Wednesday, November 30, 2011

American Airlines Flights to Jamaica secure

TOURISM interests are optimistic that American Airlines will not cut its 52 weekly flights into Jamaica despite yesterday's announcement that the airline and its parent company, AMR, were bankrupt.

Jamaica signed a controversial US$4.5-million ($385-million) airlift-guarantee deal in 2008 which provided an incentive for the US carrier to keep flying to the island from three American gateways.

Tourism Minister Edmund Bartlett defended the deal at the time, saying the Caribbean was one of the regions marked by American Airlines for reduction in air service in September of that year.

Director of Tourism John Lynch said yesterday that Jamaica does not expect the airline to back away from the deal. "We have not had any indication from American Airlines of any flight reduction at this time and so we are not expecting any cancellation in bookings," he told the Business Observer.

American Airlines currently operates three daily flights out of Miami into Kingston and three into Montego Bay, plus five flights a week each from Chicago and Dallas.

Lynch said there were a lot of forward bookings for the winter tourism season which begins on December 15 and there is no expectations that these will be cancelled.

The decision to file for Chapter 11 protection should not cause significant alarm, he said. "All major carriers have gone into Chapter 11 to adjust cost and bring it down and since (American) had the highest operating cost the decision had to be taken," he said.

However, Evelyn Smith, president of the Jamaica Hotel and Tourist Association (JHTA), said: "It is important that both public and private sector interests monitor the situation."

She also worried whether any other airline would be able to fill the gap if American did cut flights to the island.

"We will be in touch with our overseas partners to see if bookings are being cancelled even as we raise the tough question of whether we have enough seats on the other carriers into the island," she said.

Ian Burns, CEO of REDjet, said that if American did reduce its flights, his company would try to take up the slack.

"The opportunity for REDjet is good as our licence also allows us to fly to the States," he said yesterday.

The bigger airline's woes are a sign that its old fashioned business model doesn't work any more, he added.

"The future lies with smaller, private companaies like REDjet," he said. "Similarly we've seen Air Jamaica and Caribbean Airlines struggle because they have tried to follow that type of model."

Martha Pantín, American's regional spokeswoman, said that the airline cannot speculate as to any future decisions. "Our customers will see no immediate change as a result of the filing, and can be confident that they can continue depending on us," she said.

Elizabeth Brown-Scotton, chief commercial officer of MBJ Airports Ltd, which operates the Sangster International Airport in Montego Bay, said the airport is not expecting any major changes. "MBJ is not expecting nor have we been notified of any operational changes. It is business as usual."

— With additional reporting by Paul Allen

Piper PA-31-350 Navajo Chieftain, Trans North Aviation Ltd., N59773: Accident occurred November 28, 2011 in Riverwoods, Illinois

NTSB Identification: CEN12FA086 
 Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Monday, November 28, 2011 in Riverwoods, IL
Probable Cause Approval Date: 08/29/2013
Aircraft: PIPER PA-31-350, registration: N59773
Injuries: 3 Fatal,1 Serious,1 Minor.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

The airplane was dispatched on an emergency medical services flight. While being vectored for an instrument approach, the pilot declared an emergency and reported that the airplane was out of fuel. He said the airplane lost engine power and that he was heading toward the destination airport. The airplane descended through clouds and impacted trees and terrain short of its destination.

No preimpact anomalies were found during a postaccident examination. The postaccident examination revealed about 1.5 ounces of a liquid consistent with avgas within the airplane fuel system. Based on the three previous flight legs and refueling receipts, postaccident calculations indicated that the airplane was consuming fuel at a higher rate than referenced in the airplane flight manual. Based on this consumption rate, the airplane did not have enough fuel to reach the destination airport; however, a 20-knot tailwind was predicted, so it is likely that the pilot was relying on this to help the airplane reach the airport. Regardless, he would have been flying with less than the 45-minute fuel reserve that is required for an instrument flight rules flight. The pilot failed to recognize and compensate for the airplane’s high fuel consumption rate during the accident flight. It is likely that had the pilot monitored the gauges and the consumption rate for the flight he would have determined that he did not have adequate fuel to complete the flight.

Toxicology tests showed the pilot had tetrahydrocannabinol and tetrahydrocannabinol carboxylic acid (marijuana) in his system; however, the level of impairment could not be determined based on the information available. However, marijuana use can impair the ability to concentrate and maintain vigilance and can distort the perception of time and distance. As a professional pilot, the use of marijuana prior to the flight raises questions about the pilot’s decision-making.

The investigation also identified several issues that were not causal to the accident but nevertheless raised concerns about the company’s operational control of the flight. The operator had instituted a fuel log, but it was not regularly monitored. The recovered load manifest showed the pilot had been on duty for more than 15 hours, which exceeded the maximum of 14 hours for a regularly assigned duty period per 14 Code of Federal Regulations Part 135. The operator stated that it was aware of the pilot’s two driving while under the influence of alcohol convictions, but the operator did not request a background report on the pilot before he was hired. Further, the operator did not list the pilot-rated passenger as a member of the flight crew, yet he had flown previous positioning legs on the dispatched EMS mission as the pilot-in-command.

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's inadequate preflight planning and in-flight decision-making, which resulted in a loss of engine power due to fuel exhaustion during approach. Contributing to the accident was the pilot's decision to operate an airplane after using illicit drugs.

HISTORY OF FLIGHT

On November 28, 2011, about 2250 central standard time, the pilot of Lifeguard N59773, a Piper PA-31-350 Chieftain airplane, declared an emergency, reporting that the airplane was out of fuel, and indicating that the flight was gliding without engine power direct to the destination airport, Chicago Executive Airport (PWK), near Wheeling, Illinois. The emergency medical services (EMS) airplane subsequently sustained substantial damage when it impacted trees and terrain near Riverwoods, Illinois. The airline transport pilot and two passengers on board sustained fatal injuries. A pilot-rated passenger received serious injuries and the medical crew member received minor injuries. The airplane was registered to and operated by Trans North Aviation Ltd. under the provisions of 14 Code of Federal Regulations Part 135 as a non-scheduled, domestic, on-demand, EMS passenger flight. Night visual meteorological conditions prevailed at the time of the accident for the flight, which operated on an activated instrument flight rules (IFR) flight plan. The flight departed from the Jesup-Wayne County Airport (JES), near Jesup, Georgia, about 1900.

According to a load manifest form found in the wreckage, dated November 28, 2011, the crew that flew N59773 from the Crawfordsville Municipal Airport (CFJ), near Crawfordsville, Indiana, to the Perry-Houston County Airport (PXE), near Perry, Georgia, and onto the Palm Beach International Airport (PBI), near West Palm Beach, Florida, listed the pilot-rated passenger as the pilot-in-command and listed the pilot and the medical crewmember as “other crew.” This form indicated that this crew started their duty period at 0700 when they flew from CFJ and they ended their duty period at 1430 in PBI.

According to another load manifest form, also dated November 28, 2011, the crew that flew N59773 from PBI, to JES, and onto PWK listed the pilot as the pilot-in-command and listed the pilot-rated passenger and the medical crewmember as "other crew." This form indicated that this crew started their duty period at 1430 at PBI. This form indicated that they departed from PBI at 1642 and landed at JES at 1830. Fueling records showed an airplane was fueled at JES with 160 gallons of aviation gasoline (avgas) and an additional 5 gallons of avgas, which totaled a combined servicing of 165 gallons of avgas. This manifest form indicated that they departed from JES at 1900 and were destined for PWK. The duty period ending time was not completed.

A review of the recording of the approach controller’s frequency revealed that the pilot representing Lifeguard N59773 requested to fly direct to the outer marker navigation aid named PAMME. The controller indicated that the flight had to be taken on a heading to intercept the approach outside PAMME and the controller denied the request. The flight was given that heading for the instrument approach and the pilot then declared an emergency. The controller inquired if the flight was still landing at PWK. The pilot reported that he was unable, the airplane was out of fuel, and that the airplane was “coasting.” The controller asked if the field was in sight. The pilot reported negative and asked for the cloud tops. The controller indicated that the cloud deck was 1,400 feet overcast. The pilot responded that the flight was coasting down and that the pilot would report visual contact. The pilot further indicated that the flight was flying direct to PWK. The controller advised the flight of a low altitude alert and the flight acknowledged that alert. The controller again asked if the pilot had the field in sight. The pilot reported affirmative. The flight was cleared for the visual approach to runway 16 and the pilot was informed to cancel the flight’s IFR flight plan. The controller further indicated that the change to the airport’s advisory frequency was approved. There was no further recorded radio communication from the Lifeguard EMS flight. A transcript of the air traffic controller’s communications is appended to the docket associated with this investigation.

The pilot-rated passenger sat in the front right seat of the airplane. During a postaccident telephone interview, he indicated that the flight from PBI to PWK started out normal. While flying over the lower portion of Lake Michigan, the pilot selected the auxiliary fuel tanks to use up all the fuel in the auxiliary tanks. The last quarter of the main tanks was reportedly consumed “pretty fast” as monitored on the gauges. The right fuel flow warning light came on north of PWK. The pilot selected the crossfeed valve to its ON position. The fuel warning light went out. The pilot asked the air traffic controller to proceed direct to the outer marker and the air traffic control indicated that he was unable to grant that request. The fuel light came on again and the pilot declared an emergency. The pilot-rated passenger said that he had no idea of the amount of fuel that remained in the fuel tanks. The right engine subsequently started to shutter. The flight was cleared direct. The cloud tops were at 3,000 feet above mean sea level (msl). The airplane was turned left and then both engines “died” on a west heading. The airplane “coasted.” The airplane was in clouds during the descent and popped out of the clouds about 1,400 feet msl where there was about 700 feet of altitude left. The pilot rated passenger made some radio calls. The airplane was turned to a southbound heading. The pilot-rated passenger advised the pilot of suitable landing sites but the flight was unable to get to them. The landing gear was up. Flaps were up. The pilot moved the mixture to idle/cutoff and feathered the engines’ propellers. He pointed out a dark spot to the pilot and the pilot turned to it. The airplane scraped the tops of trees. The first tree impacted the pilot’s side and it came through the window. Both the pilot and the pilot-rated passenger were “on the flight controls.” The controls then went limp. The pilot-rated passenger indicated that he tried to keep the airplane away from the houses and both of his yoke handles broke off. A nearby neighbor found him in the wreckage and asked him if he was “ok.” It was about one-half hour before he was placed in an ambulance.

During a postaccident telephone interview, the medical crew member indicated that the purpose of the flight was to fly to PBI to pick up a patient and passenger and then fly them to PWK. The patient and passenger were informed that there would be one or maybe two stops for fuel. The airplane appeared to be topped off at JES. The fueling started on the right side of the airplane and continued to the left side. The fuel pump shut off after about 160 gallons were pumped. The pump was restarted and the airplane was fueled with more fuel. The flight was "ok" until it encountered “bad air” and the flight descended to about 7,000 feet. At one point in the flight, the medical crew member saw that a cockpit gauge indicated that there was one-half hour remaining before reaching the destination. The pilot remarked on how fast the airplane was flying and the ground speed was about 250 to 260 mph. The pilot reached down and switched tanks. The pilot also rocked the airplane’s wings. Both the engines shut off at the same time. Trees were observed once the flight descended through the clouds. During the accident sequence, the airplane’s nose pitched up as the airplane impacted trees. The passenger screamed and then the screaming stopped. The pilot-rated passenger sitting in the co-pilot’s seat advised them to brace. He said that the seat belt dug into him and his seat separated from its floor track. He was able to loosen his belt. He felt the door and its bottom half was open. He pushed open the top half. He did not initially see the pilot-rated passenger. He talked to a woman in a nearby house and related that there was an airplane accident. He heard people by the airplane and went to the airplane. He observed a small fire and told responders of the fire extinguisher location. The medical crew member reported that the pilot was in the front left seat, the pilot-rated passenger was in the front right seat, the patient’s wife was in the rear-facing seat behind the pilot, the patient was belted on the gurney, and he was in the forward-facing seat just in front of the rear cabin door.

The Riverwoods Police Department received an initial 911 phone call about 2250. The first responders found the wreckage near a residence northwest of the intersection or Portwine and Orange Brace roads.

PERSONNEL INFORMATION

Pilot

The 58-year-old pilot held an airline transport certificate with an airplane multi-engine land rating and he held commercial pilot privileges for single engine land airplanes. He held a flight instructor certificate with single engine, multi-engine, and instrument airplane ratings. He also held a type rating in SA-227 airplanes. A Federal Aviation Administration (FAA) 8410-3 Airman Competency/Proficiency Check Form showed that he passed a 1-hour checkride in the PA-31-350 with the operator’s Chief Pilot on June 7, 2011. The operator reported that the pilot had accumulated 6,607 hours of total flight time, 120 hours of total flight time in the PA-31-350, 171 hours of flight time in the 90 days prior to the accident, 61 hours of flight time in the 60 days prior to the accident, 5 hours of flight time in the 24 hours prior to the accident, and 12 hours of flight time in the Chieftain in the 90 days prior to the accident.

He held a first-class medical certificate, dated February 15, 2011, with limitations for hearing amplification and corrective lenses. The pilot reported on his application for that medical certificate that he had accumulated 6,350 hours of total flight time and 20 hours of flight time in the six months prior to that application. The pilot previously reported that he had a history of convictions for driving under the influence on both May 31, 2002, and February 01, 1997.

The operator initiated a background check in accordance with the Pilot Records Improvement Act of 1996 (PRIA) on the pilot. This PRIA check showed his training records and checkrides at previous employers and also revealed no legal enforcement actions resulting in a finding of a violation pertaining to the pilot. It listed a possible match and gave contact information for a Department of Transportation Compliance and Restoration Section in reference to checking the pilot's driver’s record. The operator did not get a background check from the Department of Transportation Compliance and Restoration Section on the pilot. However, the operator was aware of the pilot's history of convictions.

Pilot-rated Passenger

The 24-year-old pilot-rated passenger held a commercial pilot certificate with single engine land, multi-engine land, and instrument airplane ratings. He held a flight instructor certificate with single engine, multi-engine, and instrument airplane ratings. He held a first-class medical certificate, dated February 28, 2011, with no limitations. He recorded in his logbook that he had accumulated 314.3 hours of total flight time, 259.5 hours of pilot in command time, 66.6 hours of multi-engine time, and 7 hours of second in command time in airplanes associated with the operator. The operator’s chief pilot indicated in an e-mail that the pilot-rated passenger was compensated by the operator for the positioning flights to PBI and was considered a passenger on the flights from PBI.

AIRCRAFT INFORMATION

The airplane, serial number 31-7652044, was a 1976 Piper PA-31-350, Chieftain, with twin-engines, retractable landing gear, and a conventional semi-monocoque design. The airplane had a maximum gross weight of 7,368 pounds. Two 350-horsepower Lycoming TIO-540-J2BD engines, serial number L-7462-61H and serial number L-1701-68A, powered the airplane. Each engine drove a three-bladed, constant speed, controllable pitch, full feathering Hartzell propeller. The airplanes cockpit was equipped with dual pilot flight controls. According to a major repair and alteration form dated February 11, 1999, a Spectrum Aeromed Inc. Air Ambulance conversion had been installed in the airplane in accordance with supplemental type certificate SA1666GL.

According to the operator’s accident report, the airplane’s last annual inspection was completed on July 22, 2011. The operator indicated that the airplane had accumulated 17,630 hours of total time at the time of that inspection. An endorsement in the logbook for the airplane’s right engine indicated that an installation of a repaired engine was completed on November 18, 2011, and at that time, the Hobbs meter indicated 2832 hours.

The Chieftain’s main cabin door was a two-piece door that separated in the middle. The upper half swung up and was held in the open position by a spring-loaded support. The lower half swung down and it housed the entrance steps. To open from the inside, one must push the lock button beside the handle, pull, and lower the bottom half of the door. Then raise the upper half to the locked position. A 23 by 30 inch emergency exit is located in the right forward side of the fuselage.

The fuel system consisted of fuel cell, engine-driven and emergency fuel pumps, fuel boost pumps, control valves, fuel filters, fuel pressure and fuel flow gauges, fuel drains and non-icing fuel tank vents. Fuel could be stored in four flexible fuel cells, two in each wing. The outboard cells hold 40 gallons each and the inboard cells hold 56 gallons each, giving a total of 192 gallons, of which 182 gallons were usable.

The emergency fuel pumps were installed for use in case of an engine driven fuel pump failure, or whenever the fuel pressure fell below 34 pounds per square inch (psi). They were also operated during takeoffs, landings, and for priming the engines. Control switches for the emergency fuel pumps were located in the overhead switch panel to the right of the fuel gauges.

The fuel boost pumps operated continuously and provided fuel under pressure to the other fuel pumps, improving the altitude performance of the fuel system. The fuel boost pumps were activated when the master switch was turned on and continue to operate until the master switch was turned off or the fuel boost pump circuit breakers were pulled off. Fuel boost pump warning lights, mounted at the bottom of the windshield divider post, illuminated when the fuel boost pump pressure was less than three psi.

The fuel management controls were located in the fuel control panel at the base of the pedestal. Located here were the fuel tank selectors, fuel shutoffs and crossfeed controls. During normal operation, each engine was supplied with fuel from its own respective fuel system. The fuel controls on the right controlled the fuel from the right cells to the right engine and the controls on the left controlled the fuel from the left fuel cells to the left engine. For emergencies, fuel from one system can supply the opposite engine through a crossfeed system. The crossfeed valve was intended only for emergencies. The crossfeed control was located in the center of the fuel control panel. A warning light, located on the fuel control panel was incorporated in the firewall fuel shut-off system to indicate that one or both of the shut-off valves were not fully open.

A note in the Pilot’s Operating Manual (POM) Description - Airplane and Systems chapter, in part, stated: “The crossfeed system was not to be used for normal operation. When the crossfeed valve was on, be certain fuel selector valve on tank not in use was off. Do not use crossfeed to compensate for an inoperative emergency fuel pump.”

Right and left fuel flow warnings lights, mounted at the base of the windshield divider post, illuminated to warn the pilot of an impending fuel flow interruption. The lights were activated by a sensing probe mounted near each inboard fuel tank outlet. In the event the fuel level near the tank outlet dropped to a point where a fuel flow interruption and power loss could occur, the sensing probe would illuminate its corresponding warning light. The warning light would be on for a minimum of 10 seconds and would remain on if the condition was not corrected.

A 50,000 British thermal unit Janitrol heater installed in the right nose section furnished hot air for cabin heating and windshield defrosting. Heater fuel was supplied from the right wing fuel cells only. Information supplied by the manufacturer indicated that the heater would use about 3.9 pounds, or about .65 gallons of fuel per hour (gph) when in use.

According to the pilot-rated passenger, the pilot reportedly set his power settings from a card that was kept in his window’s visor. He indicated that the engines operated “ok” while they were running. The right engine was new and it was installed on the airplane about two and one-half weeks prior to the accident. The pilot-rated passenger also said that the right engine’s gauges were not accurate during the accident flight. In addition, the pilot increased the mixture on the right engine about one gph due to its break-in.

The POM General Specifications chapter, in part, stated:

PERFORMANCE

Published figures are for the Standard PA-31-350 airplane flown at gross weight under standard conditions at sea level unless otherwise stated. Performance for a specific airplane may vary from published figures depending upon the equipment installed, the condition of engines, airplane and equipment, atmospheric conditions and piloting technique.

METEOROLOGICAL INFORMATION

At 2252, the recorded weather at PWK was: Wind 350 degrees at 9 knots; visibility 10 statute miles; sky condition overcast 1,400 feet; temperature 2 degrees C; dew point -2 degrees C; altimeter 29.99 inches of mercury.

At 2352, the recorded weather at PWK was: Wind 360 degrees at 9 knots; visibility 10 statute miles; sky condition overcast 1,400 feet; temperature 2 degrees C; dew point -2 degrees C; altimeter 29.97 inches of mercury.

At 2252, the recorded weather at the DuPage Airport (DPA), near West Chicago, Illinois, was: Wind 340 degrees at 11 knots; visibility 10 statute miles; sky condition overcast 1,400 feet; temperature 1 degree C; dew point -3 degrees C; altimeter 29.96 inches of mercury.

At 2352, the recorded weather at DPA, was: Wind 360 degrees at 14 knots gusting to 23 knots; visibility 9 statute miles; overcast 1,000 feet; temperature -1 degree C; dew point – 3 degrees C; altimeter 29.94 inches of mercury.

AIDS TO NAVIGATION

The published inbound course for PWK’s instrument landing system (ILS) runway 16 approach was 161 degrees magnetic, with the published straight in decision height of 893 feet msl, with a height above touchdown of 250 feet above ground level (agl). The crossing altitude for the locator outer marker PAMME was 2,279 feet. The distance between PAMME and the touchdown zone was 4.9 nautical miles (nm). The touchdown zone elevation was 643 feet. The published weather minimums for the ILS runway 16 approach were a 300-foot ceiling and three-quarter mile visibility for category A, B, C, and D aircraft. The published weather minimums for the circling approach were a 500-foot ceiling and one-mile visibility for category A and B aircraft. The minimum descent altitude for the circling approach was 1,140 feet msl and the height above the airport was 493 feet agl for category A and B aircraft. The PWK ILS RWY 16 approach plate is appended to the docket associated with this investigation.

AIRPORT INFORMATION

PWK was a tower-controlled airport. The airport had an elevation of 647 feet msl and was served by three intersecting paved runways 16-34, 12-30, and 06-24. Runway 16-34 was a 5,001 foot by 150 foot grooved asphalt runway. Runway 12-30 was a 4,397 foot by 50-foot asphalt runway. Runway 06-24 was a 3,652 foot by 50-foot asphalt runway.

WRECKAGE AND IMPACT INFORMATION

The airplane impacted trees and terrain in a wooded residential neighborhood about 3 nautical miles northeast of PWK. The wreckage path was about 250 feet in length from the first found impacted tree to the main wreckage on a magnetic heading of about 130 degrees. The airplane was found fragmented along the path. The left propeller separated from its engine and was found 32 feet west of the main wreckage. The airplane fuselage came to rest facing about 280 degrees magnetic. An on-site inspection confirmed that the fuselage, empennage, wings, and all flight control surfaces were located within the wreckage debris path. The landing gear were found in the up position in their wheel wells.

The left and right throttle levers were found in the full forward position. Both left and right mixture levers were found in the forward rich position. The left and right propeller levers were found in the forward high rpm position. The Hobbs meter read 2848.8 hours. All four magneto switches were in the on position. The left fuel boost pump switch was in the on position and the right fuel boost pump switch was in the off position. Both the left and right fuel tank selectors were positioned on their respective inboard fuel tanks. The crossfeed valve was found in the on position. All fuel caps were in place in their filler necks. Approximately 1.5 ounces of a liquid consistent with avgas was found within the airplane fuel system. All four electric fuel pumps were operational when electrical power was applied to them. The flap jackscrew extension was consistent with the flaps being in the up position. Left and right engine control continuity was established. Flight control continuity was established.

Both engines’ crankshafts were rotated and each engine exhibited gear and valve train continuity. All cylinders produced thumb compression and suction. Both dual magnetos produced sparks at all leads. All removed spark plugs exhibited the appearance of normal combustion when compared to the Champion AV-27 spark plug chart. Both engines’ turbocharger impellers spun when rotated by hand. The left and right propellers were found in the feathered position. No airframe or engine preimpact anomalies were found.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot by the Lake County Coroner’s Office. The autopsy listed multiple traumatic injuries as the cause of death.

According to a preemployment drug test report, its results indicated that the pilot was negative for the tests performed on a sample collected from the pilot on April 14, 2011.

The FAA Civil Aerospace Medical Institute prepared a Final Forensic Toxicology Accident Report on toxicological samples taken during the autopsy on the pilot. The report, in part, stated:

Blood unsuitable for analysis of Tetrahydrocannabinol (Marihuana)
0.1077 (ug/ml, ug/g) Tetrahydrocannabinol (Marihuana) detected in Liver
0.0198 (ug/ml, ug/g) Tetrahydrocannabinol (Marihuana) detected in Lung
0.0157 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Liver
0.0024 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Blood

COMPANY INFORMATION

Trans North Aviation Ltd, dba Travel Care International, was a commercial on-demand air taxi operator, which was authorized to conduct Part 135 IFR, visual flight rules (VFR), day, and night operations. The company provided medical air transportation services from two bases. The company employed three pilots and one mechanic. The company operated four airplanes, which included the Piper PA-31 and Cessna 340 airplanes. The company’s website indicated they operated bases in Eagle River, Wisconsin, Green Bay, Wisconsin, Chicago, Illinois, and Charleston, South Carolina.

Trans North Aviation Ltd utilized a FAA approved pilot training program that addressed new hire, initial aircraft, recurrent, re-qualification, transition, and upgrade training. The accident pilot had previously completed all required training at the time of the accident and had passed required check rides.

The Director of Operations at Trans North Aviation Ltd monitored all flights and approved all departures. According to the operator, they familiarize themselves “with all available information prior to each flight. This information includes, but is not limited to the length and route of flight, notices to airmen, performance data (such as fuel burn and takeoff data); departure, en route and destination weather; approach minimums, maintenance items, airworthiness of the aircraft and crew, airport conditions, time and duty logs to ensure the pilot can complete the flight safely.”

Aircraft were maintained in accordance with an FAA approved inspection program. All maintenance activity was monitored by their Director of Maintenance.

According to the Trans North Aviation Ltd President, the airplanes’ fuel logs were a recommendation from a Department of Defense audit and those logs were not reviewed by management.

FAA records indicated that the operator had been in business for 48 years and that their operating certificate was issued on November 18, 1964.

TESTS AND RESEARCH

A National Transportation Safety Board (NTSB) national resource specialist prepared a performance study. The original flight planning records for the accident flight could not be located. According to the study, an on-line internet service used by the accident pilot, FltPlan.com, was able to re-create the navigation logs for the study. The accident flight plan showed a proposed departure time from JES of 1708, a proposed cruising altitude of 10,000 feet msl en route to PWK, five hours of fuel on board, and it listed DuPage Airport, near West Chicago, Illinois, as an alternate airport. Those navigation logs showed that the 182 gallons of usable fuel available for the Piper Chieftain should have been sufficient for all flight legs that day. The final accident leg from JES to PWK would have required the most fuel. FltPlan.com calculations assumed a fuel burn rate between 34-37 gallons per hour for cruise and the POM indicated a fuel burn between 26-35 gallons per hour (depending on the power setting) with the engines leaned to best economy. The average actual fuel burn computed for the flight legs flown on November 28, 2011, was 47 gallons per hour.

Fuel records recovered from the wreckage indicated that the airplane was filled to its capacity with fuel at CFJ, PXE, and at JES. The fuel records also indicated that only 75 gallons of fuel was added at PBI.

A nominal fuel burn rate of 30 gallons per hour would indicate that landing with a minimum of 22.5 gallons of fuel would meet the 45-minute IFR fuel reserve requirement: with the Chieftain’s 182 gallons of usable fuel, the maximum amount of fuel that should be added after a flight conducted under instrument flight rules is 159.5 gallons. N59773 was serviced with 167.3 gallons and 165.0 gallons at PXE and JES respectively.

ADDITIONAL DATA/INFORMATION

Code of Federal Regulations Part 135.223, IFR: Alternate airport requirements, in part, stated:

(a) Except as provided in paragraph (b) of this section, no person may operate an aircraft in IFR conditions unless it carries enough fuel (considering weather reports or forecasts or any combination of them) to -

(1) Complete the flight to the first airport of intended landing;

(2) Fly from that airport to the alternate airport; and

(3) Fly after that for 45 minutes at normal cruising speed

Code of Federal Regulations Part 135.263, Flight time limitations and rest requirements, in part, stated:

(c) Time spent in transportation, not local in character, that a certificate holder requires of a flight crewmember and provides to transport the crewmember to an airport at which he is to serve on a flight as a crewmember, or from an airport at which he was relieved from duty to return to his home station, is not considered part of a rest period.

Code of Federal Regulations Part 135.267, Flight time limitations and rest requirements, indicated that 14 hours should not be exceeded for a regularly assigned duty period.

Code of Federal Regulations Part 135.273, Duty Period Limitations and Rest Time Requirements, in part, stated, “Duty period means the period of elapsed time between reporting for an assignment involving flight time and release from that assignment by the certificate holder.”

A report, from the Milwaukee, Wisconsin, Flight Standards District Office (FSDO), generated by their Program Tracking and Reporting Subsystem (PTRS), on their activity between December 1, 2008 and the date of the accident, was reviewed. There were 59 PTRS recorded entries with results relating to the FSDO’s surveillance of Trans North Aviation Ltd. Of those, there were 54 entry results that indicated “S” for satisfactory, 2 entry results that indicated “I” for satisfactory and information provided in comments, and 3 entry results that indicated “F” for follow-up action completed or follow-up activity scheduled.

The FAA posted a web page concerning “Pilot Records Expunction Policy Changes.” The page, in part stated:

What is the Pilot Records Improvement Act (PRIA)?

PRIA is a law that requires airlines to perform background checks on pilots before hiring them. It's designed to make sure that airlines have more information to make good hiring decisions.

How does PRIA work?

PRIA requires an airline to ask the FAA and a pilot's former employers for certain records. These records include records of legal enforcement actions against individuals.

What is the new law?

The Airline Safety and Federal Aviation Administration Extension Act of 2010, signed August 1, 2010, changes how PRIA works. The changes it made require the FAA to change how it handles pilot records.

How did the new law change PRIA?

The new law requires employers to give all the records they must report under PRIA to the FAA. The FAA will put those employer records, along with all the records the FAA must provide under PRIA, into a pilot records database. Airlines will then check the pilot records database to fulfill their PRIA requirements.

How did the new law change FAA policy?

The new law required the FAA to retain certain legal enforcement records until the agency is notified that a pilot has died. Previously, some types of legal enforcement records were expunged after five years. The FAA has suspended this expunction policy while it determines the full scope of the new law's effect on the expunction policy. The law required the FAA to begin keeping the records starting August 1, 2010.

Advisory Circular 120-68E, Pilot Records Improvement Act of 1996, in part, stated:

APPENDIX 8, OVERVIEW AND USE OF FORM 8060-13

NOTE: Consult the Pilot Records Improvement Act (PRIA) Web site at http://www.faa.gov/pilots/lic_cert/pria/ for the most current information on the overview and use of Federal Aviation Administration Form 8060-13, National Driver Register Records Request.

Part I National Driver Register (NDR) Records Request. Part I of the NDR records request is used by the hiring air carrier in operation under Title 14 of the Code of Federal Regulations (14 CFR) Part 121 or 135, air operator under 14 CFR Part 125, or other person (collectively referred to as the “hiring employer”) to request NDR records concerning an individual seeking employment as a pilot with the employer.


5. Distribution. NDR requirements vary from state to state and, therefore, it is not practical to establish one firm procedure that will satisfy all requests. Notwithstanding, the requesting employer should begin its NDR request process in the manner described in the latest revision of this advisory circular or in the PRIA Office Procedures for the Air Carrier to discover a request process that will produce the most reliable and consistent results for the state.
...

11. NDR Data System Match. The hiring employer receives an NDR report that will state that (1) a data system match was not found – meaning that the record of the individual is clean, or that (2) a data system match concerning the motor vehicle driving record of the individual was found and indicated a:
a. Record of suspension from the previous 5-year period, if applicable.
b. Record of revocation from the previous 5-year period, if applicable.
c. Any conviction of driving under the influence of alcohol, if applicable.

12. The NDR Report.
a. A completed NDR report without reference to an action taken against the pilot’s driver’s license is considered a clean report. If the report does indicate a clean record, add the report to the pilot/applicant’s PRIA-related records file and the NDR request process is considered complete.

b. If the report does indicate a problem, however, it will point to a specific state(s) in which the problem(s) occurred. In these cases, the record will indicate a possible match, and the hiring employer is required to conduct further investigation. The hiring employer must disclose this information to the individual in an attempt to verify whether a positive match with the pointer record exists, or if the possible match pertains to another individual with similar identifying information.

(1) If the resulting investigation confirms the individual as a positive match with the pointer record, a second NDR request must then be sent to the state(s) indicated in the initial report, to determine the exact nature of the problem.

(2) If the resulting investigation confirms that the individual is not a match with the pointer record, then along with the results of the investigation the report is considered clean, the matter closed, and the NDR request process completed for that individual.



William Didier. 
Photo Courtesy Peter Didier.

Two days after Port Washington native William Didier, 58, died when the medical transport plane he was flying went down in a Chicago suburb, his relatives in Port are coping with the loss to their tight-knit family.

Peter Didier, William's older brother by seven years, lives on a farm a few miles north of downtown Port Washington on County Highway KW with his three sons, who together own RE/MAX United real estate in Port Washington.

It's the same farm Peter and William - better known as Bill - grew up on and shared until Bill moved to another house in Port Washington with his wife.

Bill continued to live in Port until he moved to Cedar Grove five months ago to be closer to his new job flying medical transport planes for Trans North Aviation, which owned the plane that crashed Monday night in Riverwoods, IL, about 30 miles northwest of Chicago.

It was on the family farm that Bill had his first close encounter with flying, Peter said. In 1957, their father Nick and his business partner arranged for a small plane to pick the two of them up on the farm and take them to the Milwaukee airport, where they took an airliner to New York City for the World Series.

"I remember seeing the airplane landing in the cow pasture and taxiing over to the house," Peter said. "I thought that was really cool."

After that, the brothers asked to take flying lessons and both became recreational pilots.
Read more:   http://portwashington-wi.patch.com

Two bodies found in New Zealand chopper wreckage

Divers have found the bodies of two men killed in a helicopter crash off New Zealand, as details emerge of the chopper's role in a rescue mission during firefighting efforts in the country's far north.  The bodies of the pilot and a ranger with the Department of Conservation were found by divers in the wreckage about midday on Thursday (1000 AEDT).   The five-seater Squirrel helicopter was on a rescue flight when it crashed into the sea off the Karikari Peninsula, in New Zealand's far north, on Wednesday night, the company which operates the aircraft said.

Salt Air chief executive Grant Harnish said the helicopter had been fighting a large scrub fire but had dumped its monsoon bucket after being asked to pick up people caught out by the blaze.  "The pilot had been requested by authorities to divert in order to extract people from the beach, away from approaching flames and out of harm's way," he said in a statement.   Mr Harnish said conditions were extremely difficult at the time of the crash.  "We only ever operate under those conditions if we believe human life is at risk," he said.

Two commercial divers had confirmed the bodies were in the cockpit in about seven metres of water off Karikari Moana beach.  The company was working to get the family of the pilot, who it did not name, to the crash scene.  The helicopter had been helping contain the scrub fire on the Karikari Peninsula near Matai Bay.  It crashed into the sea about 9.30pm local time.  "We cannot speculate at this stage about the cause or likely cause of the crash," Mr Harnish said.

An initial search by two helicopters and a fishing boat could not locate it and it was not until 6.30am on Thursday that it was found.  A fishing boat found an oil slick and a crew member who went into the water spotted the wreckage on the sea bed but could not see if the men were inside.  Two Civil Aviation Authority investigators and a safety adviser would look into the cause.

A CAA spokeswoman says the wreckage will be videoed before anything is removed from the water.  The fire, which is being treated as suspicious, started at 7.15pm on Wednesday. It was fanned by strong winds and quickly spread, destroying three homes and forcing five people into the sea to escape from the flames.
http://news.brisbanetimes.com.au

Infratil airport halts Iran Air fuel sales

Infratil's Manston airport in Kent, England, has stopped refuelling Iran Air flights in the face of US sanctions that had spurred fuel suppliers at Heathrow to refuse to deal with the state-owned airline.  The US imposed sanctions on Iran amid suspicions the Middle Eastern state was developing nuclear weapons under the guise of a civilian nuclear power programme. Voice of America reported on June 28 that the US toughened the sanctions, imposing new penalties on Iran Air because it was concerned the airline may be carrying military payloads for the Iranian regime.

Iran Air flights have been allowed to continue using Heathrow but were forced to fly on to Manston for fuel for return journeys to Iran.  Steve Fitzgerald, head of Wellington-based Infratil's European Airports division that includes Manston and Glasgow Prestwick, said the company had checked with British authorities that the fuel sales didn't breach any laws.  The decision to cease fuel sales was "a commercial, judgmental decision," Mr Fitzgerald said.

"There's concern among governments that dealing with Iran at the moment is sensitive.  "Iran Air was advised a week ago that Kent International Airport is no longer willing to supply them with fuel."  The Iran Air fuelling arrangements with Manston were picked up by British media including the BBC and Daily Mail Online. They come amid a deepening diplomatic rift between the UK and Iran, after protesters stormed the British embassy in Tehran. The UK responded by expelling Iranian diplomats.

Will Harrisburg International Airport (KMDT) land bigger planes?

Between 2002 and 2006, Air Canada, Delta, United and U.S. Airways all filed for Chapter 11 bankruptcy. Passengers bought tickets, planes took off, planes landed and each of the airlines emerged stronger and still doing business in the Harrisburg region.

HIA hopes for the same as American Airlines begins its journey through the bankruptcy court. Anyone scheduled to fly American out of HIA in the coming months should not be affected by the filing, airport spokesman Scott Miller said.

There are bigger long-term questions facing the airport:

Facing rising fuel costs, airlines are scrapping many routes flown by small jets, like those that account for more than half of HIA’s traffic. So far, HIA hasn’t been affected, but airlines are expected to continue cutting less profitable flights across the country.

Can the airport convince its airlines that the best way for everyone to make money is to land more and bigger planes along the Susquehanna?

HIA will need to, according to industry analysts. If not, the airport could be in the next wave of cutbacks as airlines try to save costs.  “It’s vulnerable,” said Seth Kaplin, an analyst for Airline Weekly. “It’s a sizable market, but it’s not isolated. It’s not a place where people have to fly out of there or they can’t fly at all.”  Why is all this happening now? Blame gas prices.

In the late '90s, when gas was less than a dollar a gallon, it made sense for airlines to buy or lease 50-seat jets to serve regional markets. They could make more money flying a full 50-person jet than a half-empty plane that carried three times that many.  That model doesn’t work anymore.

Because a 50-seat plane still needs a lot of fuel, the airlines only reliably make money if they fill up the larger planes. That spelled the end of commercial service to places like St. Cloud, Minn., and Oxnard, Calif. Similar markets have fewer small planes going in and out.  HIA insists it shouldn’t be lumped in with those cities.
Read more . . . http://www.pennlive.com

Dallas Love Field Airport Gate Crasher Sentenced



DALLAS - A man who led police on a car chase that end up on the runway of Dallas Love Field was sentenced Wednesday to more than 22 years in federal prison.

In August 2010, Dallas police officers tried to stop Michael Browne, 47, when they spotted him driving a truck that had been reported stolen.

After leading officers on a winding chase through rush-hour traffic, Browne crashed the vehicle through a security gate that led to the Love Field runway.

The gate was routinely used for ambulances and emergency personnel and was guarded by Love Field personnel. However, Browne rammed the gate at high speed with DPD officers close behind.

After a short pursuit on the actual runway, officers disabled Browne's truck and took him into custody.

One year ago, Browne pleaded guilty to one count of interfering with security screening personnel. Today, U.S. District Judge Barbara M. G. Lynne sentenced him to 270 months (22.5 years) in federal prison.

The case was investigated by the FBI and the TSA-Federal Air Marshal Service.

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

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.

 =========


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.

NTSB Identification: WPR12FA046
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.

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.


=================

Pinal County court records for Shawn Perry, the 39-year-old pilot whose small commuter plane crashed into the Superstition Mountains on Thanksgiving eve, reveal Perry allegedly grounded himself from his job as a pilot for Safford, Arizona-based Ponderosa Aviation, Inc. due to severe depression in 2010.

Perry had also filed for bankruptcy last year after he and his wife Karen previously underwent wage garnishment from their jobs as a pilot and flight attendant for Delta Airlines.

A response filed by the lawyer of Perry’s wife during the couple’s divorce proceedings in Nov. 2010 claim Perry wrote an email to his wife a few months prior outlining the extent of his depression.

“Today I spoke to the chief pilot at US Airways and Ponderosa and officially grounded myself due to my depression,” the document reads. “I have kind of opened a box and don’t really know what to expect from here.”

The response filed by Angela M. Wilson-Goodman of Wilson-Goodman & Fong PLLC said Perry was bi-polar and extolled suspicions that he combated thoughts of suicide. Perry wrote a short email to his wife around the time of his alleged depression-leave that simply read: “I wish you the best, I will always regret. Goodbye.”

Documents also show Perry, who perished along with his three children and two other passengers in the nighttime crash on Nov. 23, 2011, had filed for bankruptcy in Oct. 2010.

Onboard the plane were Perry, his son Luke, 6; Logan, 8; his daughter Morgan, 9; pilot Russel Hardy, 31; and plane mechanic Joseph Hardwick, 22.

Investigators with the National Transportation Safety Board are expected to release a preliminary report on the cause of the crash in the coming days.