The theory was (is?) that enhanced (i.e. freakin' certain) situational awareness vis a vis terrain would drastically reduce (eliminate?) CFIT events. But situational awareness is not at all the same thing as flight safety.

Synthetic VFR displays (and enhanced-vision displays) are wonderful. But unless and until we’re willing to install technology that will take control away from that darned human pilot when s/he’s apparently doing something stupid, we won’t have immunity from CFIT events.

Having designed control systems for a living, I’m not volunteering to craft one that would supplant the authority of the pilot-in-command regarding WHAT to do (as contrasted with one that merely implements the approved methodology for doing what the pilot commands the system to do).

That said, there’s plenty of work taking place on AUTONOMOUS aerial vehicles (aircraft that not only are un-manned; they’re un-commanded by remote pilots in real time). The day may come when a non-pilot could board an AAV, select a destination, and enjoy the fully-automated ride. Seriously.

The aircraft I fly has a TAWS that is adapted to a first generation EFIS and a Universal FMS. It will display either weather or terrain info on the MFD but not both at the same time. The pilot has to select terrain since the system defaults to weather when the avionics are first turned on. I have had this system quit displaying terrain info in mountainous terrain then start working again. The Commander in question probably had this setup unless it had new avionics installed. As far as what happened to the TAWS in this accident only the good lord knows now. May the persons who perished rest in peace. Condolences to all the families who lost loved ones.

maybe they were jamming GPS that day. ....for "testing" Taws needs GPS doesn't it?

Personal limits. I don't fly near terrain because I don't want to hit it. 'Nuf said.

With all due respect, it is our presumption that the pilots involved wished to avoid terrain, were sober and aware, and would have taken evasive action if they could have, save for some technical inadequacy of equipment. A recent crash at an airport I use regularly resulted in the deaths of the pilot, a copilot and a passenger in a twin because the PIC was high. This was from the toxicology report. No technology can overcome this, short of taking control out of the hands of the pilot. How do we know this was not the same in this case? Have we seen any evidence to the contrary? Experience or flight hours do not seem to exempt anyone from a lapse in judgement. I am also sure we all know of individuals who have managed to garner a career of aviation while barely avoiding the fate the befell them in the end. Such was the case in the above mentioned twin.

It seems to be our tendency to look for a technical solution, when really, the problem may be strictly social.

I feel for those that unintentionally lost their lives and the families of the deceased, but it is the obligation of those of us who regard this event to ask the hard questions even though they may be after the fact, involve second guessing, and perhaps place in question the reputation of those no longer able to defend themselves. We cannot always ask technology to fix our human deficiencies.

"Why not get clearance into the Class B VFR?" A good many controllers won't grant it ... I waged several battles with KMSP controllers over this pointing out that safety required a higher altitude ... I lost each time so simply began filing IFR. More work for the system and its controllers but safer for me.

As I'm certain most of you have done by now, I took a look at the route with my ForeFlight. Needless to say, this route is challenging for even the most experienced and current pilots, commanding the most capable aircraft. I don't think this accident analysis is a question of lack of advanced technology, or anything like that, but purely—

1) was the PIC aware of the enroute terrain conditions and the requisite minimum safe altitudes? (recognition)

2) with 17 miles from departure point to rapidly rising terrain, or the point of impact, what mechanical or situational awareness condition prevented the pilot from identifying and attaining the required climb gradient? (impairment)

My calculations (as per FAAO 8260.3B TERPS) a ~5,000 MSL obstacle at 17 NM from departure point) requires a 270 foot per mile climb gradient. And yes: this considers only the top of the obstacle, not any "safety factor". A "no-wind" scenario would require a minimum 540 foot-per-minute continuous climb rate from departure point to clear the obstacle.

Thomas Yarsley - yes, autonomous systems are the way to go, both for personal transportation applications, and for "pilot not sure what to do" situations.

Paul Larsen, yes, I've had the same problem, and adopted the same solution. I wonder if there's some incentive structure that causes controllers to prefer IFR to VFR flight following?

... and then ther's the ATC factor: I mean, seriously ... is there any reader of this blog that would attempt such a flight absent of ATC flight following? And the MSAW (minimum safe altitude warning) klaxon that would have alerted the controller? I mean, c'mon, folks: this stuff is basic. How many of you out there have gone on "lonely" overnight flights, and 'clicked' the mike button, just to be sure ATC was still "holding your hand?" The day we lose that "healthy" fear of flying, is the day we need to quit.

I'm not sure if this is a related topic, but we need to be more appreciative of the "non-flying" aviators amongst us. Get out there and hug a controller ... an A&P ... heck, even that ramp agent. Let them know that with out them, their observations, and their input, none of this will work. Tragedy prevention isn't always the domain of some "wonder-box".

I am not sure how the aircraft was equiped, but since it was a part 23 aircraft with turbine engines, all that was required was a Class B system, and not a more effective Class A system. If this aircraft was equipped with a Class B TAWS, then you have to consider the following: 1 - A display is not required and most likely did not have one; and 2 - a Class B system only requires Mode 1 (Excessive Descent Rate which alerts flight crews of excessive rates of Descent when near terrain) and Mode 3 (Descent After Takeoff, which warns flight crews of inadvertent descents and loss of altitude after takeoff, or during a missed approach). This means the system does not have a forward looking capability. If they were relying on TAWS to keep them safe, then that was a mistake. Modes 2 & 4 would have been key to identifying a terrain issue.

Three Years ago, I took a few hours of instruction in mountain flying in Albuquerque,NM. During the daytime flight as we were in level flight towards a ridge, my Garmin 430W issued a flashing terrain alert. My instructor told me to ignore it as he was very familiar with this area and he knew he was right. To me, this was like playing chicken with a mountain. What do I gain if he's right (nothing) and what do I lose if he's wrong (both our lives). I told him that I wasn't comfortable with holding the altitude and initiated a climb. Maybe this was an example of the thinking going on in the cockpit prior to the crash. That was such a preventable accident that thinking about it still depresses me. What a senseless loss.

Perhaps anyone who may have been familiar with the details surrounding a 1977 AC690B N318WA which ended the exact same way as this one, would want to weigh the similarities in this accident. This accident occurred Dec 3 2008 El Yunke in SJU, PR, with a highly trained pilot/mechanic who has years of experience flying into SJU. The NTSB reports has the final conversation between the pilot and ATC prior to collision with terrain. Having been a good friend of the pilot, this accident last month caused me to revert to the why, how, and what the accident.

I look at this in a more positive light... I don't have statistics available to me as I write this, so it is purely IMHO. I wonder how many lives HAVE been saved by the technology advances. We CAN'T know this. We can use the technology, but as one poster mentions (as does the author, we don't know what was going on at the moment, and we can never know what happened. Lightsquared could have been causing problems, two of the prime satellites may have been interfered by solar winds... who knows, but one CFIT accident doesn't negate the benefits that we aren't reading (or writing) about. Our society is very bent on finding negativity with events. Shine a light on the positives and realize a different perspective, folks.

I haven't flown out of Phoenix, although I've been there enough times to have some knowledge of the terrain. But at night, no matter how familiar one is with the terrain, it's virtually invisible. This isn't the first time, nor will it be the last, that an airplane with a competent pilot at the controls prangs into terrain that in the daytime would be easily avoidable but at night is indiscernible.

Some 35 years ago, in a very basically equipped Skylane, I climbed out of Las Vegas with 2 passengers, enroute to Los Angeles late in a clear but moonless night. Using the climb chart in the Jepp plates to determine required climb rate was just a little too confusing, at night without an autopilot when I was already tired from flying several hours. But my gut told me that we weren’t climbing at a rate that would allow us to clear the terrain that I was pretty sure was there but couldn’t see, so I requested a circle climb in place to the MEA. This was the identical route that the 2 CAPers flew in a technologically equipped turbo Skylane, when they smacked into the rocks in 2007.

Between them, they had over 50,000 accumulated hours; I had less than 300 at the time of my flight. The same questions could be asked as others have asked here: Why, in an airplane well equipped to tell about terrain, flown by experienced pilots intimately familiar with the terrain in the area? Conversely, why did I make the decision to circle climb to the MEA?

Perhaps as we get more experienced, flying in our familiar territory, we get too complacent. We “know” when we’re safe—but not really. Perhaps that’s where some of the emphasis needs to be, how to attack complacency. I don’t have the answer; does anyone else?

Paul, like you mention it is possible to become complacent with the technology because you "know" the terrain. For years I flew 121 into Burlington, VT and nearly every single time on left base to 33 received terrain warnings because of an adjacent hill. Pilots soon came to ignore the warning. While being vectored at Dulles at night over the ridges to the west I received a "pull up, pull up." I knew I was at the right altitude, and although I hesitated for a second, did climb 500 feet, got the scolding from the controller and filled out a captain's report. If we don't respond the alerts become meaningless.

I need the "freight dogs" to chime-in on this ... you know, the late-night, single pilot, IFR, multi-engine, hyper-caffeine types out of the Great Smokies or Appalachian mountains. Those guys will tell you what the "real deal" is.

It's always possible there was a distraction in the cabin. "Special Needs" children were on board. Supposedly the RADAR shows the plane level at 4,500. Surely the pilot knew he could not continue at that altitude on a drirect line from Mesa to Safford. for whatever reason it appears that he failed to climb at the appropriate time.The ASI recommendation that one use published departure procedures at night is a good one.

Taking off on Rwy 4 from Falcon in a fast airplane, you are heading for trouble if you don't start to make a right turn soon after take-off. I input Flat Iron Peak GPS coord's in ForeFlight and it shows they would have cleared Class B about half way from Falcon to the crash site. Videos showed they were level until impact. Why the pilot didn't start to climb from 4500' once they cleared Class B is a mystery that we will likely never know the answer to. Very tragic indeed!

Complacency certainly is one issue that seems to be a factor in a lot of CFIT accidents. One of the aircraft I fly has TIS-B, and occasionally because of the delay in the system it will erroneously show myself as "traffic". It's easy to just ignore it when I "know" it's only myself, but it does still cause me to up my scan a little bit. I've even sometimes performed evasive maneuvers to avoid...myself.

The other thing regarding complacency is having too much confidence in one's self. As I build more hours, I know I have to keep reminding myself to not become complacent and fall into the "macho" dangerous attitude. When we're student or low-time pilots, more things are new to us so we spend more time paying attention to things. But as we gain experience, it's easy to dismiss something that we wouldn't have earlier on, and it takes real discipline to keep the proper mindset.

Also, regarding not being allowed into Class B airspace... If I was truly concerned about hitting terrain or obstructions and ATC refused to allow me into the airspace, I would declare an emergency. Even just notifying the controller of the need to enter airspace for terrain or cloud avoidance has generally gotten me clearance to fly through without having to get to the point of declaring an emergency, provided I notify them of the need to enter several minutes before reaching the airspace. This just seems to go back to the need of staying ahead of the aircraft.

It seems to me that some pilots are too passive in asserting their PIC authority when necessary. Maybe I'm overly cautious at times, but as another poster mentioned, what's the worse that can happen if you err on the side of caution?

CFIT if basically a failure of the PIC to pay attention and to do an acceptable pre-flight of the route. More gadgets will no doubt help some, but reliance on a techno fix does not absolve the PIC of looking at the route, evaluating terrain and airspace issues, and then making appropriate adjustments to assure flight safety (which means adequate terrain clearance, among other factors) is maintained. The PIC of the Aero Commander was clearly at fault. No more discussion is necessary. He failed in his basic duty to evaluate the route, notice there was a rock just outside of the Class B airspace, and make appropriate adjustments. End of story. Sure, he had a plane load of kids and a bunch of buddies he wanted to talk with and enjoy. A sterile cockpit and pre-flight planning are two critical elements of EVERY flight, and especially those that take place into the black of night. If he had survived the accident he would be a candidate for charges of vehicular manslaughter by aircraft because of the gravity of his negligence.

The very best technology is still an aware and thinking human brain. Everything else fills a support role.

The very best technology is still an aware and thinking human brain. Everything else fills a support role.

Sadly, CFIT will always be with us, and in probably a majority of cases the actual “cause(s)” will remain unknown, making prevention efforts pretty much a crapshoot. The 2007 crash of the CAP C-182 into Las Vegas’ Mount Potosi was a classic example. The pilot, a neighbor of mine with 28,000 hours logged, backed by his co-pilot friend with 27,000 hours and flying a plane with all the electronics you could ask for, somehow managed to hit rock in severe clear conditions while headed home on what should have been a routine night flight.

How could such a thing happen? Was it a case of inattention to flying the airplane that was allowed to continue a bit too long? Was he somehow distracted from the task at hand by factors unknown? Was he dog tired and just not “up” to flying? Did he convince himself the aircraft was in some other position relative to the terrain or (unbelievably) simply not know the terrain was there?

We will never know the answers, so beyond the routine admonition to “plan ahead, be alert and be careful” no preventive panacea can be offered.

To me, this is a classic risk management accident where even a cursory application of the PAVE ckecklist (pilot, aircraft, environment, external pressures)would have exposed the terrain hazard with its likelihood and consequences. A pilot conscious of risk management would then have appropriately mitigated the risk (file IFR, etc.). Perhaps pilot, aircraft, and external pressures issues were also at play. The issue is that formal risk management is not taught as a part of initial or recurrent training. Although I write about this regularly in Aviation Safety magazine, we will not see any meaningful change unless pilot training reform takes hold. Robert Wright.

Robert,

PAVE, and the five hazardous attitudes. It seems to me that the more experienced a pilot becomes, the greater the chances are of falling prey to one or more of them. Except for these coming up in the written or oral exam for a new rating, I don't hear too much emphasis put on these during recurrent training.

CRIT is largely a human factor issue. Technologies help us manage our flights but does not replace airmanship...

In the “good old days” we used the easy to digest information on the VFR maps to stay away from the mountains.The GPS Terrain Page has done away with our need for “approximation” by introducing several accurately defined zones—black, yellow and red. There are several things we should take notice of with respect to this “improved approach”. First of all the “superior” nature of the GPS as compared to the VFR map justifies “throwing the VFR map in the back seat “.Secondly, only occasionally does a pilot get into a situation where ground approximation is a concern. Thirdly, the GPS system with “zones” is a lot of details to remember and very rarely needed. Fourthly, the GPS Terrain Map system defines “safety and hazard” in the same “mouth full”---“red is within 100 feet below or above the aircraft”. Hence, it is easy to “remember” the definition of red as representing a “100 feet margin” with the ground 100 feet below the plane. (Or on personal pilot observation the 100 feet is indeed “judged” to be below the airplane). However, if the 100 feet “happens to be above the plane” –a ground collision will result. Yes, I do know what the GPS designers will say; this is entirely “a pilot error”---which I agree with to some extent. However, pilots are just regular humans with all associated frailties and we do expect that the designers of pilot equipment take these human shortcomings into consideration—specifically in a very critical area like this.

I have read some Very Good Comments here and have flown into and out of the Phoenix Area quite often in the past 6 years. My feeling about the ATC folks in Phoenix is regrettably Bad! There are FAA ATC people at SKY HARBOR and a couple of area airports, and there are "Civilian Private Contract" ATC people at a couple of the area airports. They both don't like to Co-operate with each other! Who suffers? We all do!! This was entirely "Preventable" on a number of different Levels and at the Top of the List is the Pilot In Command. A little Help could have "Saved Innocent Children"! Sometimes we forget the "Real Reason" we are Paid to do a job! I am only surprised it took this long for a Tradgedy like this to take place in the Phoenix Area!

The pilot was probably used to an immediate right turn on course after takeoff, hitting direct-to on the GPS, and letting the autopilot fly the plane. The preliminary NTSB report stated that they flew runway heading for about 90 seconds for traffic before being able to turn right. A direct-to route at that point would then include the ridge. Complacency can kill.

I've flown with other pilots qualified in well equipped aircraft and had them 'punch off' alerts without telling me. Can that happen with the TAWS equipment installed in the accident aircraft? Perhaps the machanic was being too helpful to their detriment. OR they were jaw-jacking while the autopilot flew the plane. As some have pointed out, this was the perfect case for sterile cockpit.

Over the last twenty years we've had five twins and one single end in CFIT near the Great Falls MT - GTF - airport.

One of note was a BE99 mail hauler that hit the highest terrain within 60 nm, a 9500 ft mountain, impacting at 9300 ft. The trail of soot the plane left on the bare rock had a steep upward trajectory indicating they realized they were in trouble and started a climb. This was a night flight and the radar targets indicated they were maneuvering, possibly to avoid weather. The pilot was a CFI who had company permission to take a student as a pax on the revenue flight. The route was normally flown IFR but the company ops manual forbade IFR if a non-company person was on board. Could that also apply to the AZ accident aircraft?

Another was a King Air that descended into a ridge at cruise speed. He got clearance for the ILS into Belgrade MT, descended 1.6 miles too early on the airway and hit a ridge. A flight nurse and pilot wannabe was in the right seat. Another possible factor was that the autopilot altitude function was known to need 'careful monitoring' because it frequently failed to capture programmed climb and descent altitudes or leveled off when it wasn't programmed. Could that be a factor in the AZ accident?

WRT the commander CFIT event in San Juan, I knew the pilot well and some of the similarities are striking.

1) both aircraft appeared to be avoiding IFR handling in areas of terrain 2) TAWS operation was unknown. I had heard by taking out a seat you could negate the TAWS requirement. Won't know what was working in either of these accidents. 3) both crews were highly experienced and knowledgable about the area

Finally as a pilot who flies a turbine powered G1000 syn-vis cockpit, it's a stretch to call these commanders technology enabled. Everyone should fly with a minimum of a G696 class display if you don't have that capability bolted into your airplane IMHO.

What everyone seems to be ignoring is the completely ridiculous, arrogant, and dangerous airspace grab that lowered the floor of PHX Class Bravo to 5000' in the East Valley. On a recent flight from AVQ (Marana) to PRC (Prescott) my wife commented that there was very little room between Class Bravo and terrain just west of Weaver's Needle. GA pilots predicted this exact scenario when the configuration was changed, but the FAA refused to listen. If PHX Approach were not so difficult to deal with there would be more GA flight following within Class Bravo in PHX, but the combination of a stupidly-configured airspace and (some, not all) controllers who are unwilling to accept VFR flight following in PHX Class Bravo made this inevitable.

If the pilots had some terrain warning system operating, Tim Welter's proposed scenario ("Yeah, yeah -- I've seen that 'pull-up' warning before. I fly around here all the time! It's just overly-cautious technology. Don't worry; I know what I'm doing...") is what came to my mind as the most likely explanation.

1) FAA needs to take another look at Bravo at PHX and make changes to reduce risk associated with restrictive Bravo too close to terrain. 2) ATC should have a greater sense of awareness around high risk areas like the eastern edge of PHX class B, and make sure they've done everything possible to help pilots avoid accidents such as this. 3) The pilot community must continue to promote and find more effective ways to develope AND maintain a high level of risk management skills in all pilots. Hold and/or regularly attend risk management meetings at your local airport. Make risk management testing an annual online component of currency. Not just to learn and improve, but maintain that edge and not become complacent. 4) Technology can also keep improving, and will, but manufacturers must seek creative ways how to not just sell systems, but also maximize their effectiveness through training, documentation, support and ongoing enhancements.

If CFIT and other types of human error accidents teach us one thing, its that risk comes from many places and in different ways. The classic accident is always a chain of events where risk piles up until the time and space to correct runs out. We can each do our part to own it, and work to improve each aspect of flying that will reduce overall risk. Our best response to this tragic accident is to learn from it and take action in our relentless efforts to improve aviation safety.

Gadgetry doesnt help, hasnt helped, wont help. It only helps those that mandate design and sell it. Them are the benefactors of it. Training safes people, not Gadgetry. Gadgetry usually seems to me to just dull the alertness and pilots think they can safely scud-run because of their moving map GPS...

Without a doubt! If the crew doesn't know how to use or ignores a magic box it's just weight and drag.

Is it safe to say that VFR flight following or IFR itself is a magic box that takes advantage of all the toys at the ATC's disposal? If it's denied or incompetent or the crew fails to use it, what's the difference?

A great example is what we know about the Embraer Legacy that collided with a B737 over the Amazon .wikipedia*org/wiki/Gol_Transportes_A%C3%A9reos_Flight_1907 : Apparently the ATC functions were denied or limited and missed that both jets were nose to nose at the same altitude and airway. The Legacy crew - apparently new to the model - inadvertently set the transponder to standby an hour before the crash. ATC said nothing. Standby also disabled the Legacy's TCAS and left the TCAS on the B737 with nothing to warn about. Lots of toys to prevent it yet a bullet hit a bullet.

I don't understand why terminal airspace needs to be so big and generally round in shape.

It seems to me the ATC focus on IFR, to the detriment of VFR flights, is at the root of this accident. I don't think the lives of people aboard VFR flights are any less valuable than those aboard IFR flights.

I don't think it is particularly wise to conduct VFR night operations particularly in mountainous terrain. I know this is legal and lots of very experienced pilots think nothing of it, but I still think IFR is a better choice at night.

Another nearly criminal part of this story is the notion that ATC can refuse VFR traffic access to class B at night. I think ATC should encourage night VFR traffic to use class B services. If the traffic is so heavy at a particular location that night VFR traffic is too much for the overworked controllers to handle then I think more controllers (or more highly skilled controllers) should be put on that shift.

It makes sense for terminal area controllers to restrict VFR flight into the path of current IFR traffic. However, the terminal airspace and ATC restrictions on VFR flight extend to the entire Class B air space rather than the area currently in IFR use. I just isn't worth killing off people on VFR flights to make life easier for ATC. The rule should be changed to encourage VFR to use class B service, particularly at night, rather than the current rule allowing unspecified controller discretion on this life saving issue.

"Gadgetry doesnt help, hasnt helped, wont help. It only helps those that mandate design and sell it. Them are the benefactors of it. Training safes people, not Gadgetry. Gadgetry usually seems to me to just dull the alertness and pilots think they can safely scud-run because of their moving map GPS..."

I'm afraid that I have to strongly disagree with this statement. I cannot imagine any pilot who would rather fly with just a chart and compass than with a modern GPS with terrain and weather display. That is like saying that a doctor doesn't make any better decisions today with modern CAT scanners,ultrasound MRI's etc then decades ago with just using a physical exam, lab and xrays. Of course we do. The more accurate information you have the better your decision making can be. It's the decision making that is the problem not the technology. If I have good information and choose to ignore it then I am not using all the tools at my disposal and I certainly agree that training needs to concentrate on instilling an attitude of professionalism and risk management. Flying with my three GPS's I'm not just flying fat and happy when alerted to a storm cell ahead of me. I'm busy making decision to avoid the danger. That kind of information is invaluable.

The distraction issue and the fact he had relatively low hours in that type of aircraft were discussed while hanger flying out here.. Maybe he was distracted and just got to the mountain faster than he expected. If he was familiar with the area in a slower aircraft he knew he had 20 minutes before he had to continue his climb but in the faster plane he only had 15.

Paul Mulwitz on December 8, 2011, wrote:

"I don't think it is particularly wise to conduct VFR night operations particularly in mountainous terrain. I know this is legal and lots of very experienced pilots think nothing of it, but I still think IFR is a better choice at night."

In my humble opinion, I agree with Paul 100%. So what if IFR routing takes you a little out of the way? Safe arrivals trump accidents, everytime!

Many are blaming the low Class B altitude restriction but that did not force the pilot to stay 500' below it. Knowing the limits of the airspace, the pilot could have climbed out to 4900', fly level to the limit then continue up to his cruising altitude and missed the mountain. The "key" is knowing. The pilot obviously had no idea where he was and how to operate an aircraft near Class B airspace. It is not the fault of the airspace, equipment or those who designed it. Know what's in front of the airplane and don't hit it.

Having been vectored toward a mountain at night by SoCal, I dont rely on ATC to keep me safe as far as terrain is concerned. Many of you seen to think that VFR flight following would have saved them.

There are lots of good points here about the value of technology and the need to have it and use it. But lets not miss the lesson here. Barring mechanical failure, five wonderful people are gone because the pic was simply complacent in flight-planning, rdm or basic airmanship.. Clearly he knew he was heading toward rising terrain the moment he turned right after departing rwy 4. His options were many to ensure safe conduct of the flight, to include a vfr direct to a southerly waypoint (sdl vpren sad would have cost him perhaps 5 extra minutes), a bravo clearance may have saved their lives, or an ifr departure amost certainly would have. Greater attentiveness or a sterile cockpit would have prevented the tragedy. The buck stops with the pic. And missing this point surely increases the chances for the next cfit. He cant possibly have thought he was turning east out of sdl toward open prairie.