Accident Case Study: Unintended Consequences

on Wednesday November 23rd 2011 a Rockwell 690 aero commander flew into the side of the Superstition Mountains outside Phoenix Arizona at night in clear weather three adults and three children lost their lives according to the NTSB the pilots complacency and poor situational awareness caused the accident but there's more to the story a week before the accident the airplane November six Niner zero Sierra Mike was purchased from a seller in Indiana and flown with a ferry permit to Safford Arizona to join a fleet of nine other commanders used for wildfire operations under a government contract the six seat turbine powered airplane was not equipped with a terrain awareness and warning system though by regulation it should have been zero Sierra Mike was equipped with a KL and 90 GPS while this model has a basic moving map and direct to functionality it doesn't depict terrain the pilot was known however for regularly flying with an iPad and software that gave him terrain awareness but it's not clear if he was using it the night the accident occurred earlier that week the experienced pilot who was also a mechanic flew a different aero commander round trip from Safford to Mesa Falcon field and back to Safford an almost identical profile to the accident flight GPS direct to and from Mesa in a commander at night under similar weather conditions there was no reason to believe his flight two days later would end any differently on the night of the accident zero Sierra Mike with its ferry permit expired and passed its inspection window thus legally on air worthy departed Safford for a 110 nautical mile trip to Mesa Falcon field to pick up the co-owners three young children for Thanksgiving after landing at Mesa around 6 p.m. an hour after sunset the pilot called his brother and was happy to report the airplane had performed as expected about ten minutes later the three adults and three children boarded for the leg back to Sanford under a calm moonless night with clear skies upon departure Mesa tower instructed zero Sierra Mike fly straight ala kulli right time for inbound traffic runway 4 right cliff take off for right will fly river heading to advise zero syrup as requested the pilot extended his upwind leg and was cleared for the right turn almost 2 minutes after departing one minute 30 seconds later the pilot leveled off on a direct course to Safford at 4,500 feet in order to remain below the 5,000 foot floor of the Phoenix class Bravo as most pilots flying VFR out of Mesa did until clear of Phoenix airspace two and a half minutes later zero Sierra Mike impacted the face of the Flatiron region of the Superstition Mountains which rise abruptly from the surface to an elevation of about 4800 feet at the point of impact see fit or controlled flight into terrain continues to be among the leading types of fatal general aviation accidents this mishap highlights some common themes that surround see fit accidents VFR at night in sparsely lit hilly terrain and oftentimes with an experienced pilot at the controls in this case perceived airspace limitations may have also played a significant role in why the pilot flew this particular profile what we do know is that the pilot did not ask for VFR flight following or permission to transit the overlying Class bravo airspace operating so close to unlit mountainous terrain at night should certainly warrant flight following and safety alerts from ATC but in this region pilots often reported difficulties in getting flight following or permission to enter the class Bravo due to a long-standing FAA policy with a Phoenix TRACON that denies these services to VFR traffic it's likely the pilot knew this and combined with his recent flights in the area determined the risk of staying below the class Bravo was minimal but this was the exact flight he flew only two days earlier if we look at that flight path we see that a direct line between the airports keeps the airplane south of the mountains until clear of the class Bravo shelf but if we alter that route just slightly north and begin a GPS direct route to Safford from an extended upwind leg the route goes directly over the mountains in other words had the pilot made an immediate turn out after departure as normal the GPS course line between the airports would have kept them clear of the terrain but an extended upwind leg followed by a direct to route from that point took them to far north to avoid the mountains so what lessons can we draw from this tragedy to begin with we can use every tool at our disposal to ensure a safe flight for example terrain awareness technology is available on devices we already own such as smartphones and tablets in addition following published departure procedures at night guarantees clearance from obstacles most local tray cons are happy to assist VFR pilots so make a point to ask ATC for help and services VFR flight following exists for a reason having extra eyes on you especially when it's dark and you can't see what's in front of you make sense in most circumstances your request will be granted but you can't get these services if you don't ask for them but more generally and possibly more importantly always be on guard for changes to the normal way of operating when things aren't normal is when our guard should be up to the dangers that surround us in this particular instance something as seemingly innocuous as extending the upwind leg a few miles wouldn't seem to make that much of a difference but it did a safety culture is not a checklist item it is a way of operating that pays attention to the details flying a mechanically sound airplane outside of its inspection window or on an expired ferry permit may not sound like a big deal but once you start down the slippery slope of ignoring the details you may be looking at consequences bigger than you intended

Channel: Air Safety Institute

Views: 1,056,416

Keywords: airplane, plane crash, airport, pilot, emergency, safety, risk management, airplane crash, decision making, air crash investigation, flight plan, vfr, ifr, air traffic control, flight safety, safety tips, flight training, aviation safety, airplane accidents, general aviation, collision, mountain, terrain, night, Arizona, Superstition, ATC

Id: BXr3xr4rj98

Length: 7min 16sec (436 seconds)

Published: Wed Aug 24 2016

Reddit Comments

[u/[deleted]]

The analysis seems good. I like "a safety culture is a way of operating that pays attention to the details".

Very nice. Thank you for sharing, OP. It's reading up on events like this which really helps a pilot gain knowledge with which he can apply higher standards of safety.

Night VFR without ATC guidance in mountainous terrain is certainly something which requires some stronger planning.

If he had paid perhaps more attention to the sectional, things may have turned out better: "keep to the south of the Apache Junction and I'll be clear of the Superstition wilderness Area". On the sectional you see that the terrain is at 5057ft and that the Bravo airspace to the west of it is also at 5000 ft. This guy followed the magenta line straight into some mountains, it seems. Check out this screen-shot. Imgur

Can't just rely on GPS or sectional. Gotta use all the tools in the box and use them to cross-check things. I think that's best!

If I just look outside the window during daytime VFR and I see a lake, maybe I'm indeed over the lake I think I am. However, if I look outside and see a lake and my VOR needle is centered on the radial which matches what's on the sectional, then I have TWO pieces of evidence which check out to show that I'm indeed on THIS lake.

[u/wittnl]

As always a chilling reminder from AOPA to stay vigilant. What is essentially an extended upwind departure cost 6 lives due to controlled flight into terrain.

[u/13toros13]

I think there is a possibility of an additional factor or debrief point here. The pilot followed a GPS track upon turnout. The GPS track is merely a line between you and the destination or next waypoint. Thus is different than a course you've plotted for yourself and pre-programmed, which then uses GPS to navigate. You should, even in seemingly benign conditions, plan a flight snd fly the plan. A simple course plot that kept away from identified hazards would have indicated to the pilot a necessary correction immediately after turnout and saved lives. Everyone can make mistakes! Keep thinking!

[u/codejudge]

There's a reference in here to Phoenix Tracon being reluctant to do VFR+FF - is that still an issue?

[u/Jonay1990]

what was the reason for the delay in clearing the turn from ATC?

[u/skiitifyoucan]

I'm assuming if it was an expired ferry permit then it was out of annual? I'm just thinking of the chain of complacency. Out of annual, expired ferry permit, night flying , bringing kids, around mountains.

Stupid question, does ForeFlight have terrain awareness?

[u/Triggs390]

What happened to the other narrator and intro?

[u/PLIKITYPLAK]

It's like they stole my case study I did for Aviation Safety class on this accident ;) Any way, this was one of the more tragic accidents I have seen since they had just picked up the owner's 3 kids for Thanksgivings.

Also there is this chilling video of the accident from a home security camera.