Safety Matters - CFIT

No pilot should get caught between the ‘rock’ of a sense of urgency and the ‘hard place’ of terrain while trying to save a few minutes of time by avoiding airspace or a clearance. That ‘get home at all costs’ attitude is a close cousin to the Homesick Angel Syndrome covered previously in these pages- and is the motivating force behind too many pilots’ decisions to press ahead with a flight- or corner-cutting action mid-flight when all of their professional instincts scream “STOP!”

Dave Higdon  |  01st February 2012
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Dave Higdon
Dave Higdon

Dave Higdon is a highly respected, NBAA Gold Wing award-winning aviation journalist who has covered all...

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CFIT Alert:  The tricks that trip-up trips.
No pilot should get caught between the ‘rock’ of a sense of urgency and the ‘hard place’ of terrain while trying to save a few minutes of time by avoiding airspace or a clearance. That ‘get home at all costs’ attitude is a close cousin to the Homesick Angel Syndrome covered previously in these pages- and is the motivating force behind too many pilots’ decisions to press ahead with a flight- or corner-cutting action mid-flight when all of their professional instincts scream “STOP!”

This month- we focus on those accidents in which pilots fly themselves into terrain – under control… normal-flight accidents that belie any claims of complete preparation. These pilots fulfilled most of their pre-flight information needs: weather; fuel load and other obvious operational requirements – weight- balance- route and more…

The hapless subjects of the following case studies all knew the route’s heading- the needed course to arrive at a specified latitude and longitude. Yet in each of our examples the crew failed to fully appreciate the third dimension of their preferred route: altitude.

CFIT (Controlled Flight Into Terrain)- is among a pilot’s oldest nemeses. In each illustrative case highlighted here- the terrain might easily have been avoided by spending a few minutes more time – waiting on a clearance- deviating to avoid the terrain- or climbing more aggressively. CFIT accidents such as these occurred because of human issues- not technological failures or lack of information that would have otherwise made a difference.

In the newest of our three following examples the cockpit offered technology that could have warned the crew of their impending encounter with terrain; in the oldest of our examples- earlier versions of today’s advanced Terrain Avoidance and Warning System technologies was on-board. Irrespective- the details illuminate an important detail: Technology can help if available- but only if heeded by the human side of the man-machine interface.

If these sound like events you’d expect of low-time pilots- history suggests that even the best go astray this way. In all three cases featured here- our flight crews were all highly experienced and properly equipped for their flights – all were night flights in areas of rapid changes in terrain elevation.

Frustratingly- these accidents continue to happen – and too often. It doesn’t have to be this way; indeed- it shouldn’t be this way. Take note of the lessons in these following examples. They point toward practices that can preclude CFIT accidents.

Example 1: Last Stand of a country band

Country music star Reba McEntire played before a packed house on the evening prior to March 15. The after-concert activities stretched longer than the time planned for by the crew of the Hawker Siddeley 125 the band was using.

As part of the original planning for the post-show flight with McEntire’s manger and seven band members- the flight crew repositioned the HS-125 to Brown Field from Lindbergh Field to avoid being trapped by a curfew at Lindbergh.

Subsequently the pilot filed an IFR flight plan with an expected launch time of midnight local time. The pilot also received an oral briefing of the instrument departure procedure planned for the flight since he lacked a printed copy of the SID.

In the greater scheme of General Aviation- departure times are necessarily flexible- to fit the needs of the people using the airplane. In this case the departure time bent backward – to after 1:00a.m. local time. With the original midnight departure long past- that original flight plan “clocked out” and was no longer available when the crew sought the clearance.

The pilot opted to depart VFR on a northeast routing and pick up the nowunavailable IFR clearance. The flight eventually departed at 1:41a.m. local time on a northeast heading- after the pilot asked the briefer about the viability of clearing terrain while staying below the 3-500-foot floor of the San Diego Terminal Control Area (TCA- now Class B airspace) and clear of the mountains at 3-000.

Thinking the pilot meant 3-000agl- the briefer agreed it would keep the flight clear of terrain; the flight would need ATC clearance from San Diego Departure to transit the TCA. Having found no IFR flight plan- the controller was focused on re-entering the flight plan data taken orally from the flight crew.

Moments after departure the HS-125 struck a mountainside at 3-300msl; the flight was barely eight nautical miles from the airport. In contrast with the carpet of metropolitan- city lights of San Diego- the mountains opposite the coast are- in general- as black a hole as the ocean on a moonless night. It’s unlikely the crew ever saw the mountain.

Viewed in perspective- the flight was already more than 90 minutes late; the 10-15 minutes needed to depart with the clearance in hand would have been inconsequential in the larger scope of the planned travel. It’s highly likely that waiting on the process of re-filing the plan and the clearance before departure- and using the planned SID filed for the trip- would have kept the Hawker well clear of those mountains. McEntire’s manager- seven band members and the crew of two on the flight deck- would not have suffered the CFIT accident.

Reba McEntire’s 1991 tour ended that night. She continues to tour today- but only because she wasn’t on that plane- that night.

Example 2: Civil Air Patrol Flight and the mountain

Two highly experienced former air-transport pilots were flying a Civil Air Patrol (CAP) Cessna T182T on a night cross-country flight across a region with which both were familiar through years of living and flying there.

The year-old Turbo Skylane sported a Garmin G1000 with - the NTSB report noted - a “Terrain Proximity Page” on the Multifunction Display (MFD) providing the pilot with terrain elevation relative to the airplane's altitude- current aircraft location- range-marking rings- a heading box and obstacles. Yet- the report noted- the airplane lacked the Garmin TAWS option.

With more than 25-000 hours of flight time- the PIC had also completed G1000 training for the CAP airplane; the rightseater- with 28-000 hours- had not completed the G1000 training. Nevertheless- both had flown extensively throughout the region and should have been very familiar with the mountains just west of Las Vegas.

After departing North Las Vegas Airport (VGT) the crew kept the aircraft low to avoid requirements to obtain a clearance to enter the McCarran Class Bravo and turned southwest before starting to climb from 2-800 once out from under the Bravo – but they kept the climb shallow to remain below its outer rings. Between 1905:29 local time and the loss of radar contact at 1917:29 the airplane covered nearly 30 miles while climbing barely 4-500 feet to just above 7-000msl.

Law enforcement officers and other witnesses saw a fireball on Mount Potosi- about 1-000 feet below its peak at 8-514msl. While this crew filed and opened a VFR flight plan for the trip to Rosamond Skypark in California’s Antelope Valley- the crew’s cruise-climb configuration kept their ascent at less than an average of 400fpm.

The decision to avoid seeking Bravo Clearance so as to keep the T182T below the Las Vegas Class B until well along the journey- along with the shallow climb conspired to create a CFIT outcome fatal to both of the seasoned aviators.

As history would have it- Mt. Potosi is in fact the site of another CFIT accident from 55 years earlier. On that occasion a DC-3 crash killed actress Carole Lombard (33)- her mother- her press agent- and 19 other people.

That Trans Continental & Western DC-3 was returning the passengers to Los Angeles from a war-bond promotion tour when it clipped a rocky ledge on Mt. Potosi- flipped into the face of a cliff and exploded.


Example 3: Superstition Mountain vs the Commander

Finally we highlight a recent CFIT disaster involving a Rockwell 690A Turbo Commander. Turbo Commanders possess the capability to climb steeply at good speed – and good high-elevation performance – and go high and fast.

With two experienced aviators on board this particular Turbo Commander (owned by the FAR Part 135 company that the two pilots headed) along with their A&P maintenance technician and the pilot’s three small children- the flight out of Mesa- Arizona’s Falcon Field (FFZ) took up the direct heading to its destination- Safford Regional Airport (SAD) in Safford- Arizona. FARs dictate a basic TAWS system for a turbine twin such as this- but with only the Class B system required it’s unlikely to have helped here; Class B systems generally offer only Mode 1 and Mode 3 warnings – both of them descent-based; TAWS A- with the addition of Mode 2 and Mode 4 warnings- would have offered the look-forward capability needed to warn of high terrain ahead and impending terrain collision.

The expected flight time was about 45 minutes. Taking a dog-leg route around the highest terrain would have still kept the flight at under 50 minutes. Realistically- a pilot familiar with the region could arguably make the trip VFR without ever talking to a controller.

For whatever reason (or reasons) the pilot kept the Commander at 4-500 msl- however - 500 feet below the 5-000-foot floor of the Phoenix Class Bravo on an easterly heading after taking off from FFZ’s Runway 4 - and in so flying- the pilot obviated the need for a clearance to transit that airspace.

Taking the direct heading while remaining below the Bravo on a night flight (even in 40-mile Visual Meteorological Conditions) essentially set up the CFIT scenario.

The aircraft flew into the side of Superstition Mountain at an elevation of about 4-650msl – a few hundred feet below its 5-057-foot peak. With no lighting to define it- the Superstition Mountain-side probably never appeared to the pilots. Even if the Commander began climbing once clear of the Bravo’s outer ring- the timing and rate likely would have been insufficient to clear Superstition Mountain.
Getting cleared to transit the Class B would have allowed the flying pilot to climb above the mountain. The squawk remained “1200.”

The preliminary investigation reports no signs indicating an attempt to maneuver away from the mountain; and the impact marks supported the straight-and-level-toimpact scenario.

That explosion signifies that this CFIT – set up by decisions made to save time and hassle – claimed another six lives on the evening before Thanksgiving Day.

Life Saving Lessons

Three accidents; three high-time flight crews; eighteen dead; all three tragedies avoidable. Deciding to depart VFR without a planned IFR clearance is- and will remain commonplace in private aviation. Some Part 91 and 135 operators may - by company policy - prohibit such operations- but they clearly have a role and can be flown safely. In reality- in none of our three examples was weather a factor- so IFR wasn’t a requirement for flying below FL180. In all three cases- conditions were severe-clear Visual Meteorological Conditions (VMC)- but at night.

In all three cases- the need or desire to avoid the delay or hassle of obtaining clearance through Class B airspace helped set up the aircraft for its terrain encounter. In two of the three incidents- the delay in using- or opening an IFR flight plan also contributed to the set-up concluding with the accident. But in all three fatal accidents- full awareness of the terrain- of how to avoid the terrain- and acting appropriately on that information would have helped the crew avoid their tragic outcomes.

For the Hawker 125- simply fighting the rush to depart and waiting on that IFR clearance would have in all likelihood changed the outcome. For the CAP pilots of the T182T- going ahead and asking for Class B clearance might have set up the flight for a little vectoring and a climb with terrain avoidance in mind. Alternatively- simply maximizing the climb rate when permitted would have had the same effect – changing the outcome to a non-event. As for the tragedy that befell the

Turbo Commander occupants- an aggressive climb once clear of the Phoenix Bravo could have provided the needed terrain clearance – as would departing on a heading more southeast than direct-to. The two pilots – one of them the father of the three children – regularly flew the trip- and presumably knew the terrain issues well.

Sadly- in all three examples the crew made otherwise sound decisions voided by their unwillingness to risk a violation by busting the airspace limits and then asking forgiveness. At least- pursuing that last approach would have left them alive to argue the point- but as these accident scenarios played out- all three left the pilots no room for error.

The same can be said of another accident that involved another Commander- a 690B- which three years ago suffered a CFIT on approach to the airport at San Juan- Puerto Rico. In this case weather was an issue- but the pilot was on an IFR flight plan and in contact with controllers – yet failed to heed the controllers’ warning about minimum vectoring altitudes in the mountainous area outside of San Juan.

As we see from the fourth incident here- even taking all the best steps counts for nothing when pilots fail to execute according to conditions – ATC- weather and terrain. Trying to save time by hedging your bet on any one of these elements can be a one-way flight into the CFIT statistics book.

Do you have any questions or opinions on the above topic? Get them answered/published in World Aircraft Sales Magazine. Email feedback to:


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