Wednesday, November 23, 2011

Sabah, Sarawak to be major shareholders of MasWings

PETALING JAYA (Nov 23, 2011): Sabah and Sarawak state governments will be the major shareholders of MasWings when the airline becomes a regional airline.

Aviation industry sources told theSun yesterday that the several prominent businessmen from both states have also agreed to buy stakes in the airline which was expected to be relaunched by the middle of next year.

The sources however said that the both state governments will continue to hold a major share of the new airline to ensure that the service would not suffer to 'whims and fancies of the owners".

The sources said negotiations were being conducted and were expected to be made public soon.

It was learnt that the plans for the new airline was put in motion after Malaysia Airlines took over the jet service of its subsidiary, Firefly, last month.

The takeover meant Firefly no longer services Sabah and Sarawak, handing back the low fare sector to Air Asia.

Sources told theSun, the decision to end the Firefly service was taken poorly by the people in Sabah and Sarawak, prompting both state governments to lobby Prime Minister Datuk Seri Najib Abdul Razak to acquire MasWings.

It was learnt that negotiations were being carried to wet-lease at four narrow body jets so the airline could start servicing the Sabah/Sarawak to peninsula route soon. (The wet lease of an aircraft is an arrangement whereby the lessor provides at least some crew, maintenance and fuel.)

Initially it was planned that the airline was to make two daily flights from both Kuching and Kota Kinabalu to Kuala Lumpur.

Other routes for the airline may include KK to Tawau, Kuching to Bintulu/Miri and Kuching to KK.

The airline may also lease turbo-props planes to add to the six ATR-72s turbo-props already operated by MASWings for flights in both states.

Meanwhile, in Kuching, Sarawak Tourism Minister Datuk Amar Abang Johari Openg confirmed that the state may become the major shareholder of the airline.

"At this moment, it is still too premature to say much, but definitely, we will have something in mind," he told reporters when launching the Sarawak Tourism Calender for 2012 at the Media Room of the State Legislative Assembly.

He said with more shares, the State would have better say in the running of MasWings in its operations.

Abang Johari said if all goes according to plan, MasWings will start operating as a regional airline next year.

"But first, it must acquire at least four jetliners before it can start operating at a regional airline," he said, adding that currently MASWings is operating a fleet of ATR turbo-prop aircraft.

"As a regional airline, MASWings will have to fly to Singapore, Kuala Lumpur, Bangkok and Hong Kong. These are important hubs in the region," he added when asked to elaborate on his statement when winding up the debate in the State Legislative Assembly today.

On the Sarawak Tourism Calender, Abang Johari said that his ministry will organise a series of events next year as a prelude to the state's 50th anniversary in the formation of Malaysia.

"We have declared the year 2013 as a special year to mark the 50th anniversary," he said.

"Events and festivals will be our major attraction to entice immediate arrivals into the state," he added.

http://www.thesundaily.my

Abu Dhabi sets sights on sky with aerospace ambitions

The UAE plans to manufacture its own business jets before the end of the decade and become a main supplier to Boeing and Airbus, as the oil-rich region transforms itself into a global aviation hub.

Mubadala Aerospace, the Abu Dhabi state-owned maker of aircraft parts is looking to team up with companies such as Dassault Aviation, Gulfstream Aerospace and Cessna for their manufacturing and marketing capabilities, executive director Hommaid al-Shemmari said in an interview in Dubai. The business jet would seat eight to 14 passengers, he said.

Abu Dhabi, home to about 7 percent of the world’s proven oil reserves, is branching out into aerospace as the country’s biggest carriers, Emirates and Etihad, beef up their fleets to funnel travellers through the Middle East.

Emirates has transformed itself into the world’s largest airline by international traffic, and the company announce the largest deal at the Dubai Air show last week.

“You have to have a global ambition and that’s what we have for Abu Dhabi,” Shemmari said in the interview. “By 2030, we want to be one of top five aerostructure manufacturers in the world,” and among the biggest maintenance and repair centers besides Deutsche Lufthansa and Air France-KLM, he said.

The Middle East has expanded on its status as an omni-directional hub for long-haul travellers. Emirates is already the largest buyer of Airbus A380 superjumbos and Boeing 777 wide-body aircraft, of which the carrier agreed to buy an additional 50 units for $18bn at the air show.

Discussions are ongoing to build the business jet, Shemmari said. Mubadala already runs partnerships with Finmeccanica and General Electric, and it plans to build a $200m maintenance facility to service engines of Airbus A380 and Boeing 787 planes.

Any jet developed by Mubadala would face competition from the likes of Gulfstream, a unit of General Dynamics. Textron’s Cessna, Dassault Aviation’s Falcon, Embraer, and Bombardier, maker of the Global Express and Learjet aircraft.

Business aircraft run in size from the four-passenger Learjet 45XR to Gulfstream G650, a long-range luxury aircraft with 7,000-nautical mile range that debuts in 2012, to the Boeing and Airbus single-aisle 737 and A320 models that can be outfitted for 50 business passengers or more.

Mubadala also wants a partner for Strata, which makes composite parts for Airbus 330 and 340 planes at its factory in Al Ain and aims to start making Boeing plane parts.

Strata’s order book stands at $2.7bn, Shemmari said.

Strata’s composite manufacturing plant is an example of Mubadala’s strategy, said Shemmari. Abu Dhabi has the cash to invest, the cheap energy needed to power manufacturing projects, is tax-free and is pegged to the dollar, he said.

In two years, Strata is set to produce flap track fairings for A380 and A350 aircraft, and spoilers for the long-range aircraft. Strata offers “very competitive pricing” and “equivalent if not better” quality than previous suppliers, said Lee London, vice president of strategy and marketing at Airbus parent European Aeronautic, Defence & Space Co.

“Because they’ve made such good progress we are in a position where we can discuss more interesting, high-end, complicated, critical parts,” London said.

In the long-run, Mubadala would split composite parts manufacturing to 35 percent for Boeing and Airbus each with the remaining 30 percent for other companies, including military.

“When you look at the supply chain that Airbus and Boeing have today, they are changing their models, they don’t want to make everything themselves,” said Shemmari. “They want to bring more reliability into the supply chain.”

Flush with oil money and faced with depleting resources, Abu Dhabi aspires to diversify its economy by investing in industries including aerospace. Mubadala Aerospace’s parent company generated 20 percent of its revenue from aerospace in the first half. Mubadala Development Co’s revenue in the period grew 70 percent to AED13.6bn ($3.7bn).

“I’m a lucky guy,” Shemmari said. “I don’t have to worry about that. I build a business case. I go to my bosses and say ‘invest.’”

Abu Dhabi has outlined a plan to invest $500bn in industry, tourism and culture by 2030 and to increase non-oil revenue to 64 percent of the economy from 41 percent in 2007.

To be sure, not all of the region’s aerospace ambitions have turned out as planned. Dubai Aerospace Enterprise had aimed to compete in the global aircraft leasing industry in 2007. It ordered 100 planes from Boeing and another 100 from Airbus within a single week at the Dubai Air Show in 2007, only to end up cancelling every Airbus order and most of Boeing’s.

Financing may not be as problematic as finding skilled labour in a region that is known for minimal spending on research and development and importing foreign workers.

By 2030, Abu Dhabi’s population is forecast to grow to about three million from almost one million today. By then, GDP could double, with oil and gas contributing 36 percent while aerospace participates with 2 percent and 10,000 jobs, half of them filled by UAE nationals, said Shemmari.

“I want to prove that I can bring work, that I can train UAE nationals, bring expatriates, create a team that can deliver on time, on price, on quality,” he said.

Parallel runway plan in city aborted - Chennai, India.

CHENNAI: The Airports Authority of India (AAI) has dropped its plan to build a parallel runway at the Chennai airport. The decision comes after the state government informed AAI that they would rather prefer a new airport at Sriperumbudur.

The parallel runway was proposed in 2006 after studies showed that the existing terminals and runways would be inadequate to handle air traffic and the existing airport will saturate by 2015. But AAI had put the project on hold after the state government in 2009 expressed a keen interest to have an airport at Sriperumbudur.

The project was put on hold after AAI chairman V P Agrawal met the then state chief secretary K S Sripathy. They commissioned a study by the International Civil Aviation Organisation (ICAO) on the feasibility of building a new airport at Sriperumbudur.

The ICAO study, published in 2010, recommended that a parallel runway need not be constructed if a new airport was going to be built at Sriperumbudur. AAI officials handed over the report to the state government soon after Jayalalithaa took over after the elections this year. After the state government expressed its wish to have a second airport, AAI sent a letter saying that they will not require the land marked for acquisition for the parallel runway, said airport director E P Hareendranathan.

The four-runway second airport is proposed to be built on 4,823 acres at Sunguvarchathiram near Sriperumbudur, northwest of Chennai, at an estimated cost of Rs 3,500 crore, according to its initial plans.

Close to 1,000 acres in Kolapakkam, Manapakkam, Tharapakkam and Gerugambakkam area have been marked for acquisition for the parallel runway and the state government served notices to land owners in 2007. However, the government was finding it difficult to acquire land northwest of the Adyar river. It was estimated that the land acquisition would cost Rs 2,000 crore.

Residents of the areas had been protesting the move to acquire land for the runway for more than three years. They wanted the state government to build a second airport and de-notify their land. However, the state government is yet to de-notify the land that was marked for acquisition.

There was a feeling among officials that it would be more logical to have a second airport than spending money to expand the existing airport. The existing airport cannot be expanded further because land around the campus has been developed into residential localities.

AAI needs about 5,000 acres in Sripreumbudur for the construction of the new airport. Now, it remains to be seen if the government can get the work done in a fast-track mode.

http://timesofindia.indiatimes.com

Gearbox 'should have been replaced' days before North Sea helicopter tragedy

All 16 helicopter crash victims 

All 14 passengers and two crew on board the Super Puma died in the crash

AFTERMATH: Peterhead lifeboat crew retrieve the wreckage of the Eurocopter Super Puma which crashed into the North Sea, killing all 16 on board.   Picture: Colin Mearns Captain PAUL BURNHAM: Transmitted Mayday call. RICHARD MENZIES: Co-pilot of the Super Puma helicopter.

OPERATORS of a North Sea helicopter had been planning to replace its main rotor gearbox a week before the unit suffered a “catastrophic failure” leading to a crash which killed all 16 aboard, an air accident report said yesterday.

A magnetic particle had been found on the chip detector in the gearbox of the Eurocopter Super Puma, a final report by the Air Accidents Investigation Branch (AAIB) said. This had led the operator to initiate a plan to remove the main rotor gearbox and replace it with a unit from another helicopter undergoing heavy maintenance, the AAIB said.

However, actions taken following the discovery of the particle meant it was not recognised as an indication of the degradation of a part of the gearbox known as the second stage planet gear.

“The gearbox was declared serviceable by the operator and its planned replacement cancelled,” said the report.

It was this second stage planet gear that failed as a result of a fatigue crack, causing the failure of the main rotor gearbox.

As the helicopter was flying to Aberdeen from the Miller Platform in the North Sea on April 1, 2009, the main rotor separated from the fuselage and the aircraft crashed into the sea.

All 14 offshore workers and the two crewmen died.

The report told how, six seconds after expressing alarm, captain Paul Burnham transmitted “Mayday Mayday Mayday” followed one second later by co-pilot Richard Menzies transmitting “Mayday Mayday Mayday, this is Bond 85 November, emergency, currently on the 055”.

The report went on: “One second later, one of the flight crew uttered an expletive; this was the final radio transmission.”

The AAIB said the particle had been discovered on March 25, 2009. The operator’s engineers had sought the assistance of the manufacturer, Eurocopter, to deal with with what they considered to be a complex main rotor gearbox problem.

The AAIB added: “The use of verbal and email communication between the operator and manufacturer on March 25 led to a misunderstanding or miscommunication of the issue.”

The discovered particle was initially identified as a piece of scale.

However, further visual examination led the engineers to misidentify it as silver or cadmium plating which, according to the maintenance task card guiding maintenance staff, was “unimportant” and did not require the gearbox to be removed from service or to be put on “close monitoring”.

The AAIB said that after March 25, the existing detection methods did not provide any further indication of the degradation of the second stage planet gear. It added that the possibility of a material defect in the planet gear or damage due to the presence of foreign object debris “could not be discounted”.

The report said that after March 25 the maintenance task to examine the ring of magnets on the helicopter’s oil separator plates was not carried out.

The AAIB also said the helicopter did not provide an alert to the flight crew when the magnetic chip detector detected a particle.

The aircraft was at 2000ft when the accident happened. The first indication to the crew of a problem was loss of main rotor gearbox (MGB) oil pressure and the triggering of a master warning.

Two-and-a-half seconds before this indication, the co-pilot had made a radio transmission stating the helicopter was serviceable.

Immediately after the loss of MGB oil pressure, the helicopter began to descend and failed to respond to control inputs. The main rotor system separated from the helicopter approximately 20 seconds after the loss of MGB oil pressure.

During separation the main rotor blades struck the helicopter’s tail boom in several places, severing it from the fuselage.

In yesterday’s final report, which followed three interim reports, the AAIB listed 17 recommendations it had made during its investigation. They included recommendations to Eurocopter, the European Aviation Safety Agency, the UK’s Civil Aviation Authority and America’s Federal Aviation Administration.

Scotland’s Crown Office and Procurator-Fiscal Service (COPFS) welcomed the publication of the report on this “tragic incident, following a technically complex and challenging investigation”.

It went on: “The findings contained will now be fully considered by the health and safety division of COPFS.

“The division and Grampian Police have been engaged in this investigation since the tragedy occurred and will continue to progress lines of inquiry and carry out such investigation as is necessary in order that a decision may be taken in relation to the form of any proceedings.”

Welcoming the publication of the report, Bill Munro, Bond Offshore Helicopters’ managing director, said: “The report contains no recommendations for action by Bond. Following earlier interim recommendations by the AAIB, the manufacturer’s procedures have been strengthened and Bond, along with others in the industry, implemented those changes immediately.”
http://www.heraldscotland.com

Super Puma's North Sea death crash fault 'not recognised'

A fault indication which led to a North Sea helicopter crash that killed 16 men was not recognised just a week earlier, a report has found.

All 14 passengers and two crew on board lost their lives on 1 April, 2009, when the Bond Super Puma came down.

The Air Accidents Investigation Branch (AAIB) said an indication of gear degradation was not recognised.

There was then a "catastrophic failure" of the main rotor gearbox as a result of a fatigue fracture.

Eight of the victims came from the north east of Scotland, seven from Liverpool, Norfolk and Worcestershire, and one from Latvia.

The report said a magnetic particle had been found on the chip detector in the gearbox of the Eurocopter Super Puma.

However, it was not recognised as an indication of the degradation of a part of the gearbox known as the second stage planet gear.

The AAIB said: "The use of verbal and email communication between the operator and manufacturer on 25 March led to a misunderstanding or miscommunication of the issue."

It was this second stage planet gear that failed just days later as a result of a fatigue crack.

The main rotor separated from the fuselage and the aircraft crashed into the sea as the helicopter was flying to Aberdeen from the Miller Platform.

'Final transmission'

The report said the captain had transmitted a mayday followed by the co-pilot.

"One second later, one of the flight crew uttered an expletive; this was the final radio transmission," the report added.

The report makes 17 safety recommendations.


Bill Munro, managing director of Bond Offshore Helicopters, said: "The manufacturer's procedures have been strengthened and Bond, along with others in the industry, implemented those changes immediately.

"We take a rigorous approach to safety and will continue to do so as technology and best practice evolve. Our company will also implement any further actions required by the industry which are issued by the authorities and manufacturer as a result of the report.

"Our thoughts remain with the families of those who died, and their loss is a constant driver in our commitment to the highest standards of safety in all our operations."

Eurocopter said it remained committed to working closely with the regulatory authorities, investigators and its operators to prevent the risk of accidents.

'Significant developments'

A Crown Office spokesperson said: "The Crown Office and Procurator Fiscal Service (COPFS) welcomes the publication of the report on this tragic incident by the Air Accidents Investigation Branch, following a technically complex and challenging investigation.

"The findings contained therein will now be fully considered by the health and safety division of COPFS.

"The division and Grampian Police have been engaged in this investigation since the tragedy occurred and will continue to progress lines of inquiry and carry out such investigation as is necessary in order that a decision may be taken in relation to the form of any proceedings.

"The liaison with the nearest relatives of the 16 men who lost their lives will also continue and the division will keep them advised of significant developments."

Crew names

The two crew who died were Captain Paul Burnham, 31, of Methlick, Aberdeenshire, and co-pilot Richard Menzies, 24, of Droitwich Spa, who worked for Bond Offshore Helicopters.

The KCA Deutag employees killed were Brian Barkley, 30, of Aberdeen; Vernon Elrick, 41, of Aberdeen; Leslie Taylor, 41, of Kintore, Aberdeenshire; Nairn Ferrier, 40, of Dundee; Gareth Hughes, 53, of Angus; David Rae, 63, of Dumfries; Raymond Doyle, 57, of Cumbernauld; James John Edwards, 33, of Liverpool; Nolan Goble, 34, of Norwich, and Mihails Zuravskis, 39, of Latvia.

The other victims were James Costello, 24, of Aberdeen, who was contracted to Production Services Network (PSN); Alex Dallas, 62, of Aberdeen, who worked for Sparrows Offshore Services; Warren Mitchell, 38, of Oldmeldrum, Aberdeenshire, who worked for Weatherford UK; and Stuart Wood, 27, of Aberdeen, who worked for Expro North Sea Ltd.

http://www.bbc.co.uk

Male pilot dies in Miami County plane crash. Near Phillipsburg Airport ( 3I7), Phillipsburg, Ohio.





WEST MILTON - The pilot of a single-engine plane died in a crash around 8:45 p.m. Wednesday in the vicinity of S. Range Line Road and Emerick Road in Miami County.

West Milton Fire Chief Denny Frantz said at 10:30 p.m. that authorities were trying to determine the identity of the man and the origin of the plane. He said emergency responders had located a tail number on the plane and have contacted federal authorities. The coroner is enroute to the scene, he added.

The crash location is just west of West Milton. Range Line is closed at the crash scene. The crash report initially came in from a homeowner who reported hearing a large boom in the area of 6421 Range Line Road. The plane crashed nearly a mile from the road in a corn field.

Miami County Sheriff’s Office deputies were at the scene.

Chief Frantz said the plane did not burn upon impact and that debris was scattered and crumpled.


MIAMI CO., Ohio  - Emergency vehicles responded to a report of a small plane crash at 8:45 p.m. Wednesday.

Rescue crews from West Milton and nearby departments begin their investigation into the crash of a single-engine aircraft that went down southwest of West Milton. Miami County 9-1-1 received a call from a resident who heard a low-flying aircraft followed by a loud boom.

There is one confirmed fatality from the crash.

There is speculation that the aircraft may have been heading to nearby Phillipsburg Air Park. Emergency crews searched for about an hour before locating the wreckage in a field approximately a half-mile east of Rangeline and a mile south of Emerick Road.
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Emergency crews from multiple jurisdictions were at the scene of a small plane crash that occurred around 8:45 p.m. Wednesday in the vicinity of S. Range Line Road and Emerick Road in Miami County.

Emergency radio traffic indicated at least one fatality. The location is just west of West Milton. Range Line has been closed at the crash location. The crash report initially came in from a homeowner who reported hearing a large boom in the area of 6421 Range Line Road.

The Miami County Sheriff’s Office had deputies at the scene.

At 9:30 p.m., emergency crews were working in an area dense with trees next to a home on Range Line. A faint scent of smoke hung in the air.
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Emergency vehicles from several jurisdictions were responding to a report of a small plane crash around 8:45 p.m. Wednesday in a corn field in the vicinity of S. Range Line Road and Emerick Road in Miami County.

The location is just west of West Milton.

No details were immediately available. 

A Dayton Daily News reporter is enroute and this story will be updated soon.

http://www.daytondailynews.com

http://www.airnav.com/airport/3I7

Rockwell Commander 690A, Ponderosa Aviation Inc., N690SM: Fatal accident occurred November 23, 2011 in Apache Junction, Arizona

National Transportation Safety Board - Aviation Accident Final Report: http://app.ntsb.gov/pdf

Docket And Docket Items  -  National Transportation Safety Board:   http://dms.ntsb.gov/pubdms

National Transportation Safety Board -  Aviation Accident Data Summary:   http://app.ntsb.gov/pdf

http://registry.faa.gov/N690SM
 
NTSB Identification: WPR12MA046 
14 CFR Part 91: General Aviation
Accident occurred Wednesday, November 23, 2011 in Apache Junction, AZ
Probable Cause Approval Date: 12/03/2013
Aircraft: ROCKWELL 690, registration: N690SM
Injuries: 6 Fatal.

NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report.

Ponderosa Aviation, Inc. (PAI) purchased the airplane and relocated it from Indiana to PAI's base at Safford Regional Airport (SAD), Safford, Arizona, about 1 week before the accident. PAI's president conducted the relocation flight under a Federal Aviation Administration (FAA) ferry permit due to an unaccomplished required 150-hour inspection on the airplane. The airplane's arrival at SAD terminated the ferry permit, and no inspections were accomplished to render the airplane airworthy after its relocation. Although other airworthy airplanes were available, PAI's director of maintenance (DOM) (the accident pilot) and the director of operations (DO), who were co-owners of PAI along with the president, decided to use the nonairworthy airplane to conduct a personal flight from SAD to Falcon Field (FFZ), Mesa, Arizona, about 110 miles away. All available evidence indicates that the DOM was aware of the airplane's airworthiness status and that this was the first time he flew in the accident airplane. The DO flew the leg from SAD to FFZ under visual flight rules (VFR) in night visual meteorological conditions (VMC). After arriving at FFZ and in preparation for the flight back to SAD, the DOM moved to the left front seat to act as the pilot flying.

The airplane departed FFZ about 12 minutes after it arrived. The return flight was also conducted under VFR in night VMC. There was no moon, and the direction of flight was toward sparsely lit terrain. After takeoff, the air traffic control (ATC) tower controller instructed the pilot to maintain runway heading until advised due to an inbound aircraft. About 2 minutes later, the controller cleared the airplane for its requested right turn and then began a position relief briefing for the incoming controller. No subsequent communications to or from the airplane occurred, nor were any required. Radar data indicated that the airplane turned onto a course directly towards SAD and climbed to and leveled at an altitude of 4,500 feet. About 4 minutes after the right turn, while continuing on the same heading and ground track, the airplane impacted a mountain in a wings-level attitude at an elevation of about 4,500 feet.

Although the airplane was technically not airworthy due to the unaccomplished inspection, the investigation did not reveal any preimpact airframe, avionics, engine, or propeller discrepancies that would have precluded normal operation. Airplane performance derived from radar tracking data did not suggest any mechanical abnormalities or problems.

FFZ, which has an elevation of 1,394 feet mean sea level (msl), is situated about 15 miles west-northwest of the impact mountain. The mountain is surrounded by sparsely lit terrain and rises to a maximum charted elevation of 5,057 feet msl. The investigation was unable to determine whether, or to what degree, the pilot conducted any preflight route and altitude planning. If such planning had been properly accomplished, it would have accounted for the mountain and provided for terrain clearance. The pilot had flown the round trip flight from SAD to FFZ several times and, most recently, had flown a trip from SAD to FFZ in night VMC 2 days before the accident. Thus, the pilot was familiar with the route and the surrounding terrain. According to the pilot's brother (PAI's president), the pilot typically used an iPad for navigation and flew using the ForeFlight software app with the "moving map" function. The software could display FAA VFR aeronautical charts (including FAA-published terrain depictions) and overlay airplane track and position data on the chart depiction. Although iPad remnants were found in the wreckage, the investigation was unable to determine whether the pilot adhered to his normal practice of using an iPad for the flight or, if so, what its relevant display settings (such as scale or terrain depiction) were. Had the pilot been using the ForeFlight app as he normally did, he could have been able to determine that the airplane would not clear the mountain on the given flight track.

According to the pilot's brother, the pilot typically departed an airport, identified the track needed to fly directly to his destination, and turned the airplane on that track. Radar tracking data from the accident flight indicated that the airplane began its turn on course to SAD about 2 miles northeast of FFZ. Comparison of the direct line track data from FFZ to SAD with the track starting about 2 miles northeast of FFZ direct to SAD revealed that while the direct line track from FFZ to SAD passed about 3 miles south of the impact mountain, the direct track from the point 2 miles northeast of FFZ to SAD overlaid the impact mountain location. Thus, the pilot likely set on a direct course for SAD even though the delayed right turn from FFZ put the airplane on a track that intersected the mountain. The pilot did not adjust his flight track to compensate for the delayed right turn to ensure clearance from the mountain.

In addition, a sector of the Phoenix Sky Harbor (PHX) Class B airspace with a 5,000-foot floor was adjacent to the mountain range, which reduced the vertical options available to the pilot if he elected to remain clear of that airspace. The pilot's decision to remain below the overlying Class B airspace placed the airplane at an altitude below the maximum elevation of the mountain. The pilot did not request VFR flight following or minimum safe altitude warning (MSAW) services. Had he requested VFR flight following services, he likely would have received safety alerts from ATC as defined in FAA Order 7110.65. Had he requested the MSAW in particular, he likely would have received an advisory that his aircraft was in unsafe proximity to terrain. Further, the investigation was unable to determine why the pilot did not request clearance to climb into the Class B airspace or fly a more southerly route that would have provided adequate terrain clearance. On the previous night VMC flight from FFZ to SAD, the pilot stayed below the Class B airspace but turned toward SAD right after departure. In response to issues raised by this accident, the FAA conducted a Performance Data Analysis Report System (PDARS) study to determine the legitimacy of a claim that it was difficult for VFR aircraft to be granted clearance to enter Class B airspace. The PDARS study revealed that on the day of the accident, 341 VFR aircraft were provided services by Phoenix TRACON. The PDARS study, however, was unable to document how many aircraft were actually within the Class B airspace itself or how many had been refused services; the study only documented how many had been provided services. In response to a January 20, 2012, FAA internal memo formally restating the claim that it was difficult for VFR aircraft to obtain clearance into the PHX Class B airspace, the FAA conducted a comprehensive audit of the PHX Class B airspace that spanned four different time periods and was spread among several sectors during peak traffic periods to provide the most accurate picture. Of 619 requests for VFR aircraft to enter Class B airspace, 598 (96.61%) were granted. While data was not available to refute or substantiate any claims from previous years regarding difficulty obtaining clearance into the PHX Class B airspace, this data clearly indicated that difficulty obtaining clearance into the PHX Class B airspace did not exist during the four time periods in which the audit took place in the months after the accident.

The moonless night decreased the already low visual conspicuity of the mountain. The airplane was equipped with very high frequency omnirange and GPS navigation units, a radar altimeter, and an Avidyne EX-500 multifunction display. Had the pilot conducted the flight under instrument flight rules (IFR), the resultant handling by ATC would have helped ensure terrain clearance.

The airplane was not equipped with a terrain awareness and warning system (TAWS). Six years earlier, the accident airplane seating configuration was changed to reduce passenger seat provisions from six to five by removing a seat belt from the aft divan, which was originally configured with seat belts for three people. This modification rendered the airplane exempt from the TAWS requirement; however, this modification was not approved by the FAA or documented via a supplemental type certificate or FAA Form 337 (Major Repair and Modification). Per the requirements of 14 Code of Federal Regulations 91.223, TAWS is not required for airplanes with fewer than six passenger seats. In this accident, onboard TAWS equipment could have provided a timely alert to help the pilot avoid the mountain.

Based on the steady flight track; the dark night conditions; the minimal ground-based lighting; and the absence of preimpact airplane, engine, or propeller anomalies that would have affected the flight, the airplane was likely under the control of the pilot and was inadvertently flown into the mountain. This controlled flight into terrain (CFIT) accident was likely due to the pilot's complacency (because of his familiarity with the flight route and because he selected a direct route, as he had previously done, even though he turned toward the destination later than he normally did) and lack of situational awareness. In January 2008, the National Transportation Safety Board issued a safety alert titled "Controlled Flight Into Terrain in Visual Conditions: Nighttime Visual Flight Operations Are Resulting in Avoidable Accidents." The safety alert stated that recent investigations identified several accidents that involved CFIT by pilots operating under VFR at night in remote areas, that the pilots appeared unaware that the aircraft were in danger, and that increased altitude awareness and better preflight planning likely would have prevented the accidents. The safety alert suggested that pilots could avoid becoming involved in a similar accident by accomplishing several actions, including proper preflight planning, obtaining flight route terrain familiarization via sectional charts or other topographic references, maintaining awareness of visual limitations for operations in remote areas, following IFR practices until well above surrounding terrain, advising ATC and taking action to reach a safe altitude, and employing a GPS-based terrain awareness unit.

Member Sumwalt filed a concurring statement that can be found in the public docket for this accident. Member Weener joined the statement.

The National Transportation Safety Board determines the probable cause(s) of this accident to be:

The pilot's failure to maintain a safe ground track and altitude combination for the moonless night visual flight rules flight, which resulted in controlled flight into terrain. Contributing to the accident were the pilot's complacency and lack of situational awareness and his failure to use air traffic control visual flight rules flight following or minimum safe altitude warning services. Also contributing to the accident was the airplane's lack of onboard terrain awareness and warning system equipment.

Member Sumwalt filed a concurring statement that can be found in the public docket for this accident. Member Weener joined the statement.

HISTORY OF FLIGHT

On November 23, 2011, about 1831 mountain standard time, a Rockwell International (Aero Commander) 690A airplane, N690SM, was destroyed when it impacted terrain in the Superstition Mountains near Apache Junction, Arizona. The commercial pilot and the five passengers were fatally injured. The airplane was registered to Ponderosa Aviation, Inc. (PAI) and operated by PAI under the provisions of 14 Code of Federal Regulations (CFR) Part 91 as a personal flight. Night visual meteorological conditions (VMC) prevailed, and no flight plan was filed. The airplane had departed Falcon Field (FFZ), Mesa, Arizona, about 1825 and was destined for Safford Regional Airport (SAD), Safford, Arizona.

PAI's director of maintenance (DOM) and the director of operations (DO), who were co owners of PAI along with the president, conducted a personal flight from SAD to FFZ. The DO flew the leg from SAD to FFZ under visual flight rules (VFR) in night VMC. After arriving at FFZ and in preparation for the flight back to SAD, the DOM moved to the left front seat to act as the pilot flying. The airplane departed FFZ about 12 minutes after it arrived. According to a witness, engine start and taxi-out appeared normal.

Review of the recorded communications between the pilot and the FFZ tower air traffic controllers revealed that when the pilot requested taxi clearance, he advised the ground controller that he was planning an "eastbound departure." The flight was cleared for takeoff on runway 4R, and the pilot was instructed to maintain runway heading until advised, due to an inbound aircraft. About 90 seconds later, when the airplane was about 1.1 miles from the departure end of the runway, the tower local controller issued a "right turn approved" advisory to the flight, which the pilot acknowledged. Radar data revealed that the airplane flew the runway heading for about 1.5 miles then began a right turn toward SAD and climbed through an altitude of about 2,600 feet mean sea level (msl). About 1828, after it momentarily climbed to an altitude of 4,700 feet, the airplane descended to an altitude of 4,500 feet, where it remained and tracked in an essentially straight line until it impacted the mountain. The last radar return was received at 1830:56 and was approximately coincident with the impact location. The impact location was near the top of a steep mountain that projected to over 5,000 feet msl. Witnesses reported seeing a fireball, and law enforcement helicopters were dispatched.

PERSONNEL INFORMATION

Pilot (General Information)

The pilot, age 31, held a commercial pilot certificate with ratings for single-engine and multiengine land and instrument airplane. He also held a mechanic certificate with ratings for airframe and powerplant. His Federal Aviation Administration (FAA) second class medical certificate was issued in July 2011. The pilot was a co-owner of PAI and was PAI's DOM.

The pilot's personal flight records contained entries until February 2011, at which time the pilot recorded that he had 1,151.9 hours in single-engine airplanes and 951.5 hours in multiengine airplanes. On his most recent FAA medical certificate application, the pilot reported a total flight experience of 2,500 hours.

The computerized PAI flight record (which began tracking 14 CFR Part 135 flights only in February 2011) indicated that the pilot had 116.5 hours total flight experience, including 18 hours in night VMC. According to the records, during the preceding 90 and 30 days, the pilot had accumulated about 28.5 and 5.3 flight hours, respectively. The records showed that the pilot had flown 2 hours on two different flights in the week before the accident. The most recent flight was in night VMC from SAD to FFZ and back. Examination of the flight records revealed that the pilot had flown that round trip flight at least twice, in the previous 2 weeks.

Pilot Training

According to PAI and its FAA principal operations inspector (POI), employee pilots receive annual training over a 2- to 3-day period. The chief pilot organized most of the training, which consisted of regulation review, company policy, and actual flight training. The POI observed parts of the training. According to company training records, the pilot's most recent 14 CFR Part 135 competency/proficiency check was satisfactorily completed on September 24, 2011.

Pilot's 72-Hour History

According to the pilot's wife, in the 3 days before and including the accident day, the pilot awoke about 0630 and left for work about 0700. Two days before the accident, he flew to FFZ, arriving back at SAD about 2145.

Relatives of the pilot stated that nothing unusual had occurred in his life in the 72-hour period before the accident. His wife reported that the pilot did not take medications, aside from a hypothyroidism medication that he had reported to the FAA, and he did not have any physical conditions or ailments aside from the hypothyroidism.

MEDICAL AND PATHOLOGICAL INFORMATION

The Forensic Science Center in Tucson, Arizona, conducted an autopsy on the pilot; the cause of death was cited as blunt force trauma. The FAA Forensic Toxicology Research Team at the Civil Aviation Medical Institute performed toxicological testing of specimens collected during the autopsy. The results of the specimens were negative for carbon monoxide, cyanide, and listed drugs.

AIRPLANE INFORMATION

General

The airplane was manufactured in 1976 by Rockwell International, and the type certificate holder at the time of the accident was Twin Commander, LLC. The airplane was equipped with two Honeywell TPE-331-series turboshaft engines and two Hartzell three-blade propellers. Maintenance records indicated that the airframe had accumulated a total time in service of about 8,188 hours. The left engine had accumulated a total time since major overhaul of about 545 hours, and the right engine had accumulated a total time since major overhaul of about 1,482 hours.

The airplane was recently purchased by PAI and was flown about 1,200 miles from Indiana to the PAI facility at SAD about 1 week before the accident. It was certificated for single-pilot operation. At the time of the accident, the airplane was configured for a pilot (left side), a copilot (right side), and five passengers.

According to the sale advertisement listing for the airplane, the airplane was equipped with very high frequency omnirange (VOR) and GPS (KLN 90B) navigation units, a radar altimeter, and an Avidyne EX-500 multifunction display, which were destroyed in the accident.

Ferry Permit Information

At the time of purchase by PAI, the airplane was not in compliance with an FAA required 150-hour inspection requirement, and PAI requested an FAA ferry permit to fly the airplane from Eagle Creek Airpark (EYE), Indianapolis, Indiana, to the PAI facility in Safford, Arizona. On November 16, 2011, the FAA issued a ferry permit for the relocation of the airplane. The permit was valid until arrival at SAD or November 25, 2011, whichever came first. It only permitted a direct flight between EYE and SAD and only allowed the pilot and essential crew on board. The airplane was flown by the PAI president, who was the brother of the accident pilot, from EYE to SAD on November 17, 2011. The arrival at SAD terminated the ferry permit.

PAI and FAA Scottsdale Flight Standards District Office (FSDO) personnel estimated that it would normally require two people 2 days to conduct the inspection necessary to render the airplane in compliance with the outstanding airworthiness items, exclusive of correcting any identified deficiencies. All available evidence indicated that no maintenance activity was accomplished on the airplane between its arrival at SAD and its departure to FFZ on the night of the accident; the condition that warranted the ferry permit had not been corrected.

Terrain Awareness and Warning System (TAWS) Equipment Information

Title 14 CFR 91.223 stated that with certain exceptions, turbine-powered, US registered airplanes configured with six or more passenger seats and manufactured before early 2002 could not be operated after March 29, 2005, unless the airplane was equipped with an approved TAWS unit.

Since the accident airplane was manufactured in 1976 and was turbine-powered, any exclusion from the TAWS requirement required that the airplane had to be configured with five or fewer passenger seating positions. According to the type certificate holder's documentation, the airplane was manufactured and delivered with six passenger seating positions. Therefore, the airplane's as manufactured configuration required the installation of TAWS by March 2005. No records indicating that the number of passenger seating positions was ever less than six before May 2005 were located. However, a detailed review of airplane maintenance records, preaccident photographs, TAWS equipment manufacturer's data, and a detailed inventory of the recovered wreckage indicated that the accident airplane was never equipped with TAWS. (The sale advertisement information for the airplane indicated that it was equipped with a KGP-560 TAWS B unit.)

Maintenance documentation indicated that in May 2005, the airplane seating configuration was changed to reduce passenger seat provisions from six to five by removing a seat belt from the aft divan, which was originally configured with seat belts for three people. Per the requirements of 14 CFR 91.223 and the reduced passenger seat count, the airplane was not required to be equipped with TAWS.

However, FAA and manufacturer/type certificate holder guidance indicated that any seating configuration changes should be approved by either the FAA or the manufacturer/type certificate holder, and examination of the maintenance documentation for the accident airplane revealed that neither requirement had been satisfied. The seating modification was not approved by the FAA or any other agency or documented either via a supplemental type certificate and/or FAA Form 337 (Major Repair and Alteration). Postaccident review of the documentation that was used to substantiate the seating configuration change revealed that the modified seating position plan was not one of the manufacturer's/type certificate holder's approved configurations. The document that was used to substantiate the change was determined to be an altered version of the manufacturer's original document, but it was incorrectly represented as a manufacturer's original document. Attempts to determine who made the improper and unauthorized changes to the seating configuration document, or when they were made, were unsuccessful.

METEOROLOGICAL INFORMATION

The FFZ 1854 automated weather observation included wind from 350 degrees at 5 knots, visibility 40 miles, few clouds at 20,000 feet, temperature 23 degrees C, dew point -1 degrees C, and an altimeter setting of 29.93 inches of Mercury. US Naval Observatory data for November 23, 2011, indicated that the moon, which was a waning crescent of 3%, set at 1605, and local sunset occurred at 1721.

AIDS TO NAVIGATION

Neither FFZ nor SAD was equipped with a VOR ground navigation facility. Navigation between the two airports via available VOR stations would result in an indirect flight route.

The flight from SAD to FFZ and the accident flight were both conducted in VMC as VFR flights. No flight plan was filed for either flight, and neither pilot had requested air traffic control (ATC) flight following services. Available radar data and interviews with PAI personnel indicated that the pilot had flown between SAD and FFZ several times previously and that he tended to use his iPad, equipped with ForeFlight software and GPS, to fly directly between the two. The software could display FAA VFR aeronautical charts (including FAA-published terrain depiction) and overlay airplane track and position data on the chart depiction. According to the pilot's brother, the pilot's habit pattern was to depart the airport, identify the track needed to fly directly to the destination, and turn the airplane onto that track. Remnants of an iPad were found in the wreckage. Damage precluded determination of its positive association with a particular owner, its functionality, or its operational status at the time of the accident.

Radar tracking data from the accident flight indicated that the airplane began its right turn on course to SAD about 1.5 miles northeast of FFZ. Comparison of the direct line track data from two different initial locations (FFZ, and northeast of FFZ after completion of the turn) to SAD revealed that while the direct track from FFZ to SAD passed about 3 miles south of the impact mountain, the direct track from northeast of FFZ to SAD overlaid the impact mountain location. That resulting ground track was also coincident with the accident flight radar data ground track.

COMMUNICATIONS

Sequence of Events

The pilot first contacted FFZ ground control at 1820:21. The pilot was instructed to taxi to runway 4R via taxiway D, and he taxied as instructed without incident. At 1823:35, the pilot contacted FFZ local control and advised that he was holding short and was ready for departure. The pilot was advised to again hold short to wait for landing traffic. At 1825:00, the controller instructed the pilot to "fly straight out" until advised due to landing traffic and cleared him for takeoff from runway 4R. The airplane became airborne at 1826:14. At 1826:47, the controller issued the "right turn approved" advisory to the pilot. At that point, the airplane was still on the runway heading, about 1.45 nautical miles (nm) from FFZ, and climbing through an altitude of about 2,200 feet. The pilot responded to the transmission with "right turn approved." No further radio transmissions to or from the accident pilot were recorded.

AIRPORT INFORMATION

General

FFZ was equipped with two runways designated 4/22 L and R. The airplane's arrival and departure runway (4R) measured 5,101 feet by 100 feet. Airport elevation was 1,394 feet msl. The local topography consisted of a flat basin floor bounded by mountainous terrain, primarily to the north and east. FFZ was situated about 15 miles west-northwest of the impact mountain, which rose very steeply to a charted maximum elevation of 5,057 feet msl, or about 3,700 feet above FFZ.

WRECKAGE AND IMPACT INFORMATION

Accident Site

The accident site was on the northwest face near the top of the Flatiron region of Superstition Mountain. The accident site consisted of two basic terrain areas: a sloped area (about 45 degrees downhill to the northwest), abutted by a vertical rock formation on its southeast side.

The sloped area was primarily rock, interlaced with cracks, soil patches, boulders, and sparse vegetation. The rock formation rose about 100 feet above the southeastern edge of the sloped area. Airplane debris was scattered on the sloped area in a primary field that measured about 150 feet southeast-northwest by about 80 feet northeast-southwest. A significant amount of debris was clustered near the base of the vertical face, with some debris strewn or caught on the face. The southeast section of the sloped area and much of the vertical face were fire damaged, soot covered, or scorched. The northwest edge of the sloped debris field was about 150 feet southeast of the end of the sloped terrain, which then became very steep (sometimes near vertical) and fell irregularly away to the valley floor about 3,000 feet below.

On-Site Wreckage Observations

The impact site was located on steep rocky terrain at an elevation of about 4,500 feet msl that was essentially only accessible by helicopter. The wreckage was recovered by helicopter and transported to a secure facility for subsequent detailed examination.

The airplane was highly fragmented. The debris pattern axis was oriented northwest to southeast, and the debris and fire damage were arrayed in a fan-like pattern consistent with the approximate flight direction. Most airplane components were severely impact and fire-damaged. Some debris (heavier/denser items, such as engine gearbox components and generators) was found northwest (downhill) of the main debris field, consistent with those components rolling downhill after impact. The largest wreckage section was a portion of an inboard wing box with one engine attached. Paint transfer marks on the rock face were consistent with a wings-level (roll axis) impact.

Both engines and portions of their propellers were identified in the wreckage. Propeller, engine, and gearbox damage was consistent with high power rotation at impact. All three landing gear were identified in the wreckage, and damage patterns were consistent with the landing gear being retracted at impact. Some airplane skin segments exhibited significant accordion-like crush damage. Many cockpit-related items, including instruments, instrument panel sections, and pilots' seat fragments, were found on the terrain beyond the vertical rock formation; some were several hundred feet beyond the vertical rock formation.

Damage patterns were consistent with the engines developing power at the time of impact. The majority of the first-stage compressor impeller blades were separated at the hubs. The second-stage compressor impeller blades were bent opposite the direction of rotation. There was rotational scoring on the aft side of the third-stage turbine blade platforms and metal spray deposits on the suction side of the third-stage turbine blades. No preimpact discrepancies that would have precluded normal engine operation were identified.

The blade damage to both propellers was severe, with leading-edge damage, multiple bends, twisting, concave bending of the blade chord at the tips, and tips that had fractured and separated. Two separate blade angle witness marks were each consistent with impact while at a normal (not in feather and not in reverse) operating position. No preimpact discrepancies that would have precluded normal propeller operation were identified.

ORGANIZATIONAL AND MANAGEMENT INFORMATION

Ponderosa Aviation, Inc.

PAI was founded in 1975 by the pilot-rated passenger's father. Later, the pilot and his brother purchased the company, and, in January 2011, the pilot-rated passenger, who had worked there for many years, bought into a partnership with them.

At the time of the accident, PAI, which was based at SAD, employed 25 people, including 13 pilots (10 on a seasonal/part-time basis) and 9 maintenance personnel. PAI owned a total of 14 airplanes, including the accident airplane. The fleet included three Rockwell International (Aero Commander) 690 models and nine 500 models.

PAI held a 14 CFR Part 135 operating certificate for on-demand air carrier operations in the contiguous United States and the District of Columbia. However, PAI rarely exercised the privileges of that certificate and averaged about two revenue passenger transport flights per year. PAI's primary purpose for obtaining and maintaining the certificate was to be qualified to contract with the US Forest Service and the Bureau of Land Management for air attack missions (the application of aerial resources, by both fixed-wing aircraft and rotorcraft, on a fire).

Eight of the PAI airplanes were on the 14 CFR Part 135 certificate; the accident airplane had not yet been added to the certificate.

FAA Oversight

The FAA FSDO in Scottsdale, Arizona, was the assigned certificate-holding district office for PAI and oversaw about 60 Part 135 certificated operators, no Part 121 certificated operators, and about 520 Part 91 operators.

The POI was assigned to PAI in 2007. Her duties included oversight of 12 designees and 30 check airmen and POI for 54 operators. PAI was one of 10 Part 135 operators assigned to the POI. She estimated that she had about 100 hours in Rockwell International/Aero Commander airplanes, 25 of which were in the 690 model. The POI considered PAI to be a "low-maintenance operator," meaning that PAI was compliant with FAA requirements and presented few issues of concern. She physically visited PAI about once per year. Due to the distance between the FSDO and SAD, she never made unannounced visits. Her visits would take about 2 days, during which she would oversee pilot training, examine records and recordkeeping, and conduct base inspections and ramp checks. She never gave checkrides to PAI pilots; those were conducted by another inspector. The POI qualified the pilot-rated passenger as a "good" chief pilot. He was the person at PAI with whom the POI had the most contact, and she would mainly communicate her concerns and questions to him. She did not have much familiarity with the pilot.

ADDITIONAL INFORMATION

Homeowner's Surveillance Camera Imagery

The airplane's preimpact flightpath, impact explosion, postimpact fire, and initial arrival of search and rescue aircraft were captured on a private citizen's home surveillance camera. That camera was located about 6 miles south of and 3,700 feet lower than the impact site. A file that contained about 50 minutes of image data, during the period from about 1810 to 1900, was provided to the National Transportation Safety Board (NTSB). The time stamp data was provided by the camera owner and was not independently correlated or verified by the NTSB; therefore, all times are approximate.

The 1810 image depicted the mountain in silhouette form, but as night fell, the mountain disappeared from the image. No lights were visible on the mountain. Due to the night conditions, the optical resolution capability of the camera, and the distance of the airplane from the camera, the imagery provided only a macro view and associated timeline of the events. The airplane itself was not visible; its position was manifested by its blinking beacon or strobe lights only. The lights of the airplane first appeared in the field of view at 1830:00 and remained visible until 1830:48, when the lights disappeared behind the terrain. A large flash of light appeared at 1830:52, followed by a second, much larger and brighter flash about 3 seconds later. Lights indicative of a fire remained visible until about 1844, and the first responding aircraft (again only visible as lights) appeared about 1848.

Examination of the path of the airplane's lights on the image field of view did not reveal any erratic motions or changes of direction; the stability of the flightpath was similar to that depicted in the ground tracking radar data.

Weight and Balance Information

Maintenance records indicated that on at least 15 occasions, modifications that affected the airplane's weight and balance values were accomplished; however, no records of the actual revised weight and balance data were discovered during the investigation.

Calculations that used the original empty weight plus other known or presumed values resulted in an estimated accident flight weight of 8,953 pounds, which was below the maximum allowable weight, and a center of gravity within the allowable envelope.

Airplane Performance

The derived level-flight ground speed for the last 2 minutes of the flight was approximately 190 knots, which was slightly higher than the pilot's operating handbook maximum range speed for similar conditions. Surface wind data indicated that the airplane would have experienced a slight tailwind during the climbout and level-flight segments.

TAWS-Related Guidance for FAA Inspectors

Published FAA guidance for FAA inspectors to use to determine whether the airplane seating configuration changes (if properly accomplished) would have exempted the airplane from the TAWS requirement was examined in detail. The relevant FAA guidance included FAA Order 8900.1 and 14 CFR Part 1, Part 21, Part 43 (Appendix 1), Part 91, and Part 135.

Phoenix Sky Harbor (PHX) Class B Airspace Information

The Phoenix metropolitan area was designated and charted as Class B airspace, centered on PHX and the PHX VOR (PXR). The airspace elevation boundaries were defined by floor and ceiling altitudes, with lateral boundaries defined by distance and bearing from defined locations. Class B airspace is typically described as having the shape of an "upside-down wedding cake," where the airspace floor altitudes increase as the distance from the center increases. Aircraft operating under VFR are prohibited from entering Class B airspace without explicit permission from the responsible ATC facility. Mountainous terrain rises to 4,500 feet less than 1 nm east of the 5-000-foot Class B airspace, and the terrain rises to a maximum elevation of 5,057 feet about 3 1/2 miles east.

The NTSB ATC group chairman's factual report provides detailed information regarding the Class B airspace around the Phoenix area. For more information, see the docket for this accident (NTSB case number WPR12MA046).

Controlled Flight Into Terrain (CFIT) Accidents

The FAA defines a CFIT accident as a situation that occurs when a properly functioning aircraft "is flown under the control of a qualified pilot, into terrain (water or obstacles) with inadequate awareness on the part of the pilot of the impending collision."

In 1998, the FAA formed the General Aviation (GA) CFIT Joint Safety Analysis Team (JSAT) as part of the FAA "Safer Skies" program. The stated goal of the Safer Skies initiative was to significantly reduce fatal accidents over a 10-year period via a comprehensive review of aviation accident causes and implementation of safety intervention strategies. In April 1999, the GA CFIT JSAT published its final report, which identified 55 interventions to address CFIT accident causes. The FAA CFIT Joint Safety Implementation Team (JSIT) was formed to develop detailed CFIT accident reduction strategies based upon the top 10 JSAT interventions that were considered to be the most effective and feasible. The CFIT JSIT final report was published in 2000, and JSIT recommended interventions included the following:

- Improve safety culture within the aviation community,
- Promote development and use of low-cost terrain clearance and/or look-ahead device,
- Improve pilot training regarding decision-making and human factors,
- Enhance the biennial flight review and/or instrument competency check, and
- Develop and distribute mountain flying technique advisory material.

In March 2003, as part of its response to the CFIT JSIT, the FAA issued Advisory Circular (AC) 61-134, "General Aviation Controlled Flight Into Terrain Awareness." The AC "highlights the inherent risk" that CFIT poses for GA pilots. According to the AC, one primary cause of CFIT accidents was loss of situational awareness.

Situational Awareness

The Pilot's Handbook of Aeronautical Knowledge (FAA-H-8083-25) defined situational awareness as the "accurate perception of the operational and environmental factors that affect the airplane, pilot, and passengers during a specific period of time." The handbook stated that a situationally aware pilot "has an overview of the total operation and is not fixated on one perceived significant factor." The handbook stated that "some of the elements inside the airplane to be considered are the status of airplane systems, and also the pilot and passengers" and cautioned that "an awareness of the environmental conditions of the flight, such as spatial orientation of the airplane, and its relationship to terrain, traffic, weather, and airspace must be maintained."

The handbook stated that obstacles to maintaining situational awareness included fatigue, stress, and task overload and that a contributing factor in many accidents is a distraction that diverts the pilot's attention. Complacency was cited as another obstacle to maintaining situational awareness. When activities become routine, there is a tendency to relax and not put as much effort into performance. Like fatigue, complacency reduces a pilot's effectiveness in the cockpit. However, complacency is harder to recognize than fatigue, since everything is perceived to be progressing smoothly.

NTSB Safety Alert

In January 2008, the NTSB issued a safety alert titled "Controlled Flight Into Terrain in Visual Conditions: Nighttime Visual Flight Operations Are Resulting in Avoidable Accidents." The safety alert stated that recent investigations identified several accidents that involved CFIT by pilots operating under visual flight conditions at night in remote areas, that the pilots appeared unaware that the aircraft were in danger, and that increased altitude awareness and better preflight planning likely would have prevented the accidents.

The safety alert suggested that pilots could avoid becoming involved in a similar accident by proper preflight planning, obtaining flight route terrain familiarization via sectional charts or other topographic references, maintaining awareness of visual limitations for operations in remote areas, following instrument flight rules practices until well above surrounding terrain, advising ATC and taking action to reach a safe altitude, and employing a GPS-based terrain awareness unit.


NTSB Identification: WPR12MA046 
 Nonscheduled 14 CFR Part 91: General Aviation
Accident occurred Wednesday, November 23, 2011 in Apache Junction, AZ
Aircraft: ROCKWELL 690, registration: N690SM
Injuries: 6 Fatal.

NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report.

HISTORY OF FLIGHT

On November 23, 2011, about 1831 mountain standard time, a Rockwell International (Aero Commander) 690A airplane, N690SM, was destroyed when it impacted terrain in the Superstition Mountains near Apache Junction, Arizona. The commercial pilot and the five passengers were fatally injured. The airplane was registered to Ponderosa Aviation, Inc. (PAI) and operated by PAI under the provisions of 14 Code of Federal Regulations (CFR) Part 91 as a personal flight. Night visual meteorological conditions (VMC) prevailed, and no flight plan was filed. The airplane had departed Falcon Field (FFZ), Mesa, Arizona, about 1825 and was destined for Safford Regional Airport (SAD), Safford, Arizona.

PAI’s director of maintenance (DOM) and the director of operations (DO), who were co owners of PAI along with the president, conducted a personal flight from SAD to FFZ. The DO flew the leg from SAD to FFZ under visual flight rules (VFR) in night VMC. After arriving at FFZ and in preparation for the flight back to SAD, the DOM moved to the left front seat to act as the pilot flying. The airplane departed FFZ about 12 minutes after it arrived. According to a witness, engine start and taxi-out appeared normal.

Review of the recorded communications between the pilot and the FFZ tower air traffic controllers revealed that when the pilot requested taxi clearance, he advised the ground controller that he was planning an "eastbound departure." The flight was cleared for takeoff on runway 4R, and the pilot was instructed to maintain runway heading until advised, due to an inbound aircraft. About 90 seconds later, when the airplane was about 1.1 miles from the departure end of the runway, the tower local controller issued a "right turn approved" advisory to the flight, which the pilot acknowledged. Radar data revealed that the airplane flew the runway heading for about 1.5 miles then began a right turn toward SAD and climbed through an altitude of about 2,600 feet mean sea level (msl). About 1828, after it momentarily climbed to an altitude of 4,700 feet, the airplane descended to an altitude of 4,500 feet, where it remained and tracked in an essentially straight line until it impacted the mountain. The last radar return was received at 1830:56 and was approximately coincident with the impact location. The impact location was near the top of a steep mountain that projected to over 5,000 feet msl. Witnesses reported seeing a fireball, and law enforcement helicopters were dispatched.

PERSONNEL INFORMATION

Pilot (General Information)

The pilot, age 31, held a commercial pilot certificate with ratings for single-engine and multiengine land and instrument airplane. He also held a mechanic certificate with ratings for airframe and powerplant. His Federal Aviation Administration (FAA) second class medical certificate was issued in July 2011. The pilot was a co-owner of PAI and was PAI’s DOM.

The pilot's personal flight records contained entries until February 2011, at which time the pilot recorded that he had 1,151.9 hours in single-engine airplanes and 951.5 hours in multiengine airplanes. On his most recent FAA medical certificate application, the pilot reported a total flight experience of 2,500 hours.

The computerized PAI flight record (which began tracking 14 CFR Part 135 flights only in February 2011) indicated that the pilot had 116.5 hours total flight experience, including 18 hours in night VMC. According to the records, during the preceding 90 and 30 days, the pilot had accumulated about 28.5 and 5.3 flight hours, respectively. The records showed that the pilot had flown 2 hours on two different flights in the week before the accident. The most recent flight was in night VMC from SAD to FFZ and back. Examination of the flight records revealed that the pilot had flown that round trip flight at least twice, in the previous 2 weeks.

Pilot Training

According to PAI and its FAA principal operations inspector (POI), employee pilots receive annual training over a 2- to 3-day period. The chief pilot organized most of the training, which consisted of regulation review, company policy, and actual flight training. The POI observed parts of the training. According to company training records, the pilot's most recent 14 CFR Part 135 competency/proficiency check was satisfactorily completed on September 24, 2011.

Pilot’s 72-Hour History

According to the pilot’s wife, in the 3 days before and including the accident day, the pilot awoke about 0630 and left for work about 0700. Two days before the accident, he flew to FFZ, arriving back at SAD about 2145.

Relatives of the pilot stated that nothing unusual had occurred in his life in the 72-hour period before the accident. His wife reported that the pilot did not take medications, aside from a hypothyroidism medication that he had reported to the FAA, and he did not have any physical conditions or ailments aside from the hypothyroidism.

MEDICAL AND PATHOLOGICAL INFORMATION

The Forensic Science Center in Tucson, Arizona, conducted an autopsy on the pilot; the cause of death was cited as blunt force trauma. The FAA Forensic Toxicology Research Team at the Civil Aviation Medical Institute performed toxicological testing of specimens collected during the autopsy. The results of the specimens were negative for carbon monoxide, cyanide, and listed drugs.

AIRPLANE INFORMATION

General

The airplane was manufactured in 1976 by Rockwell International, and the type certificate holder at the time of the accident was Twin Commander, LLC. The airplane was equipped with two Honeywell TPE-331-series turboshaft engines and two Hartzell three-blade propellers. Maintenance records indicated that the airframe had accumulated a total time in service of about 8,188 hours. The left engine had accumulated a total time since major overhaul of about 545 hours, and the right engine had accumulated a total time since major overhaul of about 1,482 hours.

The airplane was recently purchased by PAI and was flown about 1,200 miles from Indiana to the PAI facility at SAD about 1 week before the accident. It was certificated for single-pilot operation. At the time of the accident, the airplane was configured for a pilot (left side), a copilot (right side), and five passengers.

According to the sale advertisement listing for the airplane, the airplane was equipped with very high frequency omnirange (VOR) and GPS (KLN 90B) navigation units, a radar altimeter, and an Avidyne EX-500 multifunction display, which were destroyed in the accident.

Ferry Permit Information

At the time of purchase by PAI, the airplane was not in compliance with an FAA required 150-hour inspection requirement, and PAI requested an FAA ferry permit to fly the airplane from Eagle Creek Airpark (EYE), Indianapolis, Indiana, to the PAI facility in Safford, Arizona. On November 16, 2011, the FAA issued a ferry permit for the relocation of the airplane. The permit was valid until arrival at SAD or November 25, 2011, whichever came first. It only permitted a direct flight between EYE and SAD and only allowed the pilot and essential crew on board. The airplane was flown by the PAI president, who was the brother of the accident pilot, from EYE to SAD on November 17, 2011. The arrival at SAD terminated the ferry permit.

PAI and FAA Scottsdale Flight Standards District Office (FSDO) personnel estimated that it would normally require two people 2 days to conduct the inspection necessary to render the airplane in compliance with the outstanding airworthiness items, exclusive of correcting any identified deficiencies. All available evidence indicated that no maintenance activity was accomplished on the airplane between its arrival at SAD and its departure to FFZ on the night of the accident; the condition that warranted the ferry permit had not been corrected.

Terrain Awareness and Warning System (TAWS) Equipment Information

Title 14 CFR 91.223 stated that with certain exceptions, turbine-powered, US registered airplanes configured with six or more passenger seats and manufactured before early 2002 could not be operated after March 29, 2005, unless the airplane was equipped with an approved TAWS unit.

Since the accident airplane was manufactured in 1976 and was turbine-powered, any exclusion from the TAWS requirement required that the airplane had to be configured with five or fewer passenger seating positions. According to the type certificate holder's documentation, the airplane was manufactured and delivered with six passenger seating positions. Therefore, the airplane's as manufactured configuration required the installation of TAWS by March 2005. No records indicating that the number of passenger seating positions was ever less than six before May 2005 were located. However, a detailed review of airplane maintenance records, preaccident photographs, TAWS equipment manufacturer's data, and a detailed inventory of the recovered wreckage indicated that the accident airplane was never equipped with TAWS. (The sale advertisement information for the airplane indicated that it was equipped with a KGP-560 TAWS B unit.)

Maintenance documentation indicated that in May 2005, the airplane seating configuration was changed to reduce passenger seat provisions from six to five by removing a seat belt from the aft divan, which was originally configured with seat belts for three people. Per the requirements of 14 CFR 91.223 and the reduced passenger seat count, the airplane was not required to be equipped with TAWS.

However, FAA and manufacturer/type certificate holder guidance indicated that any seating configuration changes should be approved by either the FAA or the manufacturer/type certificate holder, and examination of the maintenance documentation for the accident airplane revealed that neither requirement had been satisfied. The seating modification was not approved by the FAA or any other agency or documented either via a supplemental type certificate and/or FAA Form 337 (Major Repair and Alteration). Postaccident review of the documentation that was used to substantiate the seating configuration change revealed that the modified seating position plan was not one of the manufacturer's/type certificate holder's approved configurations. The document that was used to substantiate the change was determined to be an altered version of the manufacturer's original document, but it was incorrectly represented as a manufacturer's original document. Attempts to determine who made the improper and unauthorized changes to the seating configuration document, or when they were made, were unsuccessful.

METEOROLOGICAL INFORMATION

The FFZ 1854 automated weather observation included wind from 350 degrees at 5 knots, visibility 40 miles, few clouds at 20,000 feet, temperature 23 degrees C, dew point -1 degrees C, and an altimeter setting of 29.93 inches of Mercury. US Naval Observatory data for November 23, 2011, indicated that the moon, which was a waning crescent of 3%, set at 1605, and local sunset occurred at 1721.

AIDS TO NAVIGATION

Neither FFZ nor SAD was equipped with a VOR ground navigation facility. Navigation between the two airports via available VOR stations would result in an indirect flight route.

The flight from SAD to FFZ and the accident flight were both conducted in VMC as VFR flights. No flight plan was filed for either flight, and neither pilot had requested air traffic control (ATC) flight following services. Available radar data and interviews with PAI personnel indicated that the pilot had flown between SAD and FFZ several times previously and that he tended to use his iPad, equipped with ForeFlight software and GPS, to fly directly between the two. The software could display FAA VFR aeronautical charts (including FAA-published terrain depiction) and overlay airplane track and position data on the chart depiction. According to the pilot's brother, the pilot's habit pattern was to depart the airport, identify the track needed to fly directly to the destination, and turn the airplane onto that track. Remnants of an iPad were found in the wreckage. Damage precluded determination of its positive association with a particular owner, its functionality, or its operational status at the time of the accident.

Radar tracking data from the accident flight indicated that the airplane began its right turn on course to SAD about 1.5 miles northeast of FFZ. Comparison of the direct line track data from two different initial locations (FFZ, and northeast of FFZ after completion of the turn) to SAD revealed that while the direct track from FFZ to SAD passed about 3 miles south of the impact mountain, the direct track from northeast of FFZ to SAD overlaid the impact mountain location. That resulting ground track was also coincident with the accident flight radar data ground track.

COMMUNICATIONS

Sequence of Events

The pilot first contacted FFZ ground control at 1820:21. The pilot was instructed to taxi to runway 4R via taxiway D, and he taxied as instructed without incident. At 1823:35, the pilot contacted FFZ local control and advised that he was holding short and was ready for departure. The pilot was advised to again hold short to wait for landing traffic. At 1825:00, the controller instructed the pilot to "fly straight out" until advised due to landing traffic and cleared him for takeoff from runway 4R. The airplane became airborne at 1826:14. At 1826:47, the controller issued the "right turn approved" advisory to the pilot. At that point, the airplane was still on the runway heading, about 1.45 nautical miles (nm) from FFZ, and climbing through an altitude of about 2,200 feet. The pilot responded to the transmission with "right turn approved." No further radio transmissions to or from the accident pilot were recorded.

AIRPORT INFORMATION

General

FFZ was equipped with two runways designated 4/22 L and R. The airplane's arrival and departure runway (4R) measured 5,101 feet by 100 feet. Airport elevation was 1,394 feet msl. The local topography consisted of a flat basin floor bounded by mountainous terrain, primarily to the north and east. FFZ was situated about 15 miles west-northwest of the impact mountain, which rose very steeply to a charted maximum elevation of 5,057 feet msl, or about 3,700 feet above FFZ.

WRECKAGE AND IMPACT INFORMATION

Accident Site

The accident site was on the northwest face near the top of the Flatiron region of Superstition Mountain. The accident site consisted of two basic terrain areas: a sloped area (about 45 degrees downhill to the northwest), abutted by a vertical rock formation on its southeast side.

The sloped area was primarily rock, interlaced with cracks, soil patches, boulders, and sparse vegetation. The rock formation rose about 100 feet above the southeastern edge of the sloped area. Airplane debris was scattered on the sloped area in a primary field that measured about 150 feet southeast-northwest by about 80 feet northeast-southwest. A significant amount of debris was clustered near the base of the vertical face, with some debris strewn or caught on the face. The southeast section of the sloped area and much of the vertical face were fire damaged, soot covered, or scorched. The northwest edge of the sloped debris field was about 150 feet southeast of the end of the sloped terrain, which then became very steep (sometimes near vertical) and fell irregularly away to the valley floor about 3,000 feet below.

On-Site Wreckage Observations

The impact site was located on steep rocky terrain at an elevation of about 4,500 feet msl that was essentially only accessible by helicopter. The wreckage was recovered by helicopter and transported to a secure facility for subsequent detailed examination.

The airplane was highly fragmented. The debris pattern axis was oriented northwest to southeast, and the debris and fire damage were arrayed in a fan-like pattern consistent with the approximate flight direction. Most airplane components were severely impact and fire-damaged. Some debris (heavier/denser items, such as engine gearbox components and generators) was found northwest (downhill) of the main debris field, consistent with those components rolling downhill after impact. The largest wreckage section was a portion of an inboard wing box with one engine attached. Paint transfer marks on the rock face were consistent with a wings-level (roll axis) impact.

Both engines and portions of their propellers were identified in the wreckage. Propeller, engine, and gearbox damage was consistent with high power rotation at impact. All three landing gear were identified in the wreckage, and damage patterns were consistent with the landing gear being retracted at impact. Some airplane skin segments exhibited significant accordion-like crush damage. Many cockpit-related items, including instruments, instrument panel sections, and pilots' seat fragments, were found on the terrain beyond the vertical rock formation; some were several hundred feet beyond the vertical rock formation.

Damage patterns were consistent with the engines developing power at the time of impact. The majority of the first-stage compressor impeller blades were separated at the hubs. The second-stage compressor impeller blades were bent opposite the direction of rotation. There was rotational scoring on the aft side of the third-stage turbine blade platforms and metal spray deposits on the suction side of the third-stage turbine blades. No preimpact discrepancies that would have precluded normal engine operation were identified.

The blade damage to both propellers was severe, with leading-edge damage, multiple bends, twisting, concave bending of the blade chord at the tips, and tips that had fractured and separated. Two separate blade angle witness marks were each consistent with impact while at a normal (not in feather and not in reverse) operating position. No preimpact discrepancies that would have precluded normal propeller operation were identified.

ORGANIZATIONAL AND MANAGEMENT INFORMATION

Ponderosa Aviation, Inc.

PAI was founded in 1975 by the pilot-rated passenger’s father. Later, the pilot and his brother purchased the company, and, in January 2011, the pilot-rated passenger, who had worked there for many years, bought into a partnership with them.

At the time of the accident, PAI, which was based at SAD, employed 25 people, including 13 pilots (10 on a seasonal/part-time basis) and 9 maintenance personnel. PAI owned a total of 14 airplanes, including the accident airplane. The fleet included three Rockwell International (Aero Commander) 690 models and nine 500 models.

PAI held a 14 CFR Part 135 operating certificate for on-demand air carrier operations in the contiguous United States and the District of Columbia. However, PAI rarely exercised the privileges of that certificate and averaged about two revenue passenger transport flights per year. PAI's primary purpose for obtaining and maintaining the certificate was to be qualified to contract with the US Forest Service and the Bureau of Land Management for air attack missions (the application of aerial resources, by both fixed-wing aircraft and rotorcraft, on a fire).

Eight of the PAI airplanes were on the 14 CFR Part 135 certificate; the accident airplane had not yet been added to the certificate.

FAA Oversight

The FAA FSDO in Scottsdale, Arizona, was the assigned certificate-holding district office for PAI and oversaw about 60 Part 135 certificated operators, no Part 121 certificated operators, and about 520 Part 91 operators.

The POI was assigned to PAI in 2007. Her duties included oversight of 12 designees and 30 check airmen and POI for 54 operators. PAI was one of 10 Part 135 operators assigned to the POI. She estimated that she had about 100 hours in Rockwell International/Aero Commander airplanes, 25 of which were in the 690 model. The POI considered PAI to be a "low-maintenance operator," meaning that PAI was compliant with FAA requirements and presented few issues of concern. She physically visited PAI about once per year. Due to the distance between the FSDO and SAD, she never made unannounced visits. Her visits would take about 2 days, during which she would oversee pilot training, examine records and recordkeeping, and conduct base inspections and ramp checks. She never gave checkrides to PAI pilots; those were conducted by another inspector. The POI qualified the pilot-rated passenger as a "good" chief pilot. He was the person at PAI with whom the POI had the most contact, and she would mainly communicate her concerns and questions to him. She did not have much familiarity with the pilot.

ADDITIONAL INFORMATION

Homeowner's Surveillance Camera Imagery

The airplane’s preimpact flightpath, impact explosion, postimpact fire, and initial arrival of search and rescue aircraft were captured on a private citizen's home surveillance camera. That camera was located about 6 miles south of and 3,700 feet lower than the impact site. A file that contained about 50 minutes of image data, during the period from about 1810 to 1900, was provided to the National Transportation Safety Board (NTSB). The time stamp data was provided by the camera owner and was not independently correlated or verified by the NTSB; therefore, all times are approximate.

The 1810 image depicted the mountain in silhouette form, but as night fell, the mountain disappeared from the image. No lights were visible on the mountain. Due to the night conditions, the optical resolution capability of the camera, and the distance of the airplane from the camera, the imagery provided only a macro view and associated timeline of the events. The airplane itself was not visible; its position was manifested by its blinking beacon or strobe lights only. The lights of the airplane first appeared in the field of view at 1830:00 and remained visible until 1830:48, when the lights disappeared behind the terrain. A large flash of light appeared at 1830:52, followed by a second, much larger and brighter flash about 3 seconds later. Lights indicative of a fire remained visible until about 1844, and the first responding aircraft (again only visible as lights) appeared about 1848.

Examination of the path of the airplane's lights on the image field of view did not reveal any erratic motions or changes of direction; the stability of the flightpath was similar to that depicted in the ground tracking radar data.

Weight and Balance Information

Maintenance records indicated that on at least 15 occasions, modifications that affected the airplane's weight and balance values were accomplished; however, no records of the actual revised weight and balance data were discovered during the investigation.

Calculations that used the original empty weight plus other known or presumed values resulted in an estimated accident flight weight of 8,953 pounds, which was below the maximum allowable weight, and a center of gravity within the allowable envelope.

Airplane Performance

The derived level-flight ground speed for the last 2 minutes of the flight was approximately 190 knots, which was slightly higher than the pilot’s operating handbook maximum range speed for similar conditions. Surface wind data indicated that the airplane would have experienced a slight tailwind during the climbout and level-flight segments.

TAWS-Related Guidance for FAA Inspectors

Published FAA guidance for FAA inspectors to use to determine whether the airplane seating configuration changes (if properly accomplished) would have exempted the airplane from the TAWS requirement was examined in detail. The relevant FAA guidance included FAA Order 8900.1 and 14 CFR Part 1, Part 21, Part 43 (Appendix 1), Part 91, and Part 135.

Phoenix Sky Harbor (PHX) Class B Airspace Information

The Phoenix metropolitan area was designated and charted as Class B airspace, centered on PHX and the PHX VOR (PXR). The airspace elevation boundaries were defined by floor and ceiling altitudes, with lateral boundaries defined by distance and bearing from defined locations. Class B airspace is typically described as having the shape of an "upside-down wedding cake," where the airspace floor altitudes increase as the distance from the center increases. Aircraft operating under VFR are prohibited from entering Class B airspace without explicit permission from the responsible ATC facility. Mountainous terrain rises to 4,500 feet less than 1 nm east of the 5-000-foot Class B airspace, and the terrain rises to a maximum elevation of 5,057 feet about 3 1/2 miles east.

The NTSB ATC group chairman's factual report provides detailed information regarding the Class B airspace around the Phoenix area. For more information, see the docket for this accident (NTSB case number WPR12MA046).

Controlled Flight Into Terrain (CFIT) Accidents

The FAA defines a CFIT accident as a situation that occurs when a properly functioning aircraft "is flown under the control of a qualified pilot, into terrain (water or obstacles) with inadequate awareness on the part of the pilot of the impending collision."

In 1998, the FAA formed the General Aviation (GA) CFIT Joint Safety Analysis Team (JSAT) as part of the FAA "Safer Skies" program. The stated goal of the Safer Skies initiative was to significantly reduce fatal accidents over a 10-year period via a comprehensive review of aviation accident causes and implementation of safety intervention strategies. In April 1999, the GA CFIT JSAT published its final report, which identified 55 interventions to address CFIT accident causes. The FAA CFIT Joint Safety Implementation Team (JSIT) was formed to develop detailed CFIT accident reduction strategies based upon the top 10 JSAT interventions that were considered to be the most effective and feasible. The CFIT JSIT final report was published in 2000, and JSIT recommended interventions included the following:

- Improve safety culture within the aviation community,
- Promote development and use of low-cost terrain clearance and/or look-ahead device,
- Improve pilot training regarding decision-making and human factors,
- Enhance the biennial flight review and/or instrument competency check, and
- Develop and distribute mountain flying technique advisory material.

In March 2003, as part of its response to the CFIT JSIT, the FAA issued Advisory Circular (AC) 61-134, "General Aviation Controlled Flight Into Terrain Awareness." The AC "highlights the inherent risk" that CFIT poses for GA pilots. According to the AC, one primary cause of CFIT accidents was loss of situational awareness.

Situational Awareness

The Pilot's Handbook of Aeronautical Knowledge (FAA-H-8083-25) defined situational awareness as the "accurate perception of the operational and environmental factors that affect the airplane, pilot, and passengers during a specific period of time." The handbook stated that a situationally aware pilot "has an overview of the total operation and is not fixated on one perceived significant factor." The handbook stated that "some of the elements inside the airplane to be considered are the status of airplane systems, and also the pilot and passengers" and cautioned that "an awareness of the environmental conditions of the flight, such as spatial orientation of the airplane, and its relationship to terrain, traffic, weather, and airspace must be maintained."

The handbook stated that obstacles to maintaining situational awareness included fatigue, stress, and task overload and that a contributing factor in many accidents is a distraction that diverts the pilot’s attention. Complacency was cited as another obstacle to maintaining situational awareness. When activities become routine, there is a tendency to relax and not put as much effort into performance. Like fatigue, complacency reduces a pilot’s effectiveness in the cockpit. However, complacency is harder to recognize than fatigue, since everything is perceived to be progressing smoothly.

NTSB Safety Alert

In January 2008, the NTSB issued a safety alert titled "Controlled Flight Into Terrain in Visual Conditions: Nighttime Visual Flight Operations Are Resulting in Avoidable Accidents." The safety alert stated that recent investigations identified several accidents that involved CFIT by pilots operating under visual flight conditions at night in remote areas, that the pilots appeared unaware that the aircraft were in danger, and that increased altitude awareness and better preflight planning likely would have prevented the accidents.

The safety alert suggested that pilots could avoid becoming involved in a similar accident by proper preflight planning, obtaining flight route terrain familiarization via sectional charts or other topographic references, maintaining awareness of visual limitations for operations in remote areas, following instrument flight rules practices until well above surrounding terrain, advising ATC and taking action to reach a safe altitude, and employing a GPS-based terrain awareness unit.

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NTSB Identification: WPR12MA046 
 Nonscheduled 14 CFR Part 91: General Aviation
Accident occurred Wednesday, November 23, 2011 in Apache Junction, AZ
Aircraft: ROCKWELL 690, registration: N690SM
Injuries: 6 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report.

On November 23, 2011, about 1831 mountain standard time (MST), a Rockwell International 690A, N690SM, was substantially damaged when it impacted terrain in the Superstition Mountains near Apache Junction, Arizona, about 5 minutes after takeoff from Falcon Field (FFZ), Mesa, Arizona. The certificated commercial pilot and the five passengers, who included two adults and three children, were fatally injured. The airplane was registered to Ponderosa Aviation, which held a Part 135 operating certificate, and which was based at Safford Regional Airport (SAD), Safford, Arizona. The personal flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91. Night visual meteorological conditions prevailed, and no flight plan was filed.

According to several witnesses, the children's father, who was a co-owner of Ponderosa Aviation and who lived near SAD, regularly used the operator's airplanes to transport the children, who lived near FFZ, between FFZ and SAD or vice versa. According to a fixed base operation (FBO) line serviceman who was familiar with the children and their father, on the night of the accident, the children arrived at FFZ about 15 minutes before the airplane arrived. The airplane was marshaled into a parking spot adjacent to the FBO building; it was already dark. The father was seated in the front left seat and operating the airplane, and another individual was in the front right seat. After shutdown, the father and a third individual, whom the line serviceman had not seen before, exited the airplane. The individual in the front right seat did not exit the airplane; he remained in the cockpit with a flashlight, accomplishing unknown tasks, and subsequently repositioned himself to the front left seat.

The father went into the FBO to escort the children to the airplane. The father, three children and the third individual returned to the airplane. The individual in the front left seat remained in that seat, the third individual seated himself in the front right seat, and the father and three children situated themselves in the rear of the airplane. Engine start and taxi-out appeared normal to the line serviceman, who marshaled the airplane out of its parking spot.

Review of the recorded communications between the airplane and the FFZ air traffic control tower (ATCT) revealed that when the pilot requested taxi clearance, he advised the ground controller that he was planning an "eastbound departure." The flight was cleared for takeoff on runway 4R, and was instructed to maintain runway heading until advised, due to an inbound aircraft. About 90 seconds later, the ATCT local controller issued a "right turn approved" clearance to the flight. Review of the preliminary ground-based radar tracking data revealed that the takeoff roll began about 1826 MST, and the airplane began its right turn towards SAD when it was about 2 miles east of FFZ, and climbing through an altitude of about 2,600 feet above mean sea level (msl). About 1828, the airplane reached an altitude of 4,500 feet msl, where it remained, and tracked in an essentially straight line, until it impacted the terrain. The last radar return was received at 1830:56, and was approximately coincident with the impact location. The airplane's transponder was transmitting on a code of 1200 for the entire flight.

The impact site was located on steep rocky terrain, at an elevation of about 4,650 feet, approximately 150 feet below the top of the local peak. Ground scars were consistent with impact in a wings-level attitude. Terrain conditions, and impact- and fire-damage precluded a thorough on-site wreckage examination. All six propeller blades, both engines, and most major flight control surfaces were identified in the wreckage. Propeller and engine damage signatures were consistent with the engines developing power at the time of impact. The wreckage was recovered to a secure facility, where it will be examined in detail.

According to the operator's and FAA records, the pilot had approximately 2,500 total hours of flight experience. He held multiple certificates and ratings, including a commercial pilot certificate with single-engine, multi-engine, and instrument-airplane ratings. His most recent FAA second-class medical certificate was issued in July 2011, and his most recent flight review was completed in September 2011.

According to FAA information, the airplane was manufactured in 1976, and was equipped with two Honeywell TPE-331 series turboshaft engines. The airplane was recently purchased by the operator, and was flown from Indiana to the operator's base in Arizona about 1 week prior to the accident. The airframe had accumulated a total time in service (TT) of approximately 8,188 hours. The left engine had accumulated a TT since major overhaul (SMOH) of about 545 hours, and the right engine had accumulated a TTSMOH of 1,482 hours.

The FFZ 1854 automated weather observation included winds from 350 degrees at 5 knots; visibility 40 miles; few clouds at 20,000 feet; temperature 23 degrees C; dew point -1 degrees C; and an altimeter setting of 29.93 inches of mercury. U.S. Naval Observatory data for November 23 indicated that the moon, which was a waning crescent of 3 percent, set at 1605, and local sunset occurred at 1721.



Three children "going to spend time at the holiday with their father" were among six killed in a plane crash Wednesday night in Arizona, authorities said.

Elias Johnson with the Pinal County Sheriff's Department spoke to the Los Angeles Times from the scene of the crash on Thanksgiving morning.

"Six people -- three children, two of them boys and one girl" were killed, Johnson said. Three of those aboard were adult men.

The mother of the children lives in Arizona's Pinal County, where the crash took place in a mountainous area near Flatiron. "I personally made a visit and notification" to the mother "with the information we had late last night."

"The mother is a pilot herself," Johnson said. "She understands when a plane crashes at 230 miles an hour ... directly into the face of the mountain ... and when it's a fiery crash" there's little hope of survivors. "So she understood that."

Late Wednesday night, emergency crews had struggled to reach the crash site in the rugged Superstition Mountains east of Phoenix. A 12-person rescue crew began hiking to the site about 9 p.m., a Sheriff's Department official said.

The plane, a twin-engine Rockwell AC69, had taken off from Falcon Field Airport in Mesa, authorities said. Its registered owner is Ponderosa Aviation Inc. of Safford, Ariz., according to Federal Aviation Administration records.

The FAA and the National Transportation Safety Board are investigating the crash.





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The body of a child has been discovered after a small plane crashed this evening in Arizona's Superstition Mountains amid a fireball captured on video.
Elias Johnson, a spokesman for the Pinal County sheriff, tells ABC News that deputies have found the body of one child between the ages of 5 and 9. Johnson said that he does not know if it is the body of a male or female.
Officials continue to comb the burning, rugged scene in the dark with no immediate indication of survivors.
The crash is believed to have involved a Rockwell AC69 twin-engine plane that had just departed from Falcon Field in Mesa, Ariz., according to the FAA's Allen Kenitzer.
However, the identity of the plane was not confirmed, Pinal County Sheriff Paul Babeu told reporters late Wednesday evening as the plane's dual debris fields continued to burn.
"We have numerous conflicting reports at this time," Babeu said. "The best we can ascertain at this point, it's a dual-engine aircraft."
Babeu cited reports that the Rockwell AC69 believed involved may have carried three adults and three children, but could not confirm the reports independently.
Sheriff Babeu added that searchers had not ruled out the possibility of finding survivors.
The remains of the plane's fuselage were wedged vertically in a crevice-type formation that was not easily accessible, he added.
Officials now believe the plane crashed before 5 p.m. local time, Babeu said. Earlier reports placed the time of the crash east of Phoenix later in the evening.
About 10 people were searching the scene after being flown in two at a time by helicopter, Babeu said.
"These are jagged peaks, almost like a cliff-type of ragged terrain," he said.
Local officials earlier said crews were having difficulty reaching the crash scene on foot because of the ruggedness of the terrain.
Witnesses said they saw the plane crash, causing an eruption of flames.
"What we saw was a small plane," said Mark Klein, who lives at the base of the Superstition Mountains, according to ABC News Radio. "It only had the red and green lights on the wings on, and it just ran into the mountain. I looked, like fireworks and then a big explosion."
A video posted on YouTube purported to capture the plane crash. It showed lights moving in the darkness and then a flash in the distance. A local resident told ABC News he took the video from his house in Gold Canyon, Ariz., about seven miles away from the crash site.
Dark video transmitted from the scene after the crash appeared to show fires burning in the mountain terrain.
The Federal Aviation Administration initially said it had no reports of a plane crash in the area, suggesting early on that the incident did not involve a large commercial plane. In addition, passenger flights at major area airports all were safe and accounted for, officials told ABC News shortly after the crash.
A helicopter search light looks over the scene of an aircraft that crashed in the Superstition Mountains in Apache Junction, on Wednesday, Nov. 23, 2011. The small plane with three adults and three children on board crashed into the Superstition Mountains east of Phoenix on Wednesday, and there was no sign of survivors, authorities said.


A helicopter search light looks over the scene of an aircraft that crashed in the Superstition Mountains in Apache Junction, on Wednesday, Nov. 23, 2011. The small plane with three adults and three children on board crashed into the Superstition Mountains east of Phoenix on Wednesday, and there was no sign of survivors, authorities said.



A floodlight illuminates a fire from a small plane crash in the Superstition Mountains in Apache Junction east of Phoenix, Wednesday, Nov. 23, 2011. Authorities said there was no apparent sign of survivors in the small twin-engine plane crash.
A greyscale webcam.
In the beginning, you see a small white light traveling from the left side of the screen to the right. At about :50, the light disappears. Then a few seconds later, there is a burst of light. The light that remains on the mountainside is the fire.


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APACHE JUNCTION, Ariz. -- At approximately 6:30 p.m. a Rockwell 690A twin turboprop aircraft, tail number N690SM, crashed into the Flatiron area of the Superstition Mountains near the Lost Dutchman State Park. Reports say the plane left Falcon Field in Mesa with three children and three adults on-board. The plane was reportedly en route to Safford, Arizona.
The terrain in this area is extremely treacherous, typically taking hikers up to six hours to reach. The first person on the scene of the crash was an Arizona Department of Public Safety officer who was lowered from a helicopter. The officer reported two areas of burning debris leading officials to believe the plane was split in two upon impact.

Just before 7 p.m. scanner traffic and calls to the newsroom indicated an aircraft down in Pinal County near the Lost Dutchman State Park. Shortly after 7 p.m., the Pinal County Sheriffs Office established a command center and all available emergency personnel in the area were called to the scene.


APACHE JUNCTION, AZ - Crews working to access the wreckage of a plane that crashed into the Superstition Mountains Wednesday evening say there has been no indication of survivors.
Federal Aviation Administration spokesman Allen Kenitzer told ABC15 the Rockwell twin engine AC69 plane "crashed under unknown circumstances around 5:30 p.m. "Fuselage still burning, conflicting reports, took off from Safford, 10 deputies flown to top of mountain, searching area, will search throughout night, no passengers found, rugged terrain, fuselage stuck in crevices of mountain, doing our best in the darkness but can't locate anyone at this point, does not look promising, reports that pilot, two other adults, three children were on board.
There were six people on board when the plane went down, according to Pinal County Sheriff's Office spokesman Elias Johnson.
Kenitzer said the plane, registered to Ponderosa Aviation Inc. out of Safford, Ariz., had just departed from Falcon Field in Mesa after stopping to refuel around 4:30 p.m.
Johnson said the aircraft went down near the top of Flat Iron Mountain at a height of approximately 4,500 feet.
Johnson told ABC15 crews have had difficulty accessing the crash site, but were able to drop a Department of Public Safety officer near the top of the mountain to assess the situation.
According to Johnson, judging from a tire seen among the wreckage, officials believe the aircraft is capable of holding up to 12 people, but it is unclear how many were on board at the time of the crash.
During a press conference Wednesday night Johnson said a group of rescue workers has begun a six-hour hike up the mountain to access the crash site, but crews so far have no indication of survivors.
Air15 video over the mountain range showed many separate areas of flames spread around the crash site, apparently spreading in the thick brush.
Crews from across the Valley have responded to the mountain to assist in accessing any potential victims.
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A plane crashed and burst into flames near the peak of the Superstition Mountains in an area called Flat Iron, east of Phoenix, Wednesday night.
The Rockwell AC69 twin engine aircraft "crashed under unknown circumstances," FAA spokesman Allen Kenitzer said in a statement. The plane is registered to Ponderosa Aviation in Safford. Multiple witnesses reported a fireball and an explosion around 6:30 p.m.
A source at Falcon Field in Mesa tells CBS 5 the pilot flew in from Safford to pick up his children and says when they were returning to Safford the two-engine plane crashed. The source tells CBS 5 there were three adults and three children onboard. The crash site is located in rugged terrain near the top of the mountain. Pinal County sheriff's deputies were reporting difficulty accessing the area.
A witness hit our CBS 5 Action Button on KPHO.com. Witness Ronnie Brant lives in Fountain Hills. He says he's an aircraft mechanic and heard the plane fly over his house and it was having engine trouble.
(CNN) -- An airplane crashed Wednesday evening into a rugged mountain east of Phoenix, creating a small wildfire that crews were unable to immediately reach, Arizona officials said. The aircraft, possibly twin-engine, crashed around 6:30 p.m. in the Superstition Mountains near Apache Junction, said spokesman Elias Johnson of the Pinal County Sheriff's Office.
A man who said he witnessed the impact told CNN that a mushroom cloud of flames lit up the evening sky.
It's a six-hour hike to the site and crews were uncertain how many people were on the plane or its destination, Johnson told reporters. He indicated crews will be in a recovery operation.
A ranger dropped near the scene saw a tire from the plane that suggests it was not a commercial aircraft, he said.
A spokesperson with Falcon Executive Aviation flight school in Mesa tells KPHO-TV the pilot flew in from Safford to Falcon Field to pick up his children and says when they were returning to Safford the two-engine plane crashed. The spokesperson tells KPHO there were three adults and three children onboard.
"This is some of the toughest country you can experience," Johnson said. There were at least two debris fields. "That plane is all over the place up there."
Kevin Cunningham, 44, of Apache Junction, said he was talking on the phone from his back porch and saw the crash a few miles away.
"The flames lit up the mountain," said Cunningham, adding the plane appeared to be flying level before the crash. "I didn't see where it was in distress."
The photogenic peak is popular with hikers and horseback riders, the resident said.
"Somebody didn't know the mountain was there or they had false readings," Cunningham speculated.
APACHE JUNCTION - The Pinal County Sheriff's Office is responding to reports of a plane crash and explosion in the Superstition Mountains. Multiple witnesses reported a plane crashed into a mountain in the Flat Iron area and burst into flames just after 6:30 p.m. The plane apparently split into two.
It's not yet known what kind of aircraft crashed, where it originated, or how many people were on board.
PCSO spokesperson Elias Johnson says that search and rescue is on their way to the scene. It's an area of rough terrain, so response time is being affected.
A DPS rescue helicopter is also over the scene.
A law enforcement staging area has been set up at the Lost Dutchman State Park.
Both Sky Harbor Airport and Mesa Gateway Airport told us all planes have been accounted for.

APACHE JUNCTION, Ariz. -- Just before 7 p.m. scanner traffic and calls to the newsroom indicated an aircraft down in Pinal County near the Lost Dutchman State Park. Shortly after 7 p.m., the Pinal County Sheriffs Office established a command center and all available emergency personnel in the area were called to the scene. Authorities have confirmed that the incident is an airplane crash, however, the size and type of aircraft is not known.

Reporters form 3TV have been in touch with all local airports and military bases, none of which are reporting any missing aircraft. At this time, no further information is available.
PHOENIX (KPHO) - Witnesses tell CBS 5 News a plane has crashed into the Superstition Mountains near Flat Iron. Multiple witnesses reported a fireball and an explosion around 6:30 p.m. Wednesday..

APACHE JUNCTION, Ariz. -- At approximately 6:30 p.m. a Rockwell 690A twin turboprop aircraft, tail number N690SM, crashed into the Flatiron area of the Superstition Mountains near the Lost Dutchman State Park. Reports say the plane left Falcon Field in Mesa with three children and three adults on-board. The plane was reportedly en route to Safford, Arizona.

The terrain in this area is extremely treacherous, typically taking hikers up to six hours to reach. The first person on the scene of the crash was an Arizona Department of Public Safety officer who was lowered from a helicopter. The officer reported two areas of burning debris leading officials to believe the plane was split in two upon impact.

Just before 7 p.m. scanner traffic and calls to the newsroom indicated an aircraft down in Pinal County near the Lost Dutchman State Park. Shortly after 7 p.m., the Pinal County Sheriffs Office established a command center and all available emergency personnel in the area were called to the scene.

A greyscale webcam.
In the beginning, you see a small white light traveling from the left side of the screen to the right. At about :50, the light disappears. Then a few seconds later, there is a burst of light. The light that remains on the mountainside is the fire.

APACHE JUNCTION, AZ - Crews working to access the wreckage of a plane that crashed into the Superstition Mountains Wednesday evening say there has been no indication of survivors.
Federal Aviation Administration spokesman Allen Kenitzer told ABC15 the Rockwell twin engine AC69 plane "crashed under unknown circumstances around 5:30 p.m. "Fuselage still burning, conflicting reports, took off from Safford, 10 deputies flown to top of mountain, searching area, will search throughout night, no passengers found, rugged terrain, fuselage stuck in crevices of mountain, doing our best in the darkness but can't locate anyone at this point, does not look promising, reports that pilot, two other adults, three children were on board.
There were six people on board when the plane went down, according to Pinal County Sheriff's Office spokesman Elias Johnson.
Kenitzer said the plane, registered to Ponderosa Aviation Inc. out of Safford, Ariz., had just departed from Falcon Field in Mesa after stopping to refuel around 4:30 p.m.
Johnson said the aircraft went down near the top of Flat Iron Mountain at a height of approximately 4,500 feet.
Johnson told ABC15 crews have had difficulty accessing the crash site, but were able to drop a Department of Public Safety officer near the top of the mountain to assess the situation.
According to Johnson, judging from a tire seen among the wreckage, officials believe the aircraft is capable of holding up to 12 people, but it is unclear how many were on board at the time of the crash.
During a press conference Wednesday night Johnson said a group of rescue workers has begun a six-hour hike up the mountain to access the crash site, but crews so far have no indication of survivors.
Air15 video over the mountain range showed many separate areas of flames spread around the crash site, apparently spreading in the thick brush.
Crews from across the Valley have responded to the mountain to assist in accessing any potential victims.
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A plane crashed and burst into flames near the peak of the Superstition Mountains in an area called Flat Iron, east of Phoenix, Wednesday night.
The Rockwell AC69 twin engine aircraft "crashed under unknown circumstances," FAA spokesman Allen Kenitzer said in a statement. The plane is registered to Ponderosa Aviation in Safford. Multiple witnesses reported a fireball and an explosion around 6:30 p.m.
A source at Falcon Field in Mesa tells CBS 5 the pilot flew in from Safford to pick up his children and says when they were returning to Safford the two-engine plane crashed. The source tells CBS 5 there were three adults and three children onboard. The crash site is located in rugged terrain near the top of the mountain. Pinal County sheriff's deputies were reporting difficulty accessing the area.
A witness hit our CBS 5 Action Button on KPHO.com. Witness Ronnie Brant lives in Fountain Hills. He says he's an aircraft mechanic and heard the plane fly over his house and it was having engine trouble.
(CNN) -- An airplane crashed Wednesday evening into a rugged mountain east of Phoenix, creating a small wildfire that crews were unable to immediately reach, Arizona officials said. The aircraft, possibly twin-engine, crashed around 6:30 p.m. in the Superstition Mountains near Apache Junction, said spokesman Elias Johnson of the Pinal County Sheriff's Office.
A man who said he witnessed the impact told CNN that a mushroom cloud of flames lit up the evening sky.
It's a six-hour hike to the site and crews were uncertain how many people were on the plane or its destination, Johnson told reporters. He indicated crews will be in a recovery operation.
A ranger dropped near the scene saw a tire from the plane that suggests it was not a commercial aircraft, he said.
A spokesperson with Falcon Executive Aviation flight school in Mesa tells KPHO-TV the pilot flew in from Safford to Falcon Field to pick up his children and says when they were returning to Safford the two-engine plane crashed. The spokesperson tells KPHO there were three adults and three children onboard.
"This is some of the toughest country you can experience," Johnson said. There were at least two debris fields. "That plane is all over the place up there."
Kevin Cunningham, 44, of Apache Junction, said he was talking on the phone from his back porch and saw the crash a few miles away.
"The flames lit up the mountain," said Cunningham, adding the plane appeared to be flying level before the crash. "I didn't see where it was in distress."
The photogenic peak is popular with hikers and horseback riders, the resident said.
"Somebody didn't know the mountain was there or they had false readings," Cunningham speculated.

APACHE JUNCTION - The Pinal County Sheriff's Office is responding to reports of a plane crash and explosion in the Superstition Mountains. Multiple witnesses reported a plane crashed into a mountain in the Flat Iron area and burst into flames just after 6:30 p.m. The plane apparently split into two.

It's not yet known what kind of aircraft crashed, where it originated, or how many people were on board.

PCSO spokesperson Elias Johnson says that search and rescue is on their way to the scene. It's an area of rough terrain, so response time is being affected.
A DPS rescue helicopter is also over the scene.

A law enforcement staging area has been set up at the Lost Dutchman State Park.

Both Sky Harbor Airport and Mesa Gateway Airport told us all planes have been accounted for.
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APACHE JUNCTION, Ariz. -- Just before 7 p.m. scanner traffic and calls to the newsroom indicated an aircraft down in Pinal County near the Lost Dutchman State Park. Shortly after 7 p.m., the Pinal County Sheriffs Office established a command center and all available emergency personnel in the area were called to the scene. Authorities have confirmed that the incident is an airplane crash, however, the size and type of aircraft is not known.

Reporters form 3TV have been in touch with all local airports and military bases, none of which are reporting any missing aircraft. At this time, no further information is available.

PHOENIX (KPHO) - Witnesses tell CBS 5 News a plane has crashed into the Superstition Mountains near Flat Iron. Multiple witnesses reported a fireball and an explosion around 6:30 p.m. Wednesday.

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Pinal County authorities Wednesday evening reported that a plane had gone down in the Superstition Mountains. The county sheriff's office said a fire had broken out as a result, and that emergency crews were on the way. The size of the plane or how many passengers were aboard are not known at this time.
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A plane of unknown size has crashed in the Superstition Mountains, an official has confirmed. Multiple witnesses reported a fireball and an explosion around 6:30 p.m. Wednesday. No word on what kind of plane it is or how many people are on board.