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Air Methods Beech B100 accident

15 Jun 2009 · Rapid City, SD, United States

Beech B100 · Accident: clear air turbulence encounter en route

From Gordon Municipal Airport (KGRN) to Rapid City Regional Airport (KRAP)

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Event

NTSB case
CEN09LA388
Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
Accident
InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
Completed
API-reported fatalities
0 · all aircraft and ground
Ground fatalities
Unknown
OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
Charter & commuter
WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
Visual Meteorological Cond

Beech B100

Aircraft type
Beechcraft 100
Category
Airplane
RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
N4490M
Operator
Air Methods
Onboard fatalities
Unknown
Route
From Gordon Municipal Airport (KGRN), Gordon, NETo Rapid City Regional Airport (KRAP), Rapid City, SD
Aircraft age
Not recorded
Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
Part 135: Air Taxi & Commuter
Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
En route · descent
Defining eventThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
Clear air turbulence encounter
DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
None

Cause areas

  • Aircraft › Aircraft systems
  • Environmental issues › Conditions/weather/phenomena
  • Personnel issues › Task performance

Approximate · Coordinates from the NTSB case API, which marks them as estimated or does not say; no uncertainty radius is established.

NTSB narrative

The air-ambulance flight encountered clear-air turbulence during cruise descent. During the turbulence encounter, the patient’s unrestrained upper-torso fell off the aircraft mounted stretcher assembly. After the turbulence had subsided, the patient’s unrestrained head, neck, and upper-torso were laying off the stretcher in the center aisle. His restrained lower body remained attached to the stretcher which was elevated off the cabin floor. The cabin flight crewmembers stabilized the patient’s neck before repositioning him back onto the stretcher. The airplane then made an uneventful landing at its intended destination. The patient suffered a fracture of the C3 cervical vertebra during the turbulence encounter. The stretcher’s available over-the-shoulder restraints were not used because of an interference caused by a flexible lift system that was used to transfer the patient from the ambulance gurney to the aircraft’s stretcher. After the accident the aeromedical transport company discontinued the use of the flexible patient lift system model used during the accident flight and required flight crewmembers to only use lift systems that allowed the use of the aircraft stretcher’s available over-the-shoulder restraints.

Probable cause

The flight crewmembers’ failure to secure the patient using the available over-the-shoulder restraints and the encounter with clear-air turbulence during cruise descent.

Verbatim NTSB analysis and probable cause from the NTSB dataset

Sources

NTSB record CEN09LA388
Event ID
20090625X71751
Case number
CEN09LA388
Dataset
full-current
Source SHA-256
5cf380f0061817c0331a6b2d8cc7e0ee3a79bea469a1001dc5c10e56f35f5ab3
Source notes (4)
  • Unreviewed is an editorial label, not an investigation status. API-sourced is not report-checked or human-reviewed. Explicit event totals are used without summing aircraft injury tables; onboard allocation is withheld. Unknown values remain unknown. The operation category is mapped from the NTSB-reported FAR part and has not been reviewed.
  • Filled from the NTSB case API where the bulk record had no value: investigation status, coordinates, damage. Values present in the bulk record are kept.
  • The date is the local date, which is the same as the UTC date the NTSB stores.
  • API snapshot SHA-256: 544c51230ec04111ea4091d689abd01ed1f92635116e52a2968bd7b2db944bea; retrieved 2026-09-15T11:35:58.459Z.