Culture of ‘Complacency’ Led to 2011 Twin Commander Crash

NTSB report reveals pattern of behavior.

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.

Besides the two PAI co-owners and three children, another PAI employee onboard was killed when the Twin Commander crashed on a moonless night into a 5,000-foot mountain while on a course from Falcon Field in Mesa, Arizona, to PAI’s base at Safford Regional Airport in Safford, Arizona. The NTSB said the airplane’s nonairworthy condition was more a paperwork issue and that there is no indication of any mechanical problems. However, the Board noted the airplane was not equipped with TAWS as required by FAA regulations, but only because the seatbelt of its sixth seat, a belted lavatory, was removed by the previous owner. The FAA noted that the change was never approved or documented through the Form 337 process. Whether the seatbelt was removed solely to skirt the TAWS regulation is unknown, but that was the effect.

Contributing to the chain of events that led to the accident was the fact that the tower controller at Falcon Field delayed the Turbo Commander’s right turn on course for two minutes because of arriving traffic. That delay put the airplane on a direct path toward the mountain, which lies at the edge of the Phoenix Class B airspace. Facing criticism from local pilots that the boundary of the Phoenix Class B leaves little room for error to avoid the mountain, the FAA conducted a study that found the vast majority of pilots who requested entry into the Class B or flight following services had their approvals granted.

The accident pilot never contacted ATC after departing Falcon Field, the NTSB noted. His brother said his normal practice was to fly direct between airports. Had the Twin Commander’s turn on course not been delayed, it would have missed the mountain to the south. The pilot’s brother also said he flew with an iPad loaded with ForeFlight mapping software. The NTSB said that while it found fragments of an iPad in the wreckage, it could not determine whether ForeFlight was running. “Had the pilot been using the ForeFlight app as he normally did,” investigators wrote, “he could have been able to determine that the airplane would not clear the mountain on the given flight track.”

The NTSB blamed the accident on “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.”

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