Mountains like you have at Calgary, Denver, Milan and the like, although spectacular, aren't that much of a problem as they are some distance from the airfields in question and are "obvious".
The nasty places, IMHO, have low hills close in which don't look that forbidding until you lose a donk. MSAs may not be particularly high compared with the airfield altitude but you still have to get there. ZRH comes to mind as somewhere that has seen more than its fair share of accidents, both on departure and approach.