ASN Wikibase Occurrence # 140030
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| Date: | Wednesday 23 November 2011 |
| Time: | 18:31 LT |
| Type: |  Rockwell Aero Commander 690A |
| Owner/operator: | Ponderosa Aviation |
| Registration: | N690SM |
| MSN: | 11337 |
| Year of manufacture: | 1976 |
| Total airframe hrs: | 8188 hours |
| Engine model: | Airresearch/Honeywell TPE-331 |
| Fatalities: | Fatalities: 6 / Occupants: 6 |
| Aircraft damage: | Destroyed |
| Category: | Accident |
| Location: | Superstition Mountains, near Apache Junction, Pinal County, AZ -
 United States of America
|
| Phase: | Initial climb |
| Nature: | Private |
| Departure airport: | Mesa, AZ (FFZ) |
| Safford, AZ (SAD) | |
| Investigating agency: | NTSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
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.
Probable Cause: 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.
Accident investigation:
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Sources:
https://app.ntsb.gov/pdfgenerator/ReportGeneratorFile.ashx?EventID=20111124X85300&AKey=1&RType=HTML&IType=MA
Location
Media:
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 23-Nov-2011 23:24 | dfix | Added |
| 24-Nov-2011 00:41 | RobertMB | Updated [Time, Aircraft type, Registration, Cn, Operator, Other fatalities, Location, Phase, Departure airport, Destination airport, Source, Narrative] |
| 05-Dec-2011 09:32 | Geno | Updated [Time, Location, Source, Narrative] |
| 28-Dec-2012 12:53 | Anon. | Updated [Source, Narrative] |
| 07-Mar-2014 19:57 | Anon. | Updated [Narrative] |
| 21-Dec-2016 19:26 | ASN Update Bot | Updated [Time, Damage, Category, Investigating agency] |
| 27-Feb-2017 21:14 | PiperOnslaught | Updated [Source, Narrative] |
| 27-Nov-2017 17:25 | ASN Update Bot | Updated [Operator, Other fatalities, Departure airport, Destination airport, Source, Narrative] |
| 02-Aug-2018 14:57 | Aerossurance | Updated [Time, Other fatalities, Source, Embed code, Narrative] |
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