REPORT 1
NTSB Identification: LAX05FA015.
The docket is stored in the Docket
Management System (DMS).
Accident occurred Sunday, October 24, 2004 in San Diego, CA
Probable
Cause Approval Date: 05/26/2006
Aircraft: Learjet 35A, registration:
N30DK
Injuries: 5 Fatal.
NTSB investigators either traveled in support of this investigation or
conducted a significant amount of investigative work without any travel, and
used data obtained from various sources to prepare this aircraft accident
report.
The Safety Board adopted the final report of this accident investigation,
including the analysis and probable cause, on May 23, 2006. The Board's full
report is available on : http://www.ntsb.gov/publictn/2006/AAB0605.pdf
On
October 24, 2004, about 0025 Pacific daylight time, a Learjet 35A twin-turbofan
airplane, N30DK, registered to and operated by Med Flight Air Ambulance, Inc.
(MFAA), collided into mountainous terrain shortly after takeoff from Brown Field
Municipal Airport (SDM), near San Diego, California. The captain, the copilot,
and the three medical crewmembers received fatal injuries, and the airplane was
destroyed. The repositioning flight was operated under the provisions of 14 Code
of Federal Regulations (CFR) Part 91 with an instrument flight rules (IFR)
flight plan filed. Night visual meteorological conditions prevailed. The flight,
which was the fourth and final leg of a trip that originated the previous day,
departed SDM at 0023.
The National Transportation Safety Board determines the probable cause(s) of
this accident to be:
The failure of the flight crew to maintain terrain
clearance during a VFR departure, which resulted in controlled flight into
terrain, and the air traffic controller's issuance of a clearance that
transferred the responsibility for terrain clearance from the flight crew to the
controller, failure to provide terrain clearance instructions to the flight
crew, and failure to advise the flight crew of the MSAW alerts. Contributing to
the accident was the pilots' fatigue, which likely contributed to their degraded
decision-making.
REPORT 2
NTSB Identification: WPR12MA046
14 CFR Part 91: General
Aviation
Accident occurred Wednesday, November 23, 2011 in Apache Junction,
AZ
Probable Cause Approval Date: 12/03/2013
Aircraft: ROCKWELL 690,
registration: N690SM
Injuries: 6 Fatal.
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 years earlier, the accident airplane seating configuration
was changed to reduce passenger seat provisions from six to five by removing a
seat belt from the aft divan, which was originally configured with seat belts
for three people. This modification rendered the airplane exempt from the TAWS
requirement; however, this modification was not approved by the FAA or
documented via a supplemental type certificate or FAA Form 337 (Major Repair and
Modification). Per the requirements of 14 Code of Federal Regulations 91.223,
TAWS is not required for airplanes with fewer than six passenger seats. In this
accident, onboard TAWS equipment could have provided a timely alert to help the
pilot avoid the mountain.
Based on the steady flight track; the dark
night conditions; the minimal ground-based lighting; and the absence of
preimpact airplane, engine, or propeller anomalies that would have affected the
flight, the airplane was likely under the control of the pilot and was
inadvertently flown into the mountain. This controlled flight into terrain
(CFIT) accident was likely due to the pilot's complacency (because of his
familiarity with the flight route and because he selected a direct route, as he
had previously done, even though he turned toward the destination later than he
normally did) and lack of situational awareness. In January 2008, the National
Transportation Safety Board issued a safety alert titled "Controlled Flight Into
Terrain in Visual Conditions: Nighttime Visual Flight Operations Are Resulting
in Avoidable Accidents." The safety alert stated that recent investigations
identified several accidents that involved CFIT by pilots operating under VFR at
night in remote areas, that the pilots appeared unaware that the aircraft were
in danger, and that increased altitude awareness and better preflight planning
likely would have prevented the accidents. The safety alert suggested that
pilots could avoid becoming involved in a similar accident by accomplishing
several actions, including proper preflight planning, obtaining flight route
terrain familiarization via sectional charts or other topographic references,
maintaining awareness of visual limitations for operations in remote areas,
following IFR practices until well above surrounding terrain, advising ATC and
taking action to reach a safe altitude, and employing a GPS-based terrain
awareness unit.
Member Sumwalt filed a concurring statement that can be
found in the public docket for this accident. Member Weener joined the
statement.
The National Transportation Safety Board determines the probable cause(s) of
this accident to be:
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.
While looking at both of theses flights we need to understand the tragic mishap that took the lives of 11 people. Understanding these flights and the decisions the pilots and co pilots made resulted in the lose of live. NTSB can use these accidents and others accidents related to CFIT as well as the FAA to make changes need to improve safety for future flights.
clouds. He couldn't go through them because once inside, he wouldn't be able to see and might bump into something hard and pointy. So he had to stay in the clear and visually pick his way around the terrain in his path. But as he maneuvered under the low clouds and around the fog, he suddenly came upon a mountain's steep up-slope. He shoved the throttle forward, pulled the nose up and began a climb. But the terrain rose faster than could his aircraft. He bellied onto the rising slope while in full control of a perfectly functioning aircraft.