Aftermath: Complacency on the Ground and in the Air

Complacency is not just pilots who are lulled by routine.

Crash Icon

Crash Icon

In the third week of November 2011, a Rockwell 690 made a night VFR round trip from Safford in eastern Arizona to Falcon Field in Mesa, just east of Phoenix. On the return leg, the pilot turned right immediately after taking off from Falcon’s Runway 04R, remained at 4,500 feet until emerging from under Phoenix Class B and continued direct to Safford.

Two days later, the same pilot made the same 111 nm trip in a different 690, again at night and again under VFR, to pick up several passengers from Mesa. In this case, there were two pilots in the front seats, colleagues in the company that owned the airplane. They swapped positions at Mesa. The turnaround was quick; the 690 departed just 12 minutes after landing. This time, however, the local controller asked the pilot flying to maintain runway heading after takeoff until advised. When the 690 was a little more than a mile from the departure end of the runway, the controller cleared the pilot to begin his right turn. After a brief delay, he again turned east-southeastward and again climbed to 4,500 feet, where he remained until he passed the edge of Class B and began a shallow climb. A few seconds later, the 690 slammed into Superstition Mountain at 190 knots and exploded into fragments and flames.

It didn’t take long for video of the crash, captured by a homeowner’s surveillance camera, to find its way onto the Internet; for it to emerge that of the six people aboard the airplane that night, three were small children; or for speculation to begin about how in the world such an accident could happen just a few miles from downtown Phoenix. To some local pilots, however, it was not unexpected; it was an accident for which FAA decisions had set the stage.

As is so often the case, the National Transportation Safety Board’s finding of probable cause restates the circumstances of the accident without illuminating them. The NTSB blamed the pilot’s “complacency and lack of situational awareness” and his failure to take advantage of VFR flight following and minimum safe altitude warning services. Obviously, the pilot did not know the mountain was in his way or expect it to be, but why not? Could anything other than greater attention to preflight planning have prevented the accident, or one like it, from happening?

The role played by the FAA was in the design of the Phoenix Class B airspace. In 2007, it lowered the floor of the eastern quadrant from 8,000 to 5,000 feet. Such a change would have been unremarkable in flat terrain, but in Phoenix, which is hemmed in by mountains in several directions, it was controversial, in part because of the peak rising above 5,000 feet just outside the perimeter of Class B. The FAA, which lowered the floor to facilitate parallel instrument approaches to Phoenix Sky Harbor, took the position that VFR pilots could navigate around the obstacle or request transit through Class B to pass safely above it.

A question therefore arose after this accident about how amenable Phoenix controllers were to such requests. VFR pilots who had sought Class B clearances — of course, many VFR pilots would not even think to do so — claimed that they had frequently been denied. The pilot of the 690 had not requested such a clearance; possibly the very existence of the mountain, invisible on a moonless night, did not enter his conscious thoughts.

In January 2012, the Scottsdale FSDO prepared a scathing internal memorandum characterizing the design of the Phoenix Class B airspace as “deficient” and asserting that it was “very difficult” — more difficult than at other busy Class B locations — for VFR aircraft to obtain clearances to operate within it. The FAA accordingly conducted an audit of VFR requests for Class B clearances over several days and found that 96 percent were approved. An audit by the FAA of its own controllers in the aftermath of a potentially embarrassing fatal accident could hardly inspire much confidence, however. It would be too easy for someone to tip controllers off to the desired result, if they couldn’t figure it out for themselves.

It happened that the flight was technically illegal because the airplane, which had just changed hands and had been delivered under a ferry permit, was overdue for a required periodic inspection. It was, however, airworthy and in good condition. The new owners had other airplanes available, but for unexplained reasons — perhaps it just happened to be on the ramp, or had a nicer interior, or they wanted to learn more about their new purchase — elected to use this one for the flight to Mesa. Somewhat ironically, one of the technical discrepancies identified by the NTSB was the removal by the previous owner of one passenger seat belt, possibly with the intention of turning the airplane from a six-seater into a five-seater (not including the pilots’ seats) and thereby exempting it from the requirement that it be equipped with a costly TAWS.

The pilot’s brother told the NTSB that the pilot’s custom was to turn on course after takeoff and fly GPS direct to his destination. He used ForeFlight on an iPad for navigation. At the time of the accident, ForeFlight software did not include the “Hazard Advisory” feature, which provides warnings of terrain and obstacle conflicts in the form of colored areas on the map. Most likely, however, the pilot was simply doing what he had habitually done and did not feel the need for a map in any case. On the earlier flight, he had turned toward Safford immediately after takeoff; this time, the delayed right turn put his flight path three miles farther north and in line with the mountain.

There were three pilots in the airplane at the time of the crash. One, the father of the three children — who had voluntarily surrendered his license because of medication he was taking — was sitting with them in back. Apart from the accident pilot’s previous night flight on the same route, the NTSB’s report did not document how often the two front-seat pilots made this trip, whether they had done so in daylight or darkness or whether they had ever requested flight following or minimum safe altitude warning services.

Experience teaches that two pilots, unless they form a disciplined crew, are not necessarily better than one. Each may imagine the other knows what he is doing, and the pilot flying may interpret the other’s lack of comment as an endorsement of his actions. In the absence of a cockpit voice recorder, we can’t know whether the two even discussed the high terrain to the east. Though the NTSB’s citing of “complacency and lack of situational awareness” could be taken to imply that the pilots were completely unaware of the surrounding terrain, it’s quite possible that they discussed the mountain and believed they would pass safely south of it.

Complacency — the assumption born of habit that everything is all right — is a natural state toward which every human mind tends. Like error, it is to be expected. Yet, apropos of the surveillance video of the accident, the NTSB notes that “no lights were visible on the mountain.” This seems to me a curious and telling fact. The mountain had been acknowledged to be potentially hazardous. The FAA had decreed that pilots must know of the mountain and steer clear of it. But apparently no one had decided to mitigate the hazard by simply putting a light on the mountain.

There is enough complacency to go around, on the ground as well as in the air.

_This article is based on the NTSB’s report of the accident and is intended to bring the issues raised to our readers’ attention. It is not intended to judge or to reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft _

or accessory.

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