The National Transportation Safety Board traveled to the scene of this accident.
Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Las Vegas, Nevada
Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Las Vegas, Nevada
Cirrus Aircraft; Duluth, Minnesota
Continental Motors; Mobile, Alabama
Investigation Docket - National Transportation Safety Board:
Location: North Las Vegas, Nevada
Accident Number: WPR20FA034
Date and Time: November 26, 2019, 17:30 Local
Registration: N7GA
Aircraft: Cirrus SR-22
Aircraft Damage: Destroyed
Defining Event: Controlled flight into terr/obj (CFIT)
Injuries: 3 Fatal
Flight Conducted Under: Part 91: General aviation - Personal
Analysis
The pilot was conducting a visual flight rules (VFR) personal flight with two passengers during dark night conditions. Prior to the flight, the pilot had filed and subsequently activated a VFR flight plan from his point of departure to his intended destination.
As the pilot neared his intended destination, he contacted Nellis Air Traffic Control Facility and reported his altitude of 6,500 ft and that he had the weather at his destination airport. He also requested a practice instrument landing system (ILS) approach. The controller acknowledged the request and advised the pilot to expect the ILS approach. Throughout the following 7 minutes, the controller issued various heading changes to the pilot due to departing traffic at a nearby Air Force base, which the pilot acknowledged. The controller then issued the pilot a left turn to a westerly heading and informed the pilot that altitude was his discretion, which the pilot acknowledged.
About 1 minute, 54 seconds later, the pilot transmitted “we’re getting a low altitude alert for N7GA, we gotta turn left.” Shortly after, the controller instructed the pilot to “turn left heading 250°,” which the pilot acknowledged. No further communications from the pilot were received despite multiple attempts from the controller. Throughout this timeframe, recorded radar data showed the airplane at an altitude of 6,500 ft msl.
The airplane impacted mountainous terrain at an elevation of 6,500 ft msl, about 400 ft below the peak. The wreckage was fragmented and mostly consumed by fire. Examination revealed no anomalies with the airframe or engine that would have precluded normal operation.
Based on the available evidence, it is likely that the pilot had some sort of terrain awareness warning available; however, it was undetermined what type of system it was. While the pilot reported that he received a “low altitude alert” from an unknown source about 22 seconds before the last radar target, it’s likely that the pilot did not have sufficient time to maneuver to avoid terrain.
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot’s failure to maintain clearance from terrain during cruise flight in dark night conditions.
Findings
Personnel issues Monitoring environment - Pilot
Aircraft Altitude - Not attained/maintained
Personnel issues Use of equip/system - Pilot
Environmental issues Dark - Effect on operation
Environmental issues Mountainous/hilly terrain - Not specified
Factual Information
History of Flight
Enroute-cruise Controlled flight into terr/obj (CFIT) (Defining event)
On November 26, 2019, about 1730 Pacific standard time, a Cirrus SR-22 airplane, N7GA, was destroyed when it was involved in an accident near North Las Vegas, Nevada. The pilot and 2 passengers were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.
The pilot filed and activated a visual flight rules flight plan from his departure airport of Lake Havasu City Airport (HII), Lake Havasu, Arizona, to his intended destination of North Las Vegas Airport (VGT), North Las Vegas, Nevada.
Review of recorded communication and transcripts revealed that, at 1720:23, the pilot contacted Nellis Air Traffic Control Facility and reported an altitude of 6,500 ft and that he had “information papa.” The controller advised the pilot that the transmission was “broken” and confirmed that the pilot had information papa. The pilot responded that he had information papa for North Las Vegas and requested a practice instrument landing system (ILS) approach to runway 12 left. The controller acknowledged and informed the pilot to expect the ILS approach.
At 1723:48, the controller instructed the pilot to turn left heading 270° due to a departure of a flight of four F-35s, which were climbing through 2,200 ft, which the pilot acknowledged. At 1724:40, the controller instructed the pilot to turn left heading 240°, which the pilot read back; he also stated that he had [in sight] the last F-35 off the departure end. At 1725:30, the controller instructed the pilot to fly heading 280°, which the pilot acknowledged. The controller then advised the pilot that a flight of four F-22s would be departing runway 21 and climbing to the north. The pilot responded that he was searching. At 1726:03, the pilot asked
the controller to verify that the F-22s were departing runway 21. The controller responded affirmative and subsequently instructed the pilot to fly a heading of 310° and advised the pilot that the F-22s were departing. The pilot read back his instruction.
At 1726:54, the controller instructed the pilot to turn right heading 360°, which the pilot acknowledged. At 1727:58, the controller instructed the pilot to turn left heading 270°, which the pilot acknowledged. Five seconds later, the controller instructed the pilot, “N7GA, altitude your discretion,” which the pilot responded with his call sign. At 1729:52, the pilot stated, “we’re getting a low altitude alert for N7GA, we gotta turn left.” Shortly after, the controller instructed the pilot to “turn left heading 250°,” which the pilot acknowledged. No further communications from the pilot were received despite multiple attempts from the controller.
Recorded radar data showed a flight track consistent with communication between the pilot and the controller. From 1727:28 to 1730:14, the radar data showed the airplane on a westnorthwesterly heading at an altitude of about 6,500 ft msl, with a groundspeed varying between 161 knots and 171 knots until radar contact was lost in the area of Gass Peak.
Pilot Information
Certificate: Private
Age: 60, Male
Airplane Rating(s): Single-engine land
Seat Occupied: Unknown
Other Aircraft Rating(s): None
Restraint Used: Unknown
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 With waivers/limitations
Last FAA Medical Exam: February 22, 2019
Occupational Pilot: No
Last Flight Review or Equivalent: April 27, 2019
Flight Time: 446.7 hours (Total, all aircraft), 123.6 hours (Total, this make and model), 35.5 hours (Last 90 days, all aircraft), 7 hours (Last 30 days, all aircraft)
The pilot’s personal logbook was not located. However, a digital logbook was obtained from ForeFlight, which contained logbook entries between April 20, 1986, through November 12, 2019, for a total of 246.5 hours of flight experience. The pilot reported on his most recent Federal Aviation Administration (FAA) medical application, dated February 22, 2019, he had accumulated 446.7 hours of flight experience, of which 2.4 hours were in the previous 6 months. Additionally, the pilot and airplane were based at VGT.
Aircraft and Owner/Operator Information
Aircraft Make: Cirrus
Registration: N7GA
Model/Series: SR-22
Aircraft Category: Airplane
Year of Manufacture: 2001
Amateur Built:
Airworthiness Certificate: Normal
Serial Number: 00015
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: Unknown
Certified Max Gross Wt.: 3600 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time:
Engine Manufacturer: Continental
ELT: C126 installed, activated, did not aid in locating accident
Engine Model/Series: IO-550-N
Registered Owner:
Rated Power: 310 Horsepower
Operator: On file
Operating Certificate(s) Held: None
The airplane was equipped with an Aspen PDF1000 Pro display, which was not equipped with terrain avoidance alerts. Additionally, the airplane was equipped with a Avidyne FlightMax EX5000C multi-function color display. It was not determined if the EX5000C was configured with an optional terrain awareness warning system.
The pilot had a ForeFlight Pro Plus subscription for their electronic flight book application. Per representatives from ForeFlight, based upon his subscription, the pilot would have had access to the Hazard Advisor feature of the application, however, it would have required an Apple iPad to either have a cellular option or external GPS for location reference. The pilot also had access to the Synthetic Vision feature of the application, which would have required the use a compatible altitude and heading reference system (AHRS) device.
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual (VMC)
Condition of Light: Night/dark
Observation Facility, Elevation: KVGT, 2203 ft msl
Distance from Accident Site: 11 Nautical Miles
Observation Time: 00:53 Local
Direction from Accident Site: 184°
Lowest Cloud Condition: Clear
Visibility: 10 miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 6 knots /
Turbulence Type Forecast/Actual: None / None
Wind Direction: 110°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 29.86 inches Hg
Temperature/Dew Point: 8°C / -10°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Lake Havasu, AZ
Type of Flight Plan Filed: VFR/IFR
Destination: North Las Vegas, NV (VGT)
Type of Clearance: VFR
Departure Time: 16:43 Local
Type of Airspace: Class B
Official sunset occurred at 1627 with end of civil twilight at 1655. The moon was in a new moon phase.
Airport Information
Airport: NORTH LAS VEGAS VGT
Runway Surface Type:
Airport Elevation: 2205 ft msl
Runway Surface Condition: Unknown
Runway Used:
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: None
Wreckage and Impact Information
Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 2 Fatal
Aircraft Fire: None
Ground Injuries:
Aircraft Explosion: None
Total Injuries: 3 Fatal
Latitude, Longitude: 36.400001,-115.18083
Examination of the accident site by representatives of the FAA revealed that the airplane impacted terrain about 400 ft below the summit of Gass Peak in the vicinity of the last recorded radar target at an elevation of about 6,500 ft mean sea level. The wreckage was fragmented and mostly consumed by a postimpact fire.
Examination of the recovered airframe and engine revealed no evidence of any preexisting mechanical malfunction that would have precluded normal operation.
Additional Information
Federal Aviation Administration (FAA) order JO 7110.65Y, Air Traffic Control, paragraph 7-6-1. “Application” described basic radar services that controllers provided to a VFR aircraft.
The paragraph stated in part:
a. Basic radar services for VFR aircraft must include:
1. Safety alerts.
2. Traffic advisories.
3. Limited radar vectoring when requested by the pilot.
4. Sequencing at locations where procedures have been established for this purpose and/or when covered by a LOA [Letter of Agreement].
FAA order JO 7110.65Y, Air Traffic Control, paragraph 2-1-6, “Safety Alert,” described procedures and circumstances when controllers would provide a safety alert to a pilot.
The paragraph stated in part:
Issue a safety alert to an aircraft if you are aware the aircraft is in a position/altitude that, in your judgment, places it in unsafe proximity to terrain, obstructions, or other aircraft. Once the pilot informs you action is being taken to resolve the situation, you may discontinue the issuance of further alerts. Do not assume that because someone else has responsibility for the aircraft that the unsafe situation has been observed and the safety alert issued; inform the appropriate controller.
NOTE-1. The issuance of a safety alert is a first priority…once the controller observes and recognizes a situation of unsafe aircraft proximity to terrain, obstacles, or other aircraft. Conditions, such as workload, traffic volume, the quality/limitations of the radar system, and the available lead time to react are factors in determining whether it is reasonable for the controller to observe and recognize such situations. While a controller cannot see immediately the development of every situation where a safety alert must be
issued, the controller must remain vigilant for such situations and issue a safety alert when the situation is recognized.
Aeronautical Information Manual (AIM), paragraph 4-1-18, “Terminal Radar Services for VFR Aircraft,” described the pilot’s responsibilities when operating VFR and receiving radar services.
The paragraph stated in part:
e. PILOT RESPONSIBILITY. These services are not to be interpreted as relieving pilots of their responsibilities to see and avoid other traffic operating in basic VFR weather conditions, to adjust their operations and flight path as necessary to preclude serious wake encounters, to maintain appropriate terrain and obstruction clearance, or to remain in weather conditions equal to or better than the minimums required by 14 CFR section 91.155. Whenever compliance with an assigned route, heading and/or altitude is likely to compromise pilot responsibility respecting terrain and obstruction clearance, vortex exposure, and weather minimums, approach control should be so advised, and a revised clearance or instruction obtained.
Valeriya Anatoliivna Slyzko
Gregory Steven Akers
Nina Victorovna Morozova
Location: North Las Vegas, NV
Accident Number: WPR20FA034
Date & Time: 11/26/2019, 1730 PST
Registration: N7GA
Aircraft: CIRRUS SR-22
Injuries: 3 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal
On November 26, 2019, at 1730 Pacific standard time, a Cirrus SR22 airplane, N7GA, was destroyed when it impacted mountainous terrain about 10 nm miles north of the North Las Vegas Airport (VGT), North Las Vegas, Nevada. The private pilot and two passengers were fatally injured. The airplane was registered to Baron Von Speed LLC and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Dark night visual meteorological conditions prevailed, and a visual flight rules flight plan was filed for the cross-country flight which originated from Lake Havasu, Arizona, about 1643, with an intended destination of VGT.
Review of preliminary radar data depicted the airplane on a northwesterly heading at an altitude of 6,500 ft mean sea level (msl). The airplane maintained this altitude for most of the flight. At 1724:29, a left turn to a westerly heading was initiated, where the airplane remained for about 1 minute until it made a right turn to a northwesterly heading. About 1 minute, 18 seconds later, the airplane turned to a northerly heading for about 1 minute, 24 seconds, and subsequently returned to a northwesterly heading, where it remained until radar contact was lost 2 minutes later in the area of Gass Peak.
Examination of the accident site by representatives of the Federal Aviation Administration revealed that the airplane impacted terrain about 400 ft below the summit of Gass Peak. The wreckage was fragmented and mostly consumed by a post impact fire. The wreckage was recovered to a secure location for further examination.
Aircraft and Owner/Operator Information
Aircraft Make: CIRRUS
Registration: N7GA
Model/Series: SR-22
Aircraft Category: Airplane
Amateur Built: No
Operator: On file
Operating Certificate(s) Held: None
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual Conditions
Condition of Light: Night/Dark
Observation Facility, Elevation: KVGT, 2203 ft msl
Observation Time: 0053 UTC
Distance from Accident Site: 11 Nautical Miles
Temperature/Dew Point: 8°C / -10°C
Lowest Cloud Condition: Clear
Wind Speed/Gusts, Direction: 6 knots / , 110°
Lowest Ceiling: None
Visibility: 10 Miles
Altimeter Setting: 29.86 inches Hg
Type of Flight Plan Filed: VFR/IFR
Departure Point: Lake Havasu, AZ
Destination: North Las Vegas, NV (VGT)
Wreckage and Impact Information
Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 2 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 3 Fatal
Latitude, Longitude: 36.400000, -115.180833
Accident Number: WPR20FA034
Date & Time: 11/26/2019, 1730 PST
Registration: N7GA
Aircraft: CIRRUS SR-22
Injuries: 3 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal
On November 26, 2019, at 1730 Pacific standard time, a Cirrus SR22 airplane, N7GA, was destroyed when it impacted mountainous terrain about 10 nm miles north of the North Las Vegas Airport (VGT), North Las Vegas, Nevada. The private pilot and two passengers were fatally injured. The airplane was registered to Baron Von Speed LLC and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Dark night visual meteorological conditions prevailed, and a visual flight rules flight plan was filed for the cross-country flight which originated from Lake Havasu, Arizona, about 1643, with an intended destination of VGT.
Review of preliminary radar data depicted the airplane on a northwesterly heading at an altitude of 6,500 ft mean sea level (msl). The airplane maintained this altitude for most of the flight. At 1724:29, a left turn to a westerly heading was initiated, where the airplane remained for about 1 minute until it made a right turn to a northwesterly heading. About 1 minute, 18 seconds later, the airplane turned to a northerly heading for about 1 minute, 24 seconds, and subsequently returned to a northwesterly heading, where it remained until radar contact was lost 2 minutes later in the area of Gass Peak.
Examination of the accident site by representatives of the Federal Aviation Administration revealed that the airplane impacted terrain about 400 ft below the summit of Gass Peak. The wreckage was fragmented and mostly consumed by a post impact fire. The wreckage was recovered to a secure location for further examination.
Aircraft and Owner/Operator Information
Aircraft Make: CIRRUS
Registration: N7GA
Model/Series: SR-22
Aircraft Category: Airplane
Amateur Built: No
Operator: On file
Operating Certificate(s) Held: None
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual Conditions
Condition of Light: Night/Dark
Observation Facility, Elevation: KVGT, 2203 ft msl
Observation Time: 0053 UTC
Distance from Accident Site: 11 Nautical Miles
Temperature/Dew Point: 8°C / -10°C
Lowest Cloud Condition: Clear
Wind Speed/Gusts, Direction: 6 knots / , 110°
Lowest Ceiling: None
Visibility: 10 Miles
Altimeter Setting: 29.86 inches Hg
Type of Flight Plan Filed: VFR/IFR
Departure Point: Lake Havasu, AZ
Destination: North Las Vegas, NV (VGT)
Wreckage and Impact Information
Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 2 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 3 Fatal
Latitude, Longitude: 36.400000, -115.180833
This is just sad. Night VFR can be as bad as full IFR in the clouds. Surprised there is no flightaware track available on this one.
ReplyDeleteFly safe folks. Take-off's are optional, landings are mandatory.
DR.
Yeah and it doesn't help when ATC vectors you straight into the side of a mountain. If you read the docket, when they interviewed the controllers, they stated they had no idea of the altitude of terrain in their sector. How such a huge mistake can not even be mentioned in the main accident report is a travesty.
DeleteGreg was a very good friend. This is the first time I’ve been able to read all of this stuff. Thanks for making it available.
ReplyDeleteAllen Rockwell