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Culture of ‘Complacency’ Led to 2011 Twin Commander Crash

Gemini Sparkle

Key Takeaways:

  • The NTSB attributed the crash to a "complacency" culture within the operating company and the pilot's failure to maintain a safe ground track and altitude during a moonless night flight, resulting in controlled flight into terrain.
  • Contributing factors included the aircraft being legally unairworthy due to missed inspections (a fact known to the pilot/co-owner) and the absence of a required Terrain Awareness and Warning System (TAWS), potentially circumvented by unapproved modifications.
  • The pilot's complacency, lack of situational awareness, and failure to use ATC flight following or utilize available navigation tools were critical, especially after an ATC delay inadvertently placed the aircraft on a collision course with the mountain.
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A variety of factors contributed to the tragic crash of a Twin Commander into an Arizona mountain that killed a father and his three young children just before Thanksgiving two years ago. Linking them all, however, was a culture of “complacency” that existed among the co-owners of the company that operated the airplane, according to the National Transportation Safety Board’s scathing final accident report.

Among the troubling revelations in the NTSB’s report was the discovery that the accident airplane, a 1976 Rockwell 690A, was legally unairworthy at the time of the crash after failing to undergo required inspections when the new owners at Ponderosa Aviation Inc. took delivery of it the week before. The company’s director of maintenance, who was also the accident pilot and a company co-owner, knew about the discrepancy, and also knew that other airworthy airplanes were available for the trip, which was a personal flight to pick up the children of PAI’s director of operations, also a company co-owner and the pilot who had flown the first leg of the journey.

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