Five people boarded an aircraft for what was supposed to be a routine air ambulance flight, but instead it turned into their worst nightmare when a pilot entered a graveyard spiral and the aircraft broke apart in flight, killing everyone on board. Unfortunately, there’s no reason this ever should have happened.
And that’s why I’m going to explain the decisions and the mistakes that were made that led up to this heartbreaking tragedy. I’m Hoover and welcome to your pilot debrief. Our story begins on February 4th, 2023 when a pilot, two crew members, and two passengers took off from Reno, Nevada to conduct a routine medical transport flight to Salt Lake City, Utah.
Now, before we talk about what happened that caused this terrible tragedy, it’s important to take a moment to honor the victims. Mark and his wife Terry were the two passengers on the flight, and the purpose of the trip was to take Mark to Salt Lake City for lifesaving medical treatment.
Also on board the plane was Ed who was 32 years old and he was the flight nurse. And sitting in the back with him was Ryan who was 27 years old and the flight paramedic. Finally, Scott was 46 years old and he was the pilot flying the plane. But we’ll talk more about him in a minute. For right now, I think one of the most tragic parts about this entire story is the fact that these were more than just names and faces.
Everyone on board that plane was part of a family. And my heart goes out to the spouses, the children, and the loved ones they left behind. This is where I think it’s important to acknowledge the fact that every time a near ambulance crew launches, it’s not just another flight. You know, these are men and women who have dedicated their lives to responding in the worst conditions to help people on their worst days.
And they train for scenarios that most of us would never want to face. And that means sometimes they’re accepting a higher level of risk that comes with trying to save others. But that’s also why safety is so important when it comes to operating in that type of environment. That being said, before we talk about how they crashed, we need to start by taking a look at the pilot flying the plane.
According to the investigation, Scott was about 30 years old when he got his private pilot certificate in 2006. But it wasn’t until 12 years later that he obtained his commercial pilot and his instrument rating in 2018. Shortly after that, he became a flight instructor in January of 2019 as he continued to pursue his passion for aviation.
Eventually, Scott was hired as a pilot for PSA Airlines in May of 2021, but according to the investigation, he was unable to complete the training program due to some struggles that he had with the pre-eparture, climb, decent, and approach procedures. However, in all fairness, according to a friend that went through training at PSA with Scott, a lot of that training structure was disjointed.
And even though you would train as a crew, you were split up to take your check ride with someone new. And it seemed like Scott’s struggles were more related to operating in a crew environment and just the nature of the check ride itself. Either way, Scott didn’t finish training with PSA, and instead, he went to work as a Cessna 208 cargo pilot for a company based out of Michigan in November of 2021.
And over the course of the next 10 months, Scott gained a lot of experience flying in instrument conditions in cold weather while operating out of Michigan, Wisconsin, and Illinois before he left the company to start work as a PC12 pilot for a company called Guardian Flight in September of 2022. Now, when Scott was hired, he initially received four days of simulator training in the PC12 for a total of about seven hours.
And then he conducted five flights for about eight hours of instructional flight time before passing his check ride. He then went on to complete 3 days of initial operating experience known as IO in the aircraft where he flew seven legs for almost eight hours with another pilot and was signed off as being proficient to fly single pilot missions for the company.
However, the NTSB discovered that during his initial flight training, he received a grade of unsatisfactory for the autopilot and navigation systems on two of his training flights before eventually passing those areas on the last two flights. And according to the investigation, at the time of the crash, Scott had just over 2100 hours of total flight time, but he had only been working for Guardian for about five months.
and that meant he only had about 95 hours of experience flying the PC12 when he crashed. The reason why I’m bringing this up isn’t to try and blame Scott, but rather it’s to point out how in hindsight we can see all these minor issues starting to add up. We’re talking about a pilot that had previous issues operating in a multi-crew environment that was brand new to the PC12 that struggled a little with the autopilot during training.
And even though he had flown out of Reno a few times before, I’d argue that this was still a new environment for him where he’s about to be put to the test. And that brings us to the company he was working for and the aircraft that he was flying. If you’ve never heard of Guardian Flight, they’re an air ambulance operator that’s part of a larger network that provides critical patient transport across the country.
But here’s the thing. Unlike the airlines where you have regular flights in familiar airports, air ambulance operations are usually unpredictable. And that means you can end up being asked to fly in the weather, in mountainous terrain, or in the middle of the night. And sometimes it’s in a situation where every second counts.
And I’m sure that can sometimes put an enormous amount of pressure on the crew to make the mission happen. And that’s why Guardian had a policy known as three to go, one to say no. That meant the pilot and both crew members all had to agree to operate the flight. And all it took was for one of them to say no to cancel the mission and the company wouldn’t ask any questions.
In fact, several pilots told investigators that they liked being able to decline a flight without the fear of punishment. But you need to understand that even with a policy like this, there’s still going to be some tension between safety and operations. After all, if you say no, someone else has to cover the flight.
And considering the company was already understaffed and the patients are depending on you to make the flights happen, that pressure is real. Additionally, one of the major lessons learned from this investigation was that the NTSB discovered something unique about Guardian’s operations. You see, the company also had a policy where anyone with less than a year of experience wasn’t allowed to be paired with someone else with less than a year of experience.
Unfortunately, as you can see from the memo, this rule only applied to rotor wing operations and not any of the fixedwing flights in the PC-12. And what’s crazy to me is that Ed and Ryan had both just finished their six-month orientation, and they had only been cleared to work 14 days before the accident.
In fact, they were so new that they didn’t know how to fill out the paperwork for Terry to travel with her husband on the flight. So, even though the company policy wouldn’t allow them to fly together on a helicopter, there weren’t any issues with them being paired together on an airplane. And if you’re wondering what this has to do with Scott flying the plane, just remember they had a policy of three to go and one to say no.
But when you’re talking about two brand new crew members and an inexperienced pilot, they’re not going to have the experience to know when to say no. I also want to point out that when it comes to working as a crew, this wasn’t Scott’s normal base. You see, he was working as a float pilot for Guardian, and that meant that he rotated across their flight bases throughout the country, and he actually arrived in Reno on Monday for a one-week rotation, and the accident was on Friday.
Now, that meant Scott didn’t have a lot of local area knowledge, and the NTSB couldn’t determine how much experience he had operating at night in the weather over mountainous terrain. Additionally, the NTSB discovered that the company required that a flight risk assessment be completed before each flight, but Scott and his crew never completed one.
However, for what it’s worth, the NTSB also pointed out that considering their lack of experience, even if they had completed that risk assessment, it’s possible they still would have done the flight. Either way, this seemed to indicate a possible trend with the company because just 71 days prior to this disaster, another Guardian flight crashed in Hawaii.
And that investigation, which I covered in this video on my channel, also revealed the lack of a pre-flight risk assessment. However, now that you know more about Scott, the crew, and the company they were working for, it’s time to talk about the aircraft they were flying. Before we talk about what happened next, I just want to take a minute to say that between flying, making debrief videos, and family life, I don’t always have time to cook.
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Code pilot FB50 at factor75.com gets you 50% off plus free breakfast for one year. And now, let’s get back to the debrief. On the day of the accident, Guardian Flight received a request to transport a patient from Reno to Salt Lake City, and the flight was classified as non-emergency transport. The dayshift pilot declined the request due to bad weather and the fact that visibility was below minimums.
Towards the end of his shift, that pilot texted Scott to say that the weather had been down all day. In fact, the weather was so bad that another air ambulance company who also flew PC12s had also received a request to transport that same patient from Reno to Salt Lake City earlier that afternoon, but they also turned down the flight due to the bad weather.
Keep in mind that this was for non-emergency transport. So, I’d argue that if one air ambulance company tells you that the weather is bad, there’s probably no reason to try to make the flight happen by asking another company. And what’s crazy to me is that just a few hours later, whoever was making that request went ahead and asked Guardian Flight again to transport the patient.
The only difference was Scott was about to start his shift. And even though the dispatchers were required to inform Scott that the request had already been turned down by the dayshift pilot and also that had been turned down by the other company, that never happened. So, as far as Scott and his crew were concerned, this was the first request, and no one else had rejected the flight prior to this point.
Keep in mind that the weather in Reno at that time was light snow with 1 and 3/4 mile visibility and overcast ceilings at 2200 ft. And even though that’s good enough to take off from Reno, the problem was there was an area forecast for a winter storm in the area predicting heavy snow, low-level wind shear, turbulence, and IFR conditions, not to mention possible icing in the clouds as well.
Basically, this is not the kind of weather you want to go flying in as a single pilot at night when you’re talking about a non-emergency transport mission. Unfortunately, Scott accepted that mission around 7:15 p.m. and eventually around 8:30, everyone was at the aircraft and ready to begin the flight to Salt Lake City.
The aircraft they were flying in was a 2002 Pilatus PC12. And if you’re not familiar with this airplane, it’s a high-performance pressurized turborop aircraft. Thanks to its advanced automation and safety features, the PC12 is capable of being operated by a single pilot. However, I’d argue that it’s probably good to have a second pilot on board, especially when you’re transporting patients, sometimes in life or death situations.
Because the truth is that when you look at some of the deadliest PC12 plane crashes, most of those involve single pilot operations. Either way, when it comes to the PC12 being used for the flight, the aircraft wasn’t equipped with a cockpit voice recorder, but the NTSB was able to recover flight data from the Garmin GPS units, as well as the aircraft caution and warning system that helped them better understand what might have happened during the flight.
Eventually, they determined that the aircraft was within the weight and balance limits for the flight, and there was nothing mechanically wrong with the aircraft that would have contributed to the crash. That meant it all boiled down to what Scott did during the flight. Around 900 pm, Scott was ready to go and told to taxi to runway 17 left.
But the ground controller noticed that Scott got lost while he was exiting the ramp, and he asked him if he needed any assistance locating the ramp exit. The problem was, even though the visibility wasn’t terrible, the taxi way hadn’t been plowed in a while, making it hard to see the lines painted on the ground, and the controller had to tell Scott when to begin making his turn until he was finally able to figure out where he was going.
A few minutes later, Scott took off around 900 p.m. And after he got airborne, he switched over to talk to departure control. And it was right around that time when, according to the aircraft data, the autopilot disengaged between 1 and 3 minutes after takeoff. It’s not clear what caused the autopilot to disengage, but I can promise you that handflying an instrument departure as a single pilot at night in the weather surrounded by mountainous terrain is not a fun situation to be in, especially during a critical phase of flight like this immediately after takeoff. Either
way, thankfully, Scott was able to re-engage the autopilot. And right after he did that, the aircraft data reflected that the aircraft de ice boots cycled and the pusher ice mode was activated along with the autopilot trim being operated six times. Now, I want to try to clarify this because I realize it might be confusing, but first of all, the pusher ice mode is a feature of the stall warning system on the aircraft and it’s designed to be used in icing conditions.
And basically, when that system is activated, it assumes that there’s ice on the wings. So, the pilot’s going to get a stall warning earlier than normal, so that way they have more time to react. Either way, the NTSB wasn’t able to explain what happened here and why the autopilot went offline. We don’t know if it was because of turbulence or because of icing or maybe Scott just knocked it offline.
All we know for certain is that there was nothing wrong with the aircraft and Scott never said anything to the controller about any problems he was having, and he was able to get the autopilot back online really quickly. Also, I just want to point out that this simulation was created using ADSB data from the aircraft, which is fairly accurate, but the left side of the screen shows you the aircraft ground speed instead of the indicated air speed.
And also, more importantly, this simulation doesn’t depict the actual weather conditions. So, just imagine that Scott isn’t able to see anything outside right now because he’s in the clouds and he has to rely on his instruments to stay safe. Either way, this is a copy of the instrument departure that Scott was flying. And when he checked in with the controller, he was told to climb and maintain flight level 2550.
Scott turned left at EOS and then began a left turn at Wit to proceed direct to DAT. But a few minutes later, everything started to fall apart. Instead of climbing to flight level 2550, as he was passing through 18,000 ft, the aircraft began to level off and started turning to the right. And you can see that according to the flight data, somewhere just prior to or during that turn, the autopilot disconnected again.
And my guess is that it happened just prior to the turn because there’s no reason why the aircraft would have started turning to the right or leveled off if the autopilot was still engaged. Once again, we don’t know why the autopilot disconnected, but the NTSB concluded that there was definitely nothing wrong with the autopilot that would have kept Scott from using it.
But for some reason, he never turned it back on. Maybe he just assumed that the system was faulty and that’s why he left it off. We just don’t know. After he finished his turn back to the left, he started a shallow descent, but then a few moments later, he started climbing as he struggled to control his altitude.
And my guess is Scott was probably already disoriented by this point. Now, pay close attention to what happened next because they only had about a minute left to live. A graveyard spiral is 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 controls have the effect of tightening the turn and losing altitude at an increasing rate until the airplane structural limits are exceeded, resulting in the aircraft breaking up in flight or impacting the ground. It took roughly 3 minutes from the second time the autopilot disengaged until the time the aircraft broke apart in flight and fell to the ground below, killing everyone on board.
Scott’s final turn to the right was a classic example of a graveyard spiral that happened after he became spatially disoriented when the autopilot turned off in flight. I also want to point out that the investigation discovered that Scott had a 3cm brain tumor located in the part of his brain that was responsible for the integration of spatial and navigational information.
But it wasn’t possible to tell if that tumor played a role in the crash. In the end, this wasn’t just one mistake, but a whole series of them. an inexperienced pilot and crew, a breakdown in company procedures, and a decision to launch into the weather for a non-emergency flight that had already been turned down by others, and the end result was five people lost their lives, and the families they left behind will never be the same.
I think the biggest lesson that we can learn from this terrible tragedy is that every flight is a choice and sometimes the safest, but also the toughest decision is the one to say no. Thank you so much for watching this video. And if you want to find out what happened in the other Guardian flight crash, then be sure to check out the other video on the screen.
And I’ll see you on the next debrief.