can increase depression and affect motor skills
to a greater extent than drinking alone. For someone with a blood alcohol content of .17, any
increase in symptoms could prove devastating to their minds and bodies. If the accident pilot was
feeling these increased effects, his abilities as a pilot were probably highly degraded. If he was
experiencing any hangover symptoms on top of the effects of the alcohol and Paroxetine, it
would appear that he was in no shape to be flying that day, whether he was experiencing
hangover symptoms or not.
2.5 Flight Crew Currency Requirements
According to the information in the Airmen’s logbook, the pilot was properly licensed to
operate the aircraft under Part 61 with a Private Pilots License (Airplane Single Engine Land and
Airplane Multi Engine Land) with Instrument rating. The pilot’s logbook also revealed a
complex aircraft, high performance and pressurized aircraft endorsement after additional training
to operate the accident make and model. The accident make and model does not require the pilot
to hold a type rating, since the accident make and model weighs less than 12,500 lbs.
The pilot was issued a third class medical certificate with no limitations on May 1, 2012.
This certificate, as stated in FAR Part 61, is valid until May 31, 2014 (24 calendar months plus
the month of issue). In addition, no type rating is required to operate the accident type aircraft.
There is also evidence indicative of the pilot being current to operate the aircraft in
instrument meteorological conditions. As stated in paragraph ( c ) in the FAR’s, the pilot would
have needed to perform six instrument approaches, holding procedures, and intercepting and
tracking courses through the use of navigation systems. It is very likely that the pilot met these
requirements in the 469 hours of flight time between March 20, 2012 and October 8, 2012. The
logbook did not have recent entries of logged instrument time, but the pilot’s last instrument
proficiency check occurred on January 22, 2012 at Flight Safety International and last instrument
flight on August 2, 2012. The pilot also conducted a flight to Elizabeth City, NC in September of
2012. The pilot also logged a total of 820 hours in the accident make and model, 800 hours being

20
flown as pilot in command. According to American Air Ambulance Service, the pilot was
compensated and under payroll.
According to the Federal Aviation Regulations, the pilot in command of the aircraft
operated the flight illegally.
2.5.1 CFR Part 61.113
The pilot did not hold the correct licenses to operate this flight under 14 CFR Part 135. In
the FAR Part 61 Certification: Pilots, Flight Instructors, and Ground Instructors; Paragraph
61.113 Private pilot privileges and limitations, states:
a) Except as provided in the paragraphs of this section, no person who holds a private
pilot certificate may act as pilot in command of an aircraft that is carrying passengers or
property for compensation or hire; nor may that person, for compensation or hire, act as
pilot in command of an aircraft.
(b) A private pilot may, for compensation or hire, act as pilot in command of an aircraft
in connection with any business or employment if:
(1) The flight is only incidental to that business or employment; and
(2) The aircraft does not carry passengers or property for compensation or hire.
2.5.2 CFR Part 135.243
In addition, American Air Ambulance Service operates under CFR Part 135 operations.
CFR Part 135.243 Pilot in command qualifications, states:
(a) No certificate holder may use a person, nor may any person serve, as pilot in command in
passenger-carrying operations—
(c) Except as provided in paragraph (a) of this section, no certificate holder may use a
person, nor may any person serve, as pilot in command of an aircraft under IFR unless that
person—
(1) Holds at least a commercial pilot certificate with appropriate category and class ratings
and, if required, an appropriate type rating for that aircraft; and
(2) Has had at least 1,200 hours of flight time as a pilot, including 500 hours of cross
country flight time, 100 hours of night flight time, and 75 hours of actual or simulated
instrument time at least 50 hours of which were in actual flight; and

21
(3) For an airplane, holds an instrument rating or an airline transport pilot certificate with an
airplane category rating
2.5.3 CFR Part 135.4
Also, American Air Ambulance Service operates under CFR Part 135 operations. CFR
Part 135.4 Applicability of rules for eligible on-demand operations, states:
(a) An “eligible on-demand operation” is an on-demand operation conducted under this
part that meets the following requirements:
(1) Two-pilot crew. The flight crew must consist of at least two qualified pilots employed
or contracted by the certificate holder.
2.6 Fuel Analysis
The smell of fuel at the accident site noticed by the first responders indicates that there
was fuel left in the tanks. It was determined that the propeller was not feathered and that the
engine was rotating at the time of impact, indicating that it was sufficiently supplied with fuel. It
was therefore determined that fuel starvation or exhaustion was not a factor in this accident.
2.7 Engine Analysis
Engine RPM at the time of impact could not be determined from the examination of the
engine, however the circumferential rubbing and machining of the compressor rotor, compressor
turbine vane ring, compressor turbine, 1st stage power turbine shroud, and to the 1st stage power
turbine are highly indicative of rotational operation of the engine during impact.
The examination of the RGB revealed that two first-stage reduction carrier bolts showed
evidence of pre impact weakening under the bolt heads due to early onset fatigue cracking. There
were trace amounts of failed bolt debris released into the first-stage sun and planet gears, causing
significant damage to those gears. All evidence is consistent with the engine running during
impact.
Examination of the blades determined that the propeller blades were not feathered at the
moment of impact. The aircraft is equipped with an auto feather system which will automatically
turn the propeller blades parallel to the line of the aircraft to reduce drag when oil pressure in the
engine is lost (engine failure). This evidence is consistent with the aircraft engine running at the
moment of impact.
Based on the examination of the engine, RGB and propeller, engine or RGB failure was
not a factor in this accident.

22
2.8 Instrument Analysis
Due to impact, crush, and fire damage to all aircraft instruments there was no usable
instrument data to analyze. Aircraft instrument failure was not a factor in this accident.
2.9 Weather Analysis
Approximately 1430, there was a cluster of thunderstorms described as a severe34
forward-propagating mesoscale convective system moving in a north to south orientation
through central Florida. The squall line had expectations of further development due to surface
heating. MCSs have the potential to last several hours bringing turbulent updrafts, rain, hail,
tornados, and downdrafts. An aircraft that enters an MCS thunderstorm could be caught in strong
downdrafts and severe turbulence.
Preceding the departure, the airport was reported to be under IMC. N330SF departed on a
medevac flight with an IFR flight plan from St. Lucie County International Airport at 1650 EDT,
for Gainesville Regional Airport with expected areas of IFR to MVFR conditions, due to isolated
thunderstorms and moderate rain after 1400. The pilot’s lack of concern about the weather prior
to departure, may have led him to fly into diminishing conditions where embedded
thunderstorms existed.
Cumulonimbus clouds associated with the squall line were depicted by the Geostationary
Operations Environmental Satellite number 12 (GOES 12), ranging from northeastern Alabama,
into northern central Florida. The accident occurred on the southern side of the storm where
cloud tops were approximately 37,000ft. Higher cloud tops existed west of the crash site. The
aircraft’s last radar return put him in close proximity to a severe thunderstorm. Lightning
detection identified 55 cloud-to-ground lightning strikes within 15 statute miles of the accident
site. This is consistent with the witness hearing a “boom” before seeing the accident aircraft prior
to impact.
Radar heights of the indicated flight path and accident site were scanned and calculated.
The 0.5- degree (4,000 to 12,000 feet) elevation scan depicted large clusters of intense to
extreme echoes moving in a southerly path into central Florida. These echoes overtook the
airplane’s flight path and were indicated a heavy precipitation, supercell thunderstorm. The
accident aircraft shows damage consistent with overstress due to a strong downburst after
encountering an embedded thunderstorm and pilot induced positive G-loads from an attempted
recovery. A convective SIGMET was issued at approximately 1655 warning of an area of
embedded thunderstorms over areas of central Florida. At approximately 1700 there was a
warning of a line of strong to severe thunderstorms headed southbound through the accident site.
The warning should have given the pilot time to react and maneuver away from the unstable
conditions. However, the pilot asked Miami Center to be vectored around the storm and was later
seen by ATC radar making right turns and descending until radar services were lost. The
situation is consistent with the pilot maneuvering around a storm, using weather systems onboard
the aircraft to find a viable path to cross.
14
Severe thunderstorm is a term for a thunderstorm that has reached a determined level of severity. This level is
determined by the storm being strong enough to inflict wind or hail damage. With wind speeds up to 58MPH.

23
2.10 Flight Operations Analysis
Based on the pilot’s lack of proper certification, the Flight Operations Department did not
use all available resources of information on the flight crew’s qualifications to determine the
crew’s suitability for work at the company. It seems likely that the company trusted their pilots
to provide them with the correct information about their qualifications.

24
3.0 Conclusions
3.1 Findings
1. The investigation found that the pilot was not properly certificated and qualified in
accordance with applicable Federal regulations. The investigation also found evidence
indicating a medical or behavioral condition that may have adversely affected the pilot’s
performance on the day of the accident.
2. The investigation found that the airplane was properly certified, equipped and maintained in
accordance with Federal regulations and that the recovered components showed no evidence
of any pre-impact engine or system failures.
3. Air traffic control was properly certified and qualified in accordance with applicable Federal
regulations.
4. Despite a statement from the pilot’s spouse, evidence of heavy drinking was found through
the toxicological examination.
5. The pilot’s third-class medical was not valid, due to his use of anti-depressants.
6. The accident sequence initiated as a result of alcohol and drug use by the pilot, the effects of
either, by themselves, were compounded from the combination of both; it was impossible to
determine the history of the pilot’s use of anti-depressants.
7. The pilot’s impairment, combined with adverse weather conditions, affected his ability to
make his appropriate in-flight decisions, when faced with deteriorating weather.
8. The pilot’s flight into severe weather conditions demonstrated poor preflight planning,
possibly due to his impairment from alcohol and drug use.
9. Severe embedded thunderstorms were present in the area of the accident site.
10. The pilot’s hand and wrist injuries are consistent with his operation of the controls.
11. The airplane was found in a configuration consistent with normal cruise flight.
12. The accident was not survivable due to impact forces that exceeded human tolerance.
13. Fuel planning was not a factor in this accident.
14. Air traffic communication, aids to navigation and airport operations were not factors in this
accident.
15. There was no evidence of an in-flight fire.
16. No information could be retrieved from the instruments because of the destructive nature of
the impact forces.
17. Based on the examination of the engine, RGB and propeller, engine or RGB failure was not a
factor in this accident.
18. The circumstances of this accident demonstrate the importance of a program for the Federal
Aviation Administration to monitor and conduct ongoing assessments of pilot qualifications;
the FAA did not perform this task adequately for American Air Ambulance Services.
19. Had Federal Aviation Administration personnel been aware of American Air Ambulance
Service’s employee monitoring policy, the FAA would have had and opportunity to increase
surveillance of the company.
20. Employees (the flight nurse) may not understand the Federal Aviation Administration’s role
in aviation safety or know how to contact FAA personnel when safety concerns arise.

25
3.2 Probable Cause
The National Transportation Safety Board determined that the probable cause of this
accident was the pilot’s unfitness to operate the aircraft because of alcohol and drug use, which
caused him to be unable to make sound cockpit decisions. Contributing factors include (1) the
company’s failure to enforce pilot qualifications and certifications, (2) the pilot’s stressed state
before the flight, (3) his attitude towards hazardous weather flying, (4) his flight into instrument
meteorological conditions with embedded thunderstorms.

26
4.0 Recommendations
As a result of this investigation, the National Transportation Safety Board makes the following
recommendations:
To the Federal Aviation Administration:
1. Require increased inspections, regarding pilot flight and medical certification currency
and validity.
2. Require a line of communication from company employees to the FAA for reporting of
potential or active safety issues.
3. Conduct a detailed review of the oversight provided to American Air Ambulance Service
to determine why the oversight system failed to detect (before and after the accident) and
correct American Air Ambulance Service’s operation deficiencies, particularly in the
areas of pilot hiring, training and adherence to procedures.
To American Air Ambulance Service:
4. Inform your employees through your website, newsletters and conferences of the Federal
Aviation Administration’s role in aviation safety with respect to medical/air ambulance
services and provide FAA contact information. Urge your employees to communicate
any safety concerns related to medical/air ambulance services to the FAA.
5. Verify the accuracy and completeness of flight crew qualifications for new hires.
6. Determine optimal information presentation methods and delivery systems for flight
service station weather information briefings, including the possibility of supplementing
or replacing some portions of the current standard weather briefing with graphical data.

27
5.0 Appendices
Appendix A – Aircraft Accident Diagram

28
Appendix B – IFR flight Plan

29
Appendix C – Record of Interview
Date: November 02, 2012
Conversation with: Eye Witness
Summary and Factual Information from Conversation:
The eyewitness was contacted in relation to the accident involving American Air Ambulance
Service, Pilatus PC 12/47, N330SF on October 28, 2012. She confirmed that she lived just under
a mile from the property where the aircraft lay to rest. She stated that she had witnessed the
accident, but did not know of anyone else who had. She stated that just prior to the accident she
was working on her classic Camaro in her garage. She stated that the weather was nice earlier in
the day, but had turned bad in the past few hours. She stated that there was a huge thunderstorm
in the area during the accident, that is was cloudy and windy, but no rain had fallen yet. She
stated that as she worked on her Camaro she heard a “loud boom” that she thought was thunder;
when she looked at the sky she saw a plane “dropping and spinning with no horizontal
movement.” As she stated “horizontal movement” she held a model aircraft and showed level
flight. She stated that she did not notice any lights on the aircraft, fire coming from the aircraft or
parts/debris falling from the aircraft. However, she did notice a “huge, dark black cloud of smoke
coming from the back of the aircraft,” but she could not tell the exact location where the cloud
was coming from. She stated that the aircraft went behind the trees and she did not see or hear
the impact. She stated that she grabbed her ABC fire extinguisher and ran to the crash site,
where she was the first one on scene. She stated that she attempted to extinguish the fire, which
was located in the front of the aircraft, to no avail. She stated that the tail section was completely
separated from the aircraft from just behind the wings and that she noticed openings in the
fuselage that did not appear to be doors or windows; she stated that it was difficult to describe.
She stated that she did not hear anything coming from the aircraft, nor did she see human bodies
or remains. She stated that once firefighters arrived on scene she was cleared from the area and
that she had no further information.
I can attest that the above summary and factual information was taken on the above stated day
and is correct to the best of my knowledge.
Robin M. Buhler
Rebekah S.M. Haba
National Transportation Safety Board
Air Safety Investigators

30
Appendix D – Background Statements

31

32

33
Appendix E – Fort Pierce/St. Lucie County Intl (FPR) Airport Diagram

34
Appendix F – Gainesville Regional (GNV) Airport Diagram

35
Appendix G – Aircraft Specifications
Avionics
Honeywell 5” EFIS 50 Pilot and Co-Pilot Displays
Dual LCR-92 AHRS
Garmin GNS 430A /530A Nav/Com/GPS
Honeywell KMH 980 Hazard Avoidance System (TCAS 1, TAWS B)
Honeywell KMD 850 MFD
Dual Garmin GTX 330D Transponders
Garmin GMA 347 Audio Panel with 6-Place Intercom
Honeywell HF 950 High Frequency Radio
BFG WX-500 Stormscope
WSI Inflight Sat Weather
RVSM equipped and Certified
Honeywell KFC 325 Autopilot
Honeywell RDR 2000 Weather Radar
Honeywell KN 63 DME
Honeywell KR 87 ADF
Honeywell KRA 405B Radar Altimeter
Honeywell KNI 582 RMI
Emergency Power System
406 Mhz ELT
N330SF - 2007 Pilatus 12/47 SN 787
General
AIRFRAME
Hours: 496
Cycles: 188
ENGINE: PT6A-67B
PROPELLER: MT-Propeller

36
Equipment
Additional Air Conditioning
Cockpit Foot Warmer
Large Oxygen System
Cold Operations Package
Tail Logo Lights
Pulselight Recognition Lights
Cabin AC Power
Airshow 410 System
Cabin CD/DVD/Sat Player with Six Headphones and Jacks
Cockpit Avionics Innovations CD/AM/FM/SAT Player
NAT STX100 (Globalstar) Sat Phone with Cockpit Dialer and Wireless Cabin Handset
Tow Bar Head and Mount
Interior
BMW Platinum Interior
Executive 7- Seat (Triple Bench)
Sport Style Executive Seats
Footrests (2 Aft Cabin Seats)
Adjustable Lumbar (2 aft Cabin Seats)
Seat Leather: Aeronappa Hawk
Upper Sidewall/Headliner: Hemispheres Mirage – Safari
Lower Sidewall: Paul Brayton – Summit, SU-11, Snowmass
Wood: Quarter Cut Sapele, Deep Gloss Full Filled
Carpet: Vanguard – Warm Beach
Metal: HT805 Silver – Medium Aged

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