WPR12MA046

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.

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 yea

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. AIRCRAFT 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