Honorable Deborah Hersman, NTSB Board Member

Chairman Deborah A.P. Hersman
Closing Statement

Aviation Accident Report Pilatus PC-12/45, N128CM
Butte, Montana, March 22, 2009

Washington, DC July 12, 2011


I want to thank my fellow Board members for their participation today.

In closing, I'd like to recognize the outstanding efforts of the NTSB staff who completed the accident investigation and developed this excellent report; in particular, the staff from the Office of Aviation Safety and Office of Research and Engineering. Dennis Hogenson, the Investigator-in-Charge, and his team did an outstanding job, making sure that every stone was turned over in the investigation. And, let me add my sincere appreciation to Dennis Diaz for his determination and diligence. I think future investigators will be reading case studies on the chip level recovery in this investigation.

This accident draws attention to the actions and decisions of one individual and highlights the tragic consequences of not following procedures.

For one, limitations are limitations. They must be followed on every flight. If your airplane requires fuel with an icing inhibitor, use it. If you don't, you are risking disaster.

Second, when you get into trouble in the air, land as soon as possible. Don't exacerbate an in-flight problem by putting passenger convenience over safety. As we saw in Butte, that can be a tragic mistake.

Third, humans are fallible. This is why our recommendations are designed to offset human error. Pilot professionalism is already on our Most Wanted List of Transportation Safety Improvements - we know professionalism is achieved through monitoring, following checklists, and training like you fly and flying like you train.

We find in this accident, the simplest solution may be the best solution. This is why you heard some very basic recommendations about putting up placards to remind pilots to add icing inhibitor to their fuel. It could save lives.

Every fatal accident is tragic for the loss involved, but the two accidents we considered today are particularly sad because they both resulted in the deaths of children. Because we are focusing on child passenger safety this year, these accidents are yet another reminder that our youngest travelers don't have a voice when it comes to safety, and they rely on adults to protect them.

Today we examined two accidents in which a total of eight children lost their lives. We must be the voice for our fellow travelers who may be too young to speak up and make protecting their safety in the air, on the water, and on the roads, our priority.

We stand adjourned.