Accident Case Study: Unintended Consequences 

Wow, im sorry about your loss

Karen, My most sincere condolences.

I'm very saddened to hear of your loss. I hope that the attempts to improve awareness of the issue, the changes of procedure, and improved technology in the cockpit will help eliminate this type of accident.

My sympathies for your loss. God bless you.

so so very sorry...doc johnny...blessings dear... sicily

Holy hell I had no idea about that. Thanks for sharing!

@@rykehuss3435 😬

@@rykehuss3435 It is a serious question but one that has so many social connotations that it just cannot be asked any longer. I am amazed that my wife knows where my keys and wallet are at any given time. She can remember a to-do list without thinking, but stops at a roundabout to see if anything is coming. I can glance at the clouds to ascertain which way the wind is blowing.... in half a second I know with certainty. And can remember a map as one glance, whilst she has to turn it facing where we are going to study with much growling and scowling.

I stopped flying after only for once i found that i did not anymore meet a basic but to me very basic requirement that i could not meet anymore. This requirement was: "If you financialy can't afford to fly, don't" Only shear luck prevented me from taking off after someone else (who rented the airplane) didn't do a walk around properly.

@@andyharpist2938 You say it has stereotypes attached and then list some anecdotal evidence for some

Her ex was under strict orders to never fly the kids. He was bringing them back to custody after a visit and was flying them w/o her knowledge or permission. The most painful to see is when Karen celebrates their birthdays marking the ages they would have been. A mother's love has no limits. With Karen truer words have not been spoken

@@tommypetraglia4688 that is not true, you are thinking of the accident with the two daughters who was being piloted by a private pilot going to Telluride. I knew my kids were flying that night and they and (he) had permission.

Great point.

Yes, AND, never put the commands of any perceived "authority" figure ahead of your own!

Put this on your Night VFR Checklist! --highest obstacle

Non pilot here, why not set your flight path at 4950 just under the 5000 ceiling but above the mountains? This tragic accident seemed to by avoidable.

And stay above it, or fly around it.

That sounds reportable to someone at least... (coming from a non PPL guy btw) they just holding the airspace for ransom 😂😠

Unconscionable on the part of the FAA and/or phoenix tracon

Sounds like a liabilty issue. If the pilot in the video used it, ATC would have been in hot water

@@quasarsavage that isnt holding airspace for randsom ... they dont request money and you can fly where you want

@@ThatSB Well...try entering Class B airspace and see if you really can "fly where you want"

That's silly....why doesn't the GPS have terrain awarness. Pretty sure its not a big deal to incorporate terrain awarness into GPS. will save heaps of life.

I retired about the time GPS was becoming widely available. I flew mountainous terrain worldwide, and quite a bit in the Andes. Always learn your route prior to departure. We often went into Cali and Bogota, Colombia,La Paz, Bolivia and Santiago, Chile. With NDB, VHF, and Omega. I'd love to try it with GPS.

Kaimine My thoughts exactly, creating a safety hazard.

@Jan Forbes It looked like this guy was doing his best to avoid the Bravo Shelf though, doing this at night, he most likely didn't see the mountain infront of him and with how close that Bravo was to that raised area, there was very little room for error. I always tend to go a mile outside of a class airspace just to ensure I'm clear of the Charlie/Delta before climbing and that would have gotten me killed in this scenario. As for what you said, I agree, if I'm going on a large cross country trip, I'm going high just because there's more options higher than lower.

@Jan Forbes Of course you fly over mountains. You needed training for that? As for 7000, not if it is class bravo you wont.

A minute is a bloody eternity in an aircraft. Two miles or more.

ATC has the responsibility to notify the pilot if they observe an unsafe situation. It doesnt matter if they are handling the aircraft or not.

I used to hear that a lot from private pilots who flew in and out of Las Vegas.

Are you certain it was an IFR flight plan? I'm a controller and we're absolutely taught that for IFR aircraft, terrain separation is as important as traffic separation, we're well aware of the MVA (minimum vectoring altitudes), and in mountainous terrain we're constantly pulling up the MVA overlays especially when aircraft are close to mountains. I can't believe any controller would say that for an aircraft under IFR. I'm guessing he was actually on a VFR flight plan in which case yes, the pilot is responsible for terrain, obstacle and cloud clearance (not ATC).

Thank you for that post Sarah. You taught me quite a bit.

I was shocked when I flew there,I get treated a thousand times better at EWR and JFK where there's 1000 times the commercial traffic and the most congested airspace in the world.

@@southjerseysound7340 San Diego and LAX area ATCs almost always clear small GA aircraft through the bravo and those are much bigger and more complex airspaces!

@@MrXtachx maybe it was a bad day but I'm not in a hurry to go back anytime soon 😆

The personnel staffing LAS are true pricks with no regard for safety. I have flown in and out of there countless times and it seems their Bravo is sacred air no matter the weather-wind-turbulence.

Andrew Roberts a

Well, it was 2011, things weren't so 2016 back then. Technology moves fast.

Good point.

It says in the video that the place is infamous for not granting Bravo clearance for vfr flights.

Politics keep them from granting it,it's disgusting .

@@sea0fgreen33 Well some people have earned a bullet for that by now.

What you need is altitude high enough to stay clear of the terrain. Screw the “clearance”. Certainly pilots who fly in that area know how high the mountains are. Why would anyone fly at an altitude certain to lead to a crash?

VFR elevation figures too

thats what l was thinking...adults can decide to do risky things but ...

I’m with your wife on this one 👍

The pilot can't completely ignore ATC but a pilot always has final say in safe operation and can respond with "unable" followed by the actual vector that will be taken even if it means entering class B. If this becomes frequent in an area due to something like a mountain it may start to sink in. Of course you may be contacted later and asked to provide the reason you were unable to comply, so don't go abusing the system. Clearance from terrain due to aircraft climb rate or marginal VMC are perfectly acceptable reasons.

Yet their motto is "The Friendliest Airport in the World."

I know this is 4 years later, but what makes Las Vegas the worst? I'm planning a flight through there in the future and would like to know what to expect! Do they also routinely deny FF and transit through the bravo?

Las Vegas has been my favorite Bravo to fly in. I regularly get all sorts of neat vectors over LAS or the strip or "cleared through bravo, continue at pilots discretion." PHX is by far the worst I've ever flown in for GA aircraft, so you hit the nail on the head with that on.

I've been flying for many years and during that time I've done some pretty stupid stuff that I'm not proud of. But I've never done anything stupid with a child seated in the back.

@@Eliot451 ^ This That plane never should have left the ground with those kids.

Experience is a relative term. I agree completely that this is the type of accident that you would expect with someone who has very little experience. Yet the pilot flying was an ATP, had roughly 2000 hours TT, and was carded by the US Forest Service. Certainly enough experience to know better. Yet in the big scheme of things 2000 hours TT is merely a drop in the bucket.

Correct! Pilots fly airplanes. Controllers watch scopes.

My reply disappeared INSTANTLY! Again. Pilots fly airplanes. Controllers watch scopes!

Thank you for telling this story. I am terribly sorry for your losses. I can't help but feel that ATC was at least partially responsible for this accident. Had they not extended the upwind takeoff leg and then just sent the aircraft on it's merry way, this accident might not have ever occurred. I also can't help thinking about how a Garmin G600 with SVT would have probably kept this aircraft out of danger. I am a firm believer in the value of that technology. I will look for your book on Amazon.

Hi Tammi see my comments about ATC later in the comments.

Karen, you use the term deficient as if it is a real smoking gun. There are many areas of deficiency in the industry but impossible to address them all. Unfortunately, too often change comes as a result of tragedy instead of proactively pursuing suspect areas.It has been said thateven airliners could be made 100% safe but the cost would be too great to sustain.I applaud your work in safety and hope to see you at a seminar. God bless you and your family.

Belated condolences to you and your family ma'am.

Karen Perry You have my prayers

Mr. New: In Alabama, about 20 to 30 miles south of Montgomery is a 2000 ft radio tower. That monster is well lit, but the guy wires on it go out some distance to the side . I don't know how many wires it has, but I don't even get within five miles of its location unless I am at at least 3000 feet.

I Prayers? SMH! Send CASH!

The only one you can count on to "have your back" is you. ATC don't have the luxury of monitoring each and every flight from rotation to landing and once the aircraft is in the air and on its way, you can't realistically expect them to be your guardian angel.

C. John Graham I went to Willie as well (88-03) and that story was still related to us. We were told it was during a night solo but I never saw an official report.

Dean Martin's son was California ANG flying an F4 Phantom out of March AFB was vectored toward the San Gabriel Mountains for spacing toward landing. They forgot to turn him in a timely manner. Mr. Martin never really recovered from the loss.

Thank you Jeffrey.

I think only the pilot knew in the last 3-5 seconds as he tried to revv the engines... terrible tragedy

This was what my mind kept coming back to while watching this video. I wonder what caused the controller to request a delay in the right turn. Was there traffic nearby? I've been fascinated by this video series lately, though the tragedies involved are heartbreaking. I don't think I could handle being a controller, knowing that even something seemingly innocuous like this request could start a chain reaction leading to loss of souls.

Still it is the pilot's responsibility to be aware of obstacles

@@tomkarlsborn2384 its their responsibility, but the controller signed his death certificate.

@@bermchasin This is very true. I have been in this situation many times and had to take action against the controller's directives to avoid terrain. Sad but true.

How are ATC and regulations responsible for this guy flying his plane into a mountain? Give me a break. A responsible pilot should know obstacles along his way regardless of regulations or ATC.

@@AK-rx6hv Regulations are not responsible or the crash but definitely contributed. For one, it’s unlikely the pilot would have gotten cleared into the Bravo because of how the ATC in this area are. That section of Bravo airspace is so close to terrain, and that particular mountain only takes up a tiny amount of space on the chart which is easy to miss. Maybe they could put that as a hazard or warning area on the sectional chart, just like they do with high volume traffic areas, parachuting, gliding, or MOA’s just to give pilots extra notice. Just my opinion and I don’t like to judge the dead, because dying is enough punishment for a small mistake

Even with a train warning system, those rocks rise way too fast to get ample warning??😳😬

Flying into the terrain is inexcusable. Just like running a red light (for example). You need to know ANY terrain along AND near your flight path. Never assume if you are VFR, that you will be able to get a class bravo clearance, especially at night. This accident is clearly on the shoulders of the PIC. I was actually flying into PHX at the same time this accident. It was soooo dark that night. No moon whatsoever.

@@captainshipman7377 I'm 100% confident that if this pilot had said, "I have no TAWS and I'm flying an illegal flight with three children in the back of this plane, and I need cleared for ________" they would have granted him anything he asked. He would have needed to admit his mistake and declared an emergency. He's not the first pilot to crash because they were ashamed/afraid to admit to ATC that they were in an emergency situation. I can see that... unless there are three children in your plane with you. The issue is pilots lying by omission. If ATC had known the real situation, they would have cleared him.

I remember reading in 2013 about furlough days for controllers being implemented along with the closure of some towers. Their response was to reduce services to VFR traffic. I'd like to see increased funding for controllers assuming they'll provide VFR services.

I agree as well and what many don't know is that there was a shift change in the control tower that night. The aircraft departed at 6:24 pm and at 6:30 there was a shift change right after 690SM exited the airspace for Falcon Tower. The controllers were doing a briefing for the next shift and had someone been monitoring the situation they would have seen an aircraft heading 250 mph toward a mountain. At 6:31 pm the aircraft hit the mountain. Having said that there were a sad chain of events that happened that night...a multitude of things that had any one of them been broken, the accident may have been avoided. For the full story purchase "Angels Three: The Karen Perry Story" available on amazon. I am the mother of the 3 children who perished in this accident, a CFII/MEI and former 135 /121 pilot.

ATC killed these people with their negligence of building the Class B airspace the way they did and having the history of not providing radar service to VFR flights

you should tour a class B TRACON sometime. you'll understand why.

For a start that plane shouldn't have even been in the air. If he'd followed regulations him and the 3 kids would still be alive today

True that. It does not help that the sky glow of Phoenix is at your back in most of those cases, often making stars scarce but simultaneously feeding the illusion that the pilot can see. If a pilot doesn't _know_ where the terrain is, it will rise up and smite him.

but flying is safer than driving they say

occyman wow. Do you know where and when this happened? I’d like to read the full report it possible.

@@Lostdeltallc You may be correct considering the way you worded it. GPS's don't have dead reckoning mode, but the program that is using the GPS signal DOES! Even my own phone does this when it loses gps.

@@liamb8644 I also knew the pilot in this accident in Australia. The report is here www.atsb.gov.au/publications/investigation_reports/2004/aair/aair200402797.aspx

I agree. Although, ops as usual would have helped, with his tablet showing topographical features.

Like the regulation for the aircraft to have a GPWS which it didn’t?

@@Bartonovich52 All that stuff is expensive and accumulates fast, sometimes it's straight up impractical; there's a reason why GA craft are made to lesser standards than airliners. The same way as you can't really mandate any more safety than a helmet for motorcycling, even in spite of outrageous fatality rates.

I strongly agree with you comment.

I agree as well and what many don't know is that there was a shift change in the control tower that night one minute prior to the accident. The aircraft departed at 6:24 pm and at 6:30 there was a shift change right after 690SM exited the airspace for Falcon Tower. The controllers were doing a briefing for the next shift and had someone been monitoring the situation they would have seen an aircraft heading 250 mph toward a mountain. At 6:31 pm the aircraft hit the mountain. For the full story purchase "Angels Three: The Karen Perry Story" available on amazon. I am the mother of the 3 children who perished in this accident, a CFII/MEI and former 135 /121 pilot.

Oh wow, Karen, May God bless you.

Or one can read the unbiased NTSB report available at NTSB.GOV for the real story. I find it astounding how many people here are so quick to proudly list their flying experience in years or hours and yet, can be so incredibly ignorant of the ATC system and how it works and the statutory limitations of procedures and and airspace of different types of facilities. I'm not buying it. Sure, this plays well for all the non-pilots out there reading--but for all of you pilots commenting--you know better! FFZ is a VFR Tower. The statutory limit of the airspace is 5 miles. The accident occurred at 15 miles--more than 3 times the Class D airspace limit. I'm very sorry for your loss. I've lost a child too. I know what that feels like. I can't imagine the pain of losing three children. It's just unthinkable. But I do not think you do their memories any justice by wrongly blaming other people who were not in any way responsible for this tragedy.

I do plenty to honor the memories of my 4 family members that died in this accident (my entire family by the way). I started a non-profit for children www.3wingsoflife.org, wrote a book, and do speaking engagements including Oshkosh, Women in Aviation, aviation colleges, etc. Apparently they don't think that I am ignorant. You have missed the whole point. I am not blaming ATC. If you had read the rest of my comments in the thread you would know that. ( Re-Posting some of it in the next reply below.) So while you criticize my ability to honor my family based on a set of isolated comments taken out of context ....and leave a blanket statement that all of us here are ignorant...criticize this.... I revealed my back ground for a sense of authenticity, credibility, and establishing a point of reference. While you come across as knowledgable, I find it interesting that you fail mention what your back ground is or even if you are a pilot. I too am sorry for your loss, but you of all people you should know better that this goes far beyond the loss of our children. I think there is much value in terms of learning by examining all of the aspects of this accident. It could have happened to anyone of us, experienced or not and it could happen again. I can assure you that I am very familiar with the NTSB report. I have read it forward, backward, upside down and every which way... While it is technically accurate, and I DO recommend reading it.... it leaves a lot to be desired when considering all of the collective aspects that affected this flight. Furthermore, the NTSB report made scant mention of the airspace issue that exists around Superstition Mountain. While 10 miles might seem like a long distance, (say if you are in a C-152) when you are eating up real estate as quickly as the turbine commander does (and we are talking about an aircraft that climbs out at roughly 2,850 feet per minute) a turbine Commander does not have any trouble getting out of its own way. Im glad you mentioned the Class D airspace limit too, because you failed to mention anything about the overlying Class B airspace. And now reading further I see that you were the on duty Airport Ops manager in the PHX TRACON that night. Let me put a few things into perspective for you. I am not the slightest bit intimidated by your comments. I believe that those who work at the FAA for the most part are dedicated professionals. When something goes wrong even if they were not technically at fault I am sure that they take it hard. But tomorrow comes and they get on with their life. For those of us left behind by accidents that at the very least unfolded as ATC was standing nearby, our lives our irrevocably changed. So respectfully and with much love, contrary to what Arizona Numbers Station tells you... If anyone knows what the real story is it is me. I have never stated that ATC was the primary culprit here. (And by the way I have been flying out of PHX since 1990 as a flight instructor, and with numerous operators under Part 135 and Part 121. I can assure you that I am intimately familiar with the airspace system there.) Having said all that, there was some liability on the part of the FAA and I can tell you that as fact. And as Paul Harvey would say "AND THAT IS THE REST OF THE STORY!"

Couldn't agree more...(more) accident(s) waiting to happen. I see the airspace floor has yet to change...has there been any further discussion about that, anybody know? Just...WHY would you have the floor of an airspace volume- that some traffic has to fly under- 57' _below_ a nearby peak???

Classic GPS direct to fail. See it in boating too. Plane should have never been in the air.

@@TheBeingReal Car accidents too, with drivers going where they shouldn't because their iPhone tells them to.

@NonyaBusiness! The better question is: Shouldn't the pilot have briefed himself through the likely departure procedures and the hazards in the area. If he had done that, knowing that he wanted to stay out of Phoenix class B, he would have identified the mountains along his expected flight path, known the altitudes and possibly seen a conflict. This can all be done BEFORE a pilot takes off (especially important when visibility is limited - this was a night takeoff/departure). DO NOT rely solely on your iPad. You are correct, the iPad would have helped, but situational awareness before you takeoff is of tremendous help for unknown changes. While someone is in the middle of the changes during flight, scrolling through different menus on Foreflight, changing frequencies, setting the autopilot up, bugging the altitude to level off, setting the torque(power), props... etc. what should be in the back of your mind overriding all else is what the gotcha's are. When he was told something that he was expecting - a right turn towards his intended path, his guard may have lessened a little. When the controller said: I'll call your turn. The pilot should have thought: How far along will they take me before I can turn on course? Then a follow up question: How far off and where will that put me when I turn on course? Is that or will that be close to those mountains I saw on the way in, the ones of the map I just reviewed tonight as I planned the departure? @NonyaBusiness: I go in detail on this in hopes that you don't make a mistake by relying on your iPad/Foreflight to save your butt. It is true that it can, but it is also true that it will not - if not setup properly. Rely on proper preparation on the ground before the flight. Rely on information put into your head before the flight and things get busy. And yes, you can have your Foreflight map out, ready to go just for that purpose, dedicated for terrain avoidance. Just don't put all your eggs in one basket.

Scott Hillary no, it isn’t criminal, if you don’t fly IFR you are in charge, not ATC, learn about aviation and how it works, if you want ATC to keep you from terrain - fly IFR.

@@olasek7972 So what would ATC say if you said climbing to 6000 awaiting your instructions for the right turn. They would tell you to stay below 5000 then you tell them I'm VFR it my responsibility I'll do what I want?

David Carter such conversation would never happen between VFR pilot and the tower. Only the tower controller was involved here and he doesn’t control airspace outside of his class D which is 4 mile radius around the airport and up to about 3400 feet. This controller cares less what you do if you depart his airspace. It was the tower controller which extended his leg because there was conflicting traffic and the accident airplane was still in his area.

ianh no, the mountain was very far from this particular controller, it would make very little sense, the controller behaved very reasonably, only those who know little about flying can write such nonsensical comments

ianh controllers have other things in front of them, yes, your bad, learn about their jobs and stop write gibberish

Syclone0044 The video shows how the extended departure followed by direct flight path caused the incident. As the video says, if the pilot had asked ATC for terrain warnings, or was using his iPad app, or knew there were mountains there and once given permission to turn altered his course to join his previous flight path further south... it would have been a normal flight. The question is why he did none of those things (though they don't know if he was or wasn't using his iPad) and for that they have no proper answer beyond complacency.

Even if it didn't directly play a part - and it did - it shows that this man was willing to flip a coin as to whether his children lived or died. That's as complacent as it gets.

M Detlef Not impossible. So do you chart every flight you make? The point is had this pilot charted his flight we wouldn’t be talking about this. So quit showing us what a dickhead you are.

Probably a combination of things, to include that ATC wouldn't have had knowledge about the plane lacking a Terrain Warning system. Just awful anyway you look at it.

If the flight is VFR, it is not ATCs job. I'm a pilot and don't work for ATC but this was the pilot's responsibility. Charts and the many electronic toys all show terrain issues. Ignore them at your peril.

seems to me a pilot should familiarize themselves with terrain along their route as part of their prep

If you have ever been to Western cities like Las Vegas, Albuquerque, El Paso, Phoenix its very obvious that tall mountains loom directly over these cities. You know these mountains are there, and they are NOT hills.

Eric B When flying near or across/through mountains you should always be at an altitude of at least 1000 feet above the highest terrain.

If you want a full explanation you can read the NTSB report, or if you want an explanation that's much more interesting you can get my book smile.amazon.com/Angels-Three-Karen-Perry-Story-ebook/dp/B016WS5QQG/ref=sr_1_1?crid=3W43BHT0EEF0E&keywords=angels+three+the+karen+perry+story&qid=1570832823&sprefix=angels+thre%2Caps%2C284&sr=8-1

Roger that. .

Thank you Terry. Yes in a fast airplane the mountain is right there....thanks for reminding pilots about complacency...that played a very big role here I think. Also for much more detail about what happened please read my book: Angels Three: The Karen Perry Story. smile.amazon.com/Angels-Three-Karen-Perry-Story-ebook/dp/B016WS5QQG/ref=sr_1_1?crid=3W43BHT0EEF0E&keywords=angels+three+the+karen+perry+story&qid=1570832823&sprefix=angels+thre%2Caps%2C284&sr=8-1

There are a LOT of mountains, and except for the ones near town there with antennas on the top you won't see lights.

no. wouldnt help either

No. It is a US Wilderness area, so no electricity, vehicles....

VFR flight following is a courtesy, not a requirement. TRACON controllers are busy and keeping track of every little VFR target distracts them from controlling and separating IFR traffic. Remember, when you are VFR you are responsible for your own terrain clearance. Most of the time I used VFR flight following I was well below radar vectoring altitudes anyways.

Funny thats not what the NTSB found , they did an audit on P90 and found that they DIDNOT discourage VFR FF, but spewing you bullshit ideas is better than reading the NTSB report

yes but why did the plane not have ground proximity

@@RobertJamesChinneryH cost, and (lack of ) necessity. Plus, it might not have even mattered in this case. speed and reaction time might not have been enough to avoid the mountain. the best ground proximity and anti CFIT device is knowing exactly where you are and where the ground is at all times, and it works very well until it doesnt.

@@Bartonovich52 Well then if they aren't supplying any help when they deny your request just tell them climbing to 5500 (or whatever you have determined is highest obstacle near your route) to stay clear of terrain, if they deny your request say OK will accept your flight following then continue to advise.

That would have been Shawn Perry.

plane did not have ground proximity equipment

@M Detlef 60 mph into the rock jetty at Government Cut... gps or not, they were fkd

@@tommypetraglia4688 It was the GPS that told him to fly that way, just like the car drivers who crash because their iPhone tells them to drive where there's no road.

@@Raison_d-etre if your phone tells you to drive where there’s no road you’re not going to drive there. Anyway you just made that up, STRAWMAN ALERT!

@@steviesevieria1868 You keep using that word. I don't think it means what you think it means.

Like using a plane to visit family on thanksgiving?