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.
On Thursday, Karen Perry will pack up her house and leave it.
The toys must be boxed and the backyard swing set dismantled. The model airplanes, hanging in her sons' bedroom, will be taken down and the door closed on the princesses that decorate her daughter's walls.
The children's clothes must be gathered up and sorted through and their beds carted away, and I cannot imagine how she will do it, how she can stand it.
Karen Perry is about to lose her Gold Canyon home. On Thursday, she will walk away.
"We tried so hard to save it …," she told me this week. "It's hard not to get emotional about it. But then again, I have to remind myself that the house, it's a thing. It doesn't have a life of its own. The memories that I have, they can't be taken from me. The things that were most important to me about the house are no longer here."
It could be said that Karen is something of an expert on loss. Her marriage ended two years ago. A few days after the divorce was final, she endured a double mastectomy.
Then in November, she was wondering how the world could so suddenly collapse. At 6:31 on the evening before Thanksgiving, a twin-engine plane slammed into the Superstitions and in an instant her three children were gone.
And Karen? She was left to live on.
Within weeks, the foreclosure notice came. Like so many Arizonans, Karen was upside down in her house. After her divorce in February 2010, she couldn't afford the $3,300-a-month payments, but she couldn't bear to leave. Two of her three children had special needs and their world had already been tossed upside down with the divorce.
She tried to get a loan modification, but still the payments were too rich for a flight attendant's salary. So it wasn't a shock when word came, just weeks after the plane crash, that she would lose her house.
Her real-estate agent, Nicole Hamming, and her attorney, Scott Drucker, spent months trying to find a way that Karen could do a short sale on her house then rent it back, to give her time to grieve.
This, after all, is where her children, Morgan, 9, and Logan, 8, and the baby, 6-year-old Luke, were growing up. It's where she can feel them still.
Until Thursday, that is.
This week, Freddie Mac OK'd the short sale but denied Karen's request to waive the requirement that it be an "arm's length" transaction. Freddie Mac requires that the buyer and seller have no connection when a property is being sold for less than owed.
The arm's length rule was put in place in September 2010 to combat mortgage fraud, according to Freddie Mac spokesman Brad German. Previously, borrowers had been short-selling to straw buyers, who then returned the property to them, at a greatly reduced price.
Under the arm's length rule, Karen can't stay long term in the house even if the buyer is willing to rent it to her at the market rate.
"I'm told this was looked at by the business unit," German said, "and I'm told that they do not see a reason to be changing our rules, that we stick by our rules. That the rules are there for a reason."
While I can appreciate the reason, it seems to me that on occasion circumstance should trump rule. Like maybe every time a mother loses all of her children on the night before Thanksgiving.
A mother who knows she must go but can't yet let go.
Would it really have rocked the real-estate world to give Karen Perry a break?
German told me she could, under Freddie Mac's rules, remain for up to 90 days, provided the buyer agreed. But that offer didn't come through until late Friday. By then, Karen had resigned herself to moving.
She'll spend the next few days saying goodbye. Friends will pack away the children's things and the well-loved swing set will go to a good home. A local company, Sure Clean Restoration, has donated boxes and packing materials. Hamming is looking for someone to donate use of a moving van. (If you can help, call her at 480-363-0814.)
On Monday, Karen hopes to find a house in Gold Canyon that she can rent for a year, someplace big enough to hold one woman, two dogs and a so-very-short lifetime of memories.
Source: http://www.usatoday.com
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.
