Superstition Crash Final report

[CT4ME]

The final report for the 2011 Thanksgiving crash was done earlier this month.
No changes from the earlier reports - pilot error. But a continued absence of discussion about the air space problem. There is some serious ass-protecting going on here. Local aviation experts, the AOPA, and even several FAA investigators all conclude it was a major contributing factor. In the attached video report, a local retired senior controller agrees. He's also a assoc. Professor teaching aviation at ASU and Embry-Riddle, and a lawyer.
I get it. The family is suing the FAA, and it wouldn't look good if the report slammed the FAA. I'll be watching that lawsuit for the real report.
BTW, the attached TV news reports are pretty good and accurate, for a TV news report

 

[olasek]

The family is suing the FAA, and it wouldn't look good if the report slammed the FAA.

I wonder if NTSB's reports have any relevance in such court cases. But it will be interesting to watch how much luck they will have in their legal battles. I personally think it is another frivolous lawsuit to deflect blame from one's stupid mistake. What's even more ironic this pilot was flying this route many times and he always flew "direct" necessarily clearing the mountain by not a huge margin but this time a delayed right turn from the origination airport put him on a direct collision course. Maybe the family should also be suing the tower controller by delaying his turn and inadvertently causing the accident And I wonder who they are going to sue for falsifying aircraft documentation to avoid installing TAWS mandatory on this aircraft - something that could have saved their lives.

 

[Hiperbiper]

The final report for the 2011 Thanksgiving crash was done earlier this month.
No changes from the earlier reports - pilot error. But a continued absence of discussion about the air space problem. There is some serious ass-protecting going on here. Local aviation experts, the AOPA, and even several FAA investigators all conclude it was a major contributing factor. In the attached video report, a local retired senior controller agrees. He's also a assoc. Professor teaching aviation at ASU and Embry-Riddle, and a lawyer.
I get it. The family is suing the FAA, and it wouldn't look good if the report slammed the FAA. I'll be watching that lawsuit for the real report.
BTW, the attached TV news reports are pretty good and accurate, for a TV news report

I don't see any CYA going on...Pilot flying VFR and not receiving FF does a CFIT.
They could have used FF. They could have filed IFR. They could have asked for clearance into Bravo (you can't say it's too hard to get in if you never ask to be let in,,,).
Heck; they could have used a $500.00 Lowrance 2000 off Fleabay.
But they did none of the above and they smacked into a mountain that hasn't moved since last time they passed it. Nobody's fault but the guy in the seat.

JMPO

Chris

 

[CT4ME]

Any accident is a chain of events. It's the NTSB's job to find out what those events were. Not mentioning the airspace issue is egregious. Not mentioning the lack of a beacon on top of a peak that juts 500 feet just seconds out of class B is egregious. Doing a bogus survey after the memo about uncooperative ATC access to class B is fishy.

 

[olasek]

Not mentioning the airspace issue is egregious.

Perhaps NTSB felt there was no "issue". Perhaps the B-floor has to be there. The only ass-protecting going here is the family "protecting" their idiot pilot who was unable to exercise even minimum care hauling his kids for holidays.

 

[Palmpilot]

Perhaps NTSB felt there was no "issue". Perhaps the B-floor has to be there. The only ass-protecting going here is the family "protecting" their idiot pilot who was unable to exercise even minimum care hauling his kids for holidays.

I thought the pilot whose kids were killed was not the one flying.

 

[olasek]

As I recall that the only other adult on this aircraft was an aircraft mechanic (pilot's business acquaintance) and I don't think he was operating the controls, I don't think he was PIC, unless I missed something.

 

[Henning]

What is the FAAs liability supposed to be here? The dude flew into the side of a hill on his own, he wasn't at a cleared or restricted altitude nor on an assigned heading. If you think that hill with no beacon is funky, check out the ones on approach to DVT. Maybe if he selected WingX Pro with SVT rather than Foreflight he would have missed that hill.

 

[BillTIZ]

Biggest hammer I see in the report is the aircraft was "non-airworthy" on paper. A ferry permit to move it to the southwest US and no actions taken to rectify the airworthiness.

Flown the route a 100 times, and most likely always or near always got cleared on course and missed the mountain by 1/2 mike or more. Delay the turn, the situation changes, but complacent in "knowing the route" leads to failure.

 

[Geico266]

Wow. Just wow.

I thought everyone knew the "Direct To" button doesn't take into account terrain, obstacles, or controlled airspace.

Oh well, that is one way to find out is doesn't include terrain and to let others know it doesn't. Please make a mental note.

I will never look at Foreflight the same again!

 

[BillTIZ]

As I recall that the only other adult on this aircraft was an aircraft mechanic (pilot's business acquaintance) and I don't think he was operating the controls, I don't think he was PIC, unless I missed something.

The other "pilot/A&P" was director of maintenance for the company. I think it's in the report that they swapped seats.

 

[Fearless Tower]

The problem is that while the airspace is tight, it didn't cause that crash. That crash was pure and simple the result of haphazard preflight planning coupled with an unexpected ATC call (FFZ Tower telling them to maintain RH for other traffic) that caused the pilot to lose his situational awareness.

The airspace may be tight, but honestly my opinion is that the bigger issue is Phoenix TRACON's generally negative attitude towards VFR GA that encourages pilots to go it alone and not even try to ask for clearance through the Bravo knowing they likely won't get it. I've heard that has improved somewhat specifically since the crash though, so perhaps something positive came out of it.

 

[Fearless Tower]

The other "pilot/A&P" was director of maintenance for the company. I think it's in the report that they swapped seats.

There was a company mechanic (young kid IIRC) in the right seat. The other 'pilot' was a company exec and former Delta pilot who was sitting in the back with his kids.

 

[olasek]

The other "pilot/A&P" was director of maintenance for the company. I think it's in the report that they swapped seats.

You could be right.
I rechecked and there were 6 people on this aircraft, not 5 as I originally thought. Also the NTSB's report says the "pilot" was 31 but the father of the children was 39 from some other newspaper accounts.

 

[Fearless Tower]

I thought the pilot whose kids were killed was not the one flying.

That is correct, in fact because of the crap getting sprayed all over the media at the time (that pilot had self grounded himself after a bout with depression) the NTSB in a preliminary report made very specific notes on who was sitting where in the aircraft.

There were three adults onboard. Two were pilots. The one with the kids was sitting in back with his kids.

 

[Palmpilot]

...FFZ Tower telling them to maintain RH for other traffic...

What does "maintain RH" mean?

 

[weilke]

The final report for the 2011 Thanksgiving crash was done earlier this month.
No changes from the earlier reports - pilot error. But a continued absence of discussion about the air space problem. There is some serious ass-protecting going on here. Local aviation experts, the AOPA, and even several FAA investigators all conclude it was a major contributing factor. In the attached video report, a local retired senior controller agrees. He's also a assoc. Professor teaching aviation at ASU and Embry-Riddle, and a lawyer.
I get it. The family is suing the FAA, and it wouldn't look good if the report slammed the FAA. I'll be watching that lawsuit for the real report.
BTW, the attached TV news reports are pretty good and accurate, for a TV news report

You must be reading a different NTSB report. The one I have in front of me goes in great detail on the airspace issue. The ATC group chairmans report item 5.0 deals with the issue for 2 1/2 pages and the public docket documents 15 through 40 are all related to the airspace issue.

Their conclusion was simply that in light of the fact that 96% of aircraft that requested a bravo clearance received it but there was no trace of a bravo request by the accident pilot, the argument that the airspace design or actions of the tracon are somehow responsible doesn't hold much water.

You can disagree with their conclusion, but if you read the report, you cant really make a case that anything was buried or ignored.

Appended is member Sumwalts concurrence with the board findings. I find it difficult to disagree with his assessment. They removed the TAWS because they were cheap, flew 'direct to' with an ipad rather than following airways around the rocks and didn't bother to ask for bravo clearance or VFR advisories. Yes, flying VFR at night in the mountains carries additional risk, no shame in obtaining all the help you can get.

 

[weilke]

Perhaps NTSB felt there was no "issue". Perhaps the B-floor has to be there. The only ass-protecting going here is the family "protecting" their idiot pilot who was unable to exercise even minimum care hauling his kids for holidays.

I believe the lawsuits are from the ex-wife who lost the children due to the actions of her ex-husband and his pilot.

As for the bearing of the report on the lawsuits: By statute, the conclusions of the NTSB are excluded from use in litigation. The factual data contained in the docket is available to a litigant. Given that the FAA/NTSB have put an abundance of information on the airspace issue into the docket, any claim that this is a CYA snow-job is misplaced.

 

[weilke]

What does "maintain RH" mean?

Runway heading.

Had he turned on his schedule, he would have missed the mountain, the extended upwind is what put him into a different position.

Appended is Figure 06 from the Operations group report. It shows a trip made by the same company 2 days earlier with inbound and outbound radar tracks (yellow and blue). The outbound track (red) on the day of the accident shows the extended upwind including the point where the 'direct to' button was pressed (either on a device or in the pilots mind).

 

[olasek]

The one I have in front of me goes in great detail on the airspace issue. The ATC group chairmans report item 5.0 deals with the issue for 2 1/2 pages and the public docket documents 15 through 40 are all related to the airspace issue.

Correct, everyone reads the report but few look at the docket and at least in this case - it is massive.

 

[flyingron]

And why on earth did we have a bunch of passengers on a ferry permit?

 

[weilke]

And why on earth did we have a bunch of passengers on a ferry permit?

They would have hit the same hill had they used on of the other turbine commanders owned by the company. The plane hit the hill due to a operational error, not because the spar inspection was a couple of hours late. It speaks to either sloppyness or intentional disregard when it comes to paperwork, I dont see how it is causal as the flight would have happened in the same way in any of the other company aircraft.

 

[Palmpilot]

They would have hit the same hill had they used on of the other turbine commanders owned by the company. The plane hit the hill due to a operational error, not because the spar inspection was a couple of hours late. It speaks to either sloppyness or intentional disregard when it comes to paperwork, I dont see how it is causal as the flight would have happened in the same way in any of the other company aircraft.

Apparently the sloppiness or intentional disregard with respect to paperwork extended to preflight planning and night terrain avoidance procedures as well.

In light of the maintain runway heading instruction, and the track chart you posted, it sounds like the preflight planning needed to include how to guarantee terrain separation if an unexpected ATC instruction was received. That's something I will want to keep in mind the next time I make a night VFR departure.

 

[gismo]

Any accident is a chain of events. It's the NTSB's job to find out what those events were. Not mentioning the airspace issue is egregious. Not mentioning the lack of a beacon on top of a peak that juts 500 feet just seconds out of class B is egregious. Doing a bogus survey after the memo about uncooperative ATC access to class B is fishy.

I don't see how the Class B geometry can be considered a cause of this accident. Nothing in the layout of that airspace prevents a pilot from flying a bit further under the shelf to get clear of the mountains. Sure it would be more convenient if they could just climb into the Bravo while heading in their desired direction but that's about time and money, not safety.

 

[Henning]

They would have hit the same hill had they used on of the other turbine commanders owned by the company. The plane hit the hill due to a operational error, not because the spar inspection was a couple of hours late. It speaks to either sloppyness or intentional disregard when it comes to paperwork, I dont see how it is causal as the flight would have happened in the same way in any of the other company aircraft.

It's the same thing, sloppy, dismissive attitude carried over into navigation.

 

[Henning]

And why on earth did we have a bunch of passengers on a ferry permit?

They didn't, there was no ferry permit for this flight.

 

[frfly172]

You get complacent,fail to do proper planning for night flight,you run the risk of serious conseq

 

[weilke]

In light of the maintain runway heading instruction, and the track chart you posted, it sounds like the preflight planning needed to include how to guarantee terrain separation if an unexpected ATC instruction was received. That's something I will want to keep in mind the next time I make a night VFR departure.

The VFR flyway chart for that area has a checkpoint VPREN designed to line up traffic between the mountains and the restricted area. Just plan your course and stay away from the --> D button.

 

[Palmpilot]

The VFR flyway chart for that area has a checkpoint VPREN designed to line up traffic between the mountains and the restricted area. Just plan your course and stay away from the --> D button.

When I fly into the Phoenix area at night, I tend to stay over highways or lighted urban areas. I also use the VP checkpoints to keep me clear of the airspace that's set aside for Luke AFB. And I keep a sectional open to double check my assumptions about terrain heights.

 

[airheadpenguin]

" Had he requested the MSAW in particular, he likely would have received an advisory that his aircraft was in unsafe proximity to terrain"

I wasn't aware that there were two classes of services, do you typically have to request both?

Sent from my Nexus 10 using Tapatalk 4

 

[Konaflygirl]

I wonder if NTSB's reports have any relevance in such court cases. But it will be interesting to watch how much luck they will have in their legal battles. I personally think it is another frivolous lawsuit to deflect blame from one's stupid mistake. What's even more ironic this pilot was flying this route many times and he always flew "direct" necessarily clearing the mountain by not a huge margin but this time a delayed right turn from the origination airport put him on a direct collision course. Maybe the family should also be suing the tower controller by delaying his turn and inadvertently causing the accident And I wonder who they are going to sue for falsifying aircraft documentation to avoid installing TAWS mandatory on this aircraft - something that could have saved their lives.

Well.... I am the "the family".....actually the only remaining member of the family. I have been flying airplanes for more than 20 years, worked under 135/121 and as a CFII, MEI. Nothing could be more painful for me as a mother... than to not only lose all 3 of my children and my former husband, but to lose them doing what I loved most in the world. Thank you all for your interest in this story. There are many things that disturb me and will never make sense. I have seen and heard the tower tapes, I have read and seen every single detail of this accident..... including the over 700 photos of the accident scene. I have hiked to the crash site 5 times and collected many items of the crash, and in fact am now the "owner" of the pieces left. As a pilot, I am left devastated. As a mother, I am left devastated. There is no doubt that many factors played into this unfortunate chain of events. In my professional opinion, the airspace needs a serious review and I hope the right decisions are made so that pilots have a greater margin of safety flying around the Superstition Mountain. ~Karen Perry~

 

[Henning]

Sorry for your loss, it must be a tough one. I suspect that so much operation in the area created some complacency, and that always seems to defy sense. Some things never do make sense.

 

[Konaflygirl]

Runway Heading

 

[Henning]

Runway Heading

I don't understand... What would you like to see the outcome of the airspace review be?

 

[Z06_Mir]

The airspace may be tight, but honestly my opinion is that the bigger issue is Phoenix TRACON's generally negative attitude towards VFR GA that encourages pilots to go it alone and not even try to ask for clearance through the Bravo knowing they likely won't get it. I've heard that has improved somewhat specifically since the crash though, so perhaps something positive came out of it.

I've generally found PHX approach to be some of the most professional and accommodating controllers, as long as a pilot you speak clearly and act like you know what you're doing. I do believe that statistic that 96% of people who ask for a class B clearance get it.

Well.... I am the "the family".....actually the only remaining member of the family. I have been flying airplanes for more than 20 years, worked under 135/121 and as a CFII, MEI. Nothing could be more painful for me as a mother... than to not only lose all 3 of my children and my former husband, but to lose them doing what I loved most in the world. Thank you all for your interest in this story. There are many things that disturb me and will never make sense. I have seen and heard the tower tapes, I have read and seen every single detail of this accident..... including the over 700 photos of the accident scene. I have hiked to the crash site 5 times and collected many items of the crash, and in fact am now the "owner" of the pieces left. As a pilot, I am left devastated. As a mother, I am left devastated. There is no doubt that many factors played into this unfortunate chain of events. In my professional opinion, the airspace needs a serious review and I hope the right decisions are made so that pilots have a greater margin of safety flying around the Superstition Mountain. ~Karen Perry~

Karen, I am so sorry for you loss. I hope that you can find some peace and I hope in time more questions can be answered for you.

 

[Konaflygirl]

Thank you, yes this is the toughest life lesson that I have ever had to face. I do agree that complacency....played a role here. I wish to God that Shawn Perry had been at the flight controls that night. I know that Shawn would not have made this mistake. But he was in the back calming our children. If I let my mind go crazy with it, I can feel intense disdain for Russel Hardy...His attitude allowed him to F*ck up. He killed himself, leaving a wife and child behind. He killed my whole family. Every checkride that I have taken the examiner would say "I have to feel that I could put my family with you and they would be safe." Their families all were.....but my family members are all dead.

 

[Henning]

Thank you, yes this is the toughest life lesson that I have ever had to face. I do agree that complacency....played a role here. I wish to God that Shawn Perry had been at the flight controls that night. I know that Shawn would not have made this mistake. But he was in the back calming our children. If I let my mind go crazy with it, I can feel intense disdain for Russel Hardy...His attitude allowed him to F*ck up. He killed himself, leaving a wife and child behind. He killed my whole family. Every checkride that I have taken the examiner would say "I have to feel that I could put my family with you and they would be safe." Their families all were.....but my family members are all dead.

When I took my PPME check ride with Betty Faux I asked her, "How do you decide whether to pas or fail someone?" Her response was was just that "I ask if I would feel safe having you fly my daughter somewhere."

As an aside, I see this as another accident synthetic vision would have prevented.

 

[Konaflygirl]

I would like to see the class B raised from 5000' near the peak of the mountain (which is at 5047 ft) raised to 7000.' This would provide a much greater margin of safety for VFR traffic. This would require more than a 3.5 degree glidepath for the incoming commercial traffic, which is perfectly acceptable. It just cost money to make the changes.

 

[Henning]

I would like to see the class B raised from 5000' near the peak of the mountain (which is at 5047 ft) raised to 7000.' This would provide a much greater margin of safety for VFR traffic. This would require more than a 3.5 degree glidepath for the incoming commercial traffic, which is perfectly acceptable. It just cost money to make the changes.

Interesting.

 

[dans2992]

Wow. Just wow.

I thought everyone knew the "Direct To" button doesn't take into account terrain, obstacles, or controlled airspace.

Oh well, that is one way to find out is doesn't include terrain and to let others know it doesn't. Please make a mental note.

I will never look at Foreflight the same again!

Foreflight has since added a "hazards" layer with color coded terrain and obstacles.

If I'm flying at night in this area, I'm either getting positive control from PHX approach, or have my exact route planned out. I also make it a point to always have some kind of terrain warning system as well, and I much prefer the ones with audio alerts.

I don't use the terrain alerting system to avoid the terrain, but if it ever goes off it means "hey dumbass, your preflight planning here sucked!" I had one of those moments on my first flight after purchasing a portable GPS a long time ago. I don't think I was going to hit the mountain, but I've always had "firmer" plans at night ever since. Never again.