Wednesday, March 16, 2022

Controlled Flight into Terrain: Cirrus SR22, N7GA; fatal accident occurred November 26, 2019 in North Las Vegas, Nevada

Gregory Steven Akers

Valeriya Anatoliivna Slyzko

Nina Victorovna Morozova
















Aviation Accident Final Report - National Transportation Safety Board

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 
Cirrus Aircraft; Duluth, Minnesota 
Continental Motors Inc; 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.

Gregory Steven Akers, age 60, passed away tragically November 26th 2019 in a plane crash on Gass Peak north of Las Vegas along with his wife Valeriya Slyzko and mother-in-law Nina Victorovna Morozova. He began his passion for flying in 1981, which led to his career as an Air Traffic Controller starting in Dallas/Ft Worth, Texas and retiring in 2015 from MaCarren International Air Port, Las Vegas, Nevada.

Gregory was born in 1959 at Shaw AFB, South Carolina. As a Military Brat he lived in Ft. Walton Beach, Florida, Tampa, Florida, Medenbach, Germany, Wiesbaden, Germany and Universal City Texas. He attended Wiesbaden Highschool and Judson Highschool. He enjoyed going back to Wiesbaden which he considered home and he travelled throughout Europe extensively. He was passionate about flying, fast cars, and photography the latter which became his profession after retiring from the FAA.

Gregory is survived by his father, William Akers; brother Jeff Akers and sister in law Terry Akers, nephew Jack Akers, ex-wife Ilia Akers, his beloved Chihuahua puppies Billy, Heidi, and Olav; numerous cousins and many, many friends who will miss him immensely.

Gregory was preceded in death by his mother Chris Akers. Mass will be held for Greg, Valeriya and Nina at 10:00 am, Friday December 20th 2019 at St Peter the Apostle, 204 South Boulder Hwy, Henderson Nevada and Memorial Service on Saturday December 21st 2019 at 2:00pm with a Missing Man Flyover at 2:30pm, at Davis Funeral Home, 6200 South Eastern Ave, Las Vegas, Nevada.

Valeriya Anatoliivna Slyzko, age 48, passed away tragically November 26th 2019 in a plane crash on Gass Peak north of Las Vegas along with her husband Greg Akers and mother Nina Victorovna Morozova. Valeriya was born in 1971 in Kadiivka City, Ukraine. She moved to Dallas, Texas in 1997 and married Greg in 1998, where they lived till moving to Henderson, Nevada in 2003.

Valeriya worked for the United States Postal Service processing office where she had many friends where all say they were blessed to have known her. She was known as a very kind person who always had a smile, who loved everybody, defended everybody and never had a bad word to say about anyone.

Valeriya is survived by her father in law, William Akers; brother in law Jeff Akers and sister in law Terry Akers, nephew Jack Akers, her beloved Chihuahua puppies Billy, Heidi, and Olav; and many, many friends who will miss her immensely. Mass will be held for Valeriya at 10:00 am, Friday December 20th 2019 at St Peter the Apostle, 204 South Boulder Hwy, Henderson Nevada and Memorial Service on Saturday December 21st 2019 at 2:00pm, at Davis Funeral Home, 6200 South Eastern Ave, Las Vegas, Nevada.

Nina Victorovna Morozova, age 71, passed away tragically November 26th 2019 in a plane crash on Gass Peak north of Las Vegas along with her daughter Valeriya Anatoliivna Slyzko and son in law Greg Akers. 

Nina was born 1948 in Ukraine. She moved to Henderson, Nevada with her daughter and son in law in 2015. She was known as a very kind person by all who knew her and her neighbors who spoke fondly of her remember her daily walks with their puppies. Mass will be held for Nina at 10:00 am, Friday December 20th 2019 at St Peter the Apostle, 204 South Boulder Hwy, Henderson Nevada and Memorial Service on Saturday December 21st 2019 at 2:00pm at Davis Funeral Home, 6200 South Eastern Ave, Las Vegas, Nevada.

11 comments:

  1. 246 hours total with 171 hours dual says a lot.

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    1. Flydoc, do tell us what exactly those numbers say to you... That the pilot had the means to seek out extra training in a desire to be as safe and proficient as possible? That he was working on additional ratings? That he sought out ample instruction in the 8 different types of aircraft listed in his logbook?

      Anyone who thinks the inclination to obtain extra training is an undesirable and negative trait for a pilot to have says a lot about how the "macho" hazardous attitude is clearly alive and well. There are plenty of "Flying Docs" with God complexes who thought they could get by with the legal minimum amount of training and instead got their obituary featured on this website.

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  2. And ATC was complicit in this unnecessary tragic accident despite what the refs say. Good grief, they vectored him into higher terrain knowing his altitude was 6,500’.

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    1. ATC is not required to insure aircraft or terrain separation services but provide advisories as necessary to flights not on an IFR flight plan. The pilot was advised, “N7GA, altitude your discretion,” and the pilot responded with his call sign. That was a tacit acknowledgement by the pilot that ATC was not dictating altitude. Gass Peak is on the sectional map, with its altitude, right where it was struck by the accident aircraft. It's a sad outcome but preventable by a cursory glance at the charts.

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    2. The truly shocking part for me was this gem that was buried in the docket but never mentioned in the final report. This is from the interview with the approach controller that was working the aircraft:

      "I did not believe the ELT could have been from N7GA because it was reported so quickly and I had just observed the aircraft at 6,800 MSL. Although the MVA in the area is 8,000 MSL, I did not believe that the aircraft was at an unsafe altitude because regulations dictate that MVAs in mountainous areas are 2,000 feet above the highest obstacle."

      So essentially the controller had NO CLUE what the terrain elevation was in the area he was responsible for and just assumed it must be below 6,000 MSL due to the MVA. Yet somehow the NTSB places 100% of the blame on the pilot and makes no recommendation about:
      1. Training controllers about the terrain in their sector.
      2. Depicting Gass peak on ATC scopes.
      3. Increasing the MVA around Gass peak so it is actually 2,000 feet above terrain.
      4. Implementing a MSAW system to prevent future accidents.

      Compare this to the 2004 NTSB report about N30DK where a controller also vectored a VFR aircraft into terrain at night. In that report, the NTSB stated:

      "The controller’s explanation that he was not required to monitor or provide terrain clearance assistance to a VFR flight is contrary to the primary purposes of ATC, which are to prevent a collision and to remain vigilant for situations that warrant the issuance of alerts to flight crews regarding hazardous proximity to terrain, obstacles, and other aircraft. The controller’s apparent perception that flight crews operating under VFR are always able to avoid terrain and obstacles regardless of flight conditions is incorrect, and his failure to take appropriate action placed the airplane in an unsafe situation. The controller had the knowledge and opportunity to alert the flight crew to an unsafe condition, but he failed to do so. "

      So why is the NTSB letting ATC completely off the hook in this case where arguably this single private pilot made less mistakes than the two commercially rated pilots aboard N30DK did?

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    3. Excellent point. I have no read the full report and I obviously don't know all of the details that went into this investigation. But it would seem that either the controller has some unknown influence with a government or political entity that got him off the hook, or he successfully BS'd his way through his interview with the NTSB.

      And if his comments cited above are any indication, it's probably the latter. His explanation comes off much differently than that of the controller in the 2004 accident, who all but admits he did not know his responsibilities.

      Either way, it seems highly irregular that the controller's actions were not cited as a contributory cause or, at the very least, that his performance was not criticized or questioned.

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    4. Rob, you make a good point, and I think it's a bit of both. The controller in this accident was a military controller at Nellis, whereas the controller in the 2004 accident was a FAA civilian controller. It is seemingly harder to hold military controllers responsible in accidents where only civilians are killed.

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  3. Im an IFR student, 650+ tt pilot, when I practice Instrument approaches one should always brief the plate.... the ILS for 12L at KVGT MSA for the northern quadrant is 11,000 feet. The western MSA is 13,200. so sad the loss to this familly and to our GA community.

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  4. Interestingly, this is not the first time ATC has fatally vectored a VFR aircraft right into the side of Gass Peak at night. On October 14, 1999, N1024B departed KVGT and was given a suggested heading by ATC to stay out of the Bravo that led them to smash right into Gass Peak.

    Even more interesting was that in that report, the NTSB actually did partially blame ATC, saying "Contributing factors were the improper issuance of a suggested heading by air traffic control personnel, inadequate flight progress monitoring by radar departure control personnel, and failure of the radar controller to identify a hazardous condition and issue a safety alert."

    So if in 1999, ATC gives an aircraft a suggested heading, later queries them about it and fails to stop them from hitting the side of a mountain, they are partially at fault, but in 2019, ATC gives an aircraft in the Bravo a mandatory heading towards the same mountain and never says anything and has no clue about the terrain in their sector, they are somehow completely not at fault? How does that NTSB logic work?

    Considering how the NTSB thought everything that ATC did for N7GA was fine per the report, sadly this will almost definitely not be the last time a VFR aircraft in the Las Vegas area gets accidentally vectored into Gass Peak.

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    1. Seems like "altitude at pilot's discretion" diverted the investigation from examining the terrain related implications of how the trainee chose headings.

      "Attachment 4 Controllers Statements" in the docket details on sheet one and two that a trainee (designated RD) was being mentored. The function of the *T selection may need to be examined, as there may not have been any positional altitude smarts built into that function:

      "N7GA was given a turn back to the west to set up for the ILS approach. When discussing vectoring N7GA for the approach, RD used the *T function which allowed him to see a heading to issue to N7GA. As we were discussing the heading, N7GA made a transmission of which the only word I understood or heard was “TERRAIN.”

      https://data.ntsb.gov/Docket/Document/docBLOB?ID=12410806&FileExtension=pdf&FileName=Attachment%204%20%20Controllers%20Statements-Rel.pdf

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  5. A photo of the pilot's setup in his SR22:
    https://www.instagram.com/p/B4JH1EPhJCh/

    The pilot worked as an ATC controller at the Las Vegas tower for a period of time.

    A memorial for those on board who perished:
    http://baronvonspeed.com/?page_id=2380

    Rest in peace...

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