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