Aviation Accident Summaries

Aviation Accident Summary LAX03FA298

North Las Vegas, NV, USA

Aircraft #1

N8604N

Piper PA-28R-200

Aircraft #2

N146PM

Piper PA-46-350P

Analysis

The Piper Arrow (N8604N) was landing on runway 12R and the Piper Mirage (N146PM) had started the takeoff roll on runway 7 when they collided at the intersection of the two runways. The Piper Arrow was cleared to land on runway 12R, 54 seconds before the Piper Mirage was given a takeoff clearance on the intersecting runway. During this time frame, the local controller and local assist controller were both viewing the D-Brite radar and looking out the tower cab's rear windows for a helicopter that had entered the class D airspace without authorization. With both controllers attention diverted to the helicopter, they failed to effectively monitor the runway operation and did not ensure proper separation was maintained between the two airplanes operating on the intersecting runways. Radar data indicated when the pilot of the Piper Arrow contacted the LC-1 controller and reported inbound for landing, the airplane was approximately 6 miles north-northeast of the airport and tracking a course of about 200 degrees. The airplane remained on that course, and the pilot was cleared to land when the airplane was approximately 2 1/4 miles north-northwest of the airport. About 20 seconds later the airplane began a left turn towards the airport. The airplane’s radar track indicated the pilot of the Piper Arrow flew a standard base leg to final approach, in accordance with the issued clearance. When the LC-1 controller cleared the pilot of the Piper Mirage for takeoff, the Piper Arrow was about 1 1/2 miles northeast of the airport on final to runway 12R with the data tag on the D-Brite radar showing a ground speed of 110 knots. Assuming that Piper Arrow’s ground speed remained 110 knots or less during the remainder of the approach, the airplane was about 1 minute away from touchdown. This meant that the pilot of the Piper Mirage had less than 1 minute to power up his aircraft, taxi on to runway 7, begin a departure roll, and travel about 725 feet in order to pass through the intersection of runway 12R before the Piper Arrow crossed the landing threshold for runway 12R. While this is not impossible, the minimal time available for Piper Mirage to depart before the Piper Arrow arrived warranted close monitoring by the controllers to ensure that separation was maintained at the intersection.

Factual Information

HISTORY OF FLIGHT On September 23, 2003, at 1255 Pacific daylight time, a Piper PA-28R-200 (Arrow), N8604N, and a Piper PA-46-350P Malibu Mirage (turboprop conversion) , N146PM, collided at the crossing points of runways 7 and 12R at the North Las Vegas Airport (VGT), North Las Vegas, Nevada. The Arrow was on final for runway 12R, and the Mirage had started the takeoff roll on runway 7. West Air Aviation operated the Arrow, and the pilot/owner operated the Mirage. Both airplanes were being operated under the provisions of 14 CFR Part 91. The private pilot in the Arrow and the private pilot in the Mirage both sustained serious injuries. Both airplanes sustained substantial damage. The Arrow departed St. George, Utah, at 1200, destined for North Las Vegas, and the Mirage was originating on a cross-country flight en route to Salt Lake City, Utah. Visual meteorological conditions prevailed for both flights, and no flight plans had been filed. The departing airplane (Mirage) had started the takeoff roll on runway 7. The landing airplane (Arrow) was on final approach for runway 12R, when they collided at the crossing points of the runways. The landing airplane was cleared to land on runway 12R, 54 seconds before the departing airplane on the intersecting runways. The local controller (LC-1) and local assist controller (LA-1) were both viewing the D-Brite radar and looking out the tower cabs rear windows for a helicopter that had entered the Class D airspace without authorization. At 1949:08, the pilot of N146PM contacted the VGT ground controller (GC) and advised ready to taxi. The GC controller instructed the pilot to taxi to runway 7, which he acknowledged. At 1951:17, the pilot of N8604N contacted the VGT local controller (LC-1) and advised, "we’re about six miles out inbound from due north just handed off by Nellis with [ATIS6] papa." The LC-1 controller replied, "five thousand five hundred six north," which the pilot confirmed. The LC-1 controller instructed the pilot to continue on a left base for runway 12R. The pilot acknowledged the instructions. Radar data indicated the airplane was approximately 6 miles north-northeast of VGT, tracking a course of approximately 200 degrees, ground speed was 120 knots, and the altitude was 5,500 feet. At 1953:38, the LC-1 controller contacted the pilot of N8604N and advised, "runway one two right cleared to land." The pilot acknowledged the transmission. Radar data indicated N8604N was about 2 ¼ miles north-northwest of the airport tracking a course of approximately 200 degrees at 3,500 feet. The ground speed was 110 knots. There were no further ATC communications with the pilot of N8604N. At 1953:59, radar data indicated the airplane began a left turn towards the airport. Fourteen seconds later, the last radar return for the airplane indicated N8604N was 1 ½ miles northwest of the airport at an altitude of 3,000 feet with ground speed of 110 knots. At 1954:16, the pilot of N146PM contacted the LC-1 controller and advised, "ready to go seven." The LC-1 controller replied, "Meridian six papa mike North Las Vegas tower roger runway one correction runway seven cleared for take off left turn." The pilot acknowledged the transmission. During the interview the pilot stated he was holding short of runway 7 when he acknowledged the takeoff clearance. He then powered up the aircraft and began a departure roll. At 1954:21, N8604N’s data block indicated the radar track entered "coast" status meaning the Las Vegas computer system could no longer associate the flight plan information with the radar returns. The LC-1 controller stated during the interview that at this time he was briefly engaged in a discussion with the local assist (LA-1) controller, who was positioned to his left, about a helicopter operating in close proximity to the airport. When he returned his attention back to the runways, he observed N146PM in a takeoff roll approaching the runway 12R intersection. He then began to scan the area for N8604N and observed the aircraft about to land runway 12R. Shortly thereafter, the collision occurred at the intersection of runway 7 and 12R. Facility personnel immediately initiated emergency notification procedures. National Transportation Safety Board investigators interviewed two witnesses regarding the accident. They were in their hangar listening to the local area traffic via a handheld radio. The Arrow was cleared to land on runway 12R. During this time, the Mirage was taxiing to runway 7. As the Mirage was cleared for takeoff on runway 7, the witness walked outside to view the airplane's takeoff. It started the takeoff roll for runway 7, and the Arrow was on final for runway 12R. The Arrow began to slow and entered the landing flare. The airplanes collided at the crossing point of runways 7 and 12R. As the airplanes collided, an explosion erupted and the airplanes skidded to a stop. The witnesses were questioned about their experience with air traffic control tower operations at the airport. They said that departures from runway 7 were not common, although the tower would accommodate pilots when able. They commented that the tower controller was "one of the best." PERSONNEL INFORMATION Piper Arrow Pilot Information The certificated private pilot was rated for single engine land airplanes, and held a third-class medical certificate with no restrictions. The pilot had accumulated 412 total flight hours with 26 hours in the make and model of the accident airplane. Piper Malibu Mirage Pilot Information The certificated private pilot was rated for airplane single engine land and instrument, and held a second-class medical certificate requiring corrective lenses. The pilot had accumulated 1,755 total flight hours with 88 hours in the make and model of the accident airplane. AIRCRAFT INFORMATION Piper Arrow Information At the time of the accident the airplane had accumulated 4,523 total flight hours, with 35 hours since the last documented annual inspection. Piper Malibu Mirage Information The airplane was modified with the addition of a Pratt and Whitney PT6-35 turboprop engine and had accumulated 68 hours since the conversion. The airframe accumulated 965 total flight hours as of the last documented annual inspection occurring on February 12, 2003. WRECKAGE AND IMPACT INFORMATION The Arrow came to rest on a magnetic heading of 290 degrees and was inverted. The Arrow had red and blue accent colors. Its left wing was resting on top of the left wing of the Mirage. The trailing edge of the right aileron exhibited black rub marks. The engine area sustained extensive fire damage. The Mirage came to rest on a magnetic heading of 212 degrees, east of runway 12R, and south of runway 7. A skid mark, approximately 105 feet in length, ran straight from runway 7 to the intersection of runways 7 and 12R. The entire left aileron was present at the spar end. The outer 5 feet of the left aileron skin sustained impact damage and was mostly missing. The outboard 2 feet of left aileron spar assembly exhibited red transfer signatures. Slightly aft of the pilot's side window, red and blue scratches ran perpendicular to the longitudinal axis of the airplane. The fuselage was punctured below the pilot's side window; the hole was about 1-foot in diameter. The Mirage had black deice boots on the wing leading edge. AIRPORT INFORMATION The North Las Vegas Airport is located approximately 3 miles northwest of downtown Las Vegas, Nevada, in a densely populated area. Two major thoroughfares border the airport; Interstate 15 to the east and U.S Highway 95 to the south and west. The airport is located within a valley surrounded by mountainous terrain varying from 3,000 feet to 10,000 feet. It is part of the Nevada Clark County Airport System and is considered a general aviation reliever airport for the Las Vegas McCarran International Airport (LAS). Flight operations at the airport are approximately 85 percent general aviation. Annual operations average 230,000. The airport has 3 runways, 7/25, 12R/30L, and 12L/30R. Airport elevation is 2,205 feet. Runway 12R is 5,000 feet long and 75 feet wide with no displaced threshold. Runway threshold crossing height is 25 feet. True runway heading is 134 degrees. The runway is equipped with four lighted precision approach path indicator (PAPI) lights located on the left side of the runway (3.00 degrees glide path) and touchdown aiming point markings at 1,000 feet. Runway 12R intersects runway 7 at a point about 850 feet from the approach end of the runway. Runway 7 is 5,004 feet long and 75 feet wide and intersects runway 12R at a point 650 feet from the approach end of the runway. AIR TRAFFIC CONTROL INFORMATION VGT is a Level 7 ATC tower facility. At the time of the accident, four certified professional controllers and one developmental controller were working in the tower cab. The LC-1, LA-1, and GC positions were staffed. On-the-job training (OJT) instruction was being conducted on the GC position. A controller-in-charge (CIC) was assigned to oversee the tower operation because VGT is not authorized to staff a supervisory position. The tower cab is located on the east side of the airport situated between runways 7/25 and 12L/30R. The LC-1 position is located in the northwest corner of the tower cab. The LA-1 position is located directly to the left of the LC-1 position. Facility standard operating procedures require controllers assigned to the LA-1 position to monitor the LC frequency and provide assistance to the LC controller in performing their duties. At the time of the accident, runways 7 and 12R/12L were designated as the active runways in use. Runways 12R/12L were used for both arriving and departing aircraft. Runway 7 was used only for departing aircraft. According to facility personnel, this is a commonly used runway configuration. The tower is equipped with two DBRITE displays located at the LC-1 and GC positions. The DBRITE provides the VGT tower controllers with a visual display of the airport surveillance radar/beacon signals and data that is received from the LAS ARTS IIIA system. The data is derived from the Las Vegas ASR-9 radar located approximately 8 miles south southeast of VGT. The video map presentation depicts references to VGT, VFR reporting points, and airspace boundaries for VGT, LAS, and NATCF. Radar coverage is limited below 800 feet above ground level (agl) in the vicinity of the final approach course for runway 12R due to the surrounding terrain. The tower is not equipped with an ground movement safety system. Facility personnel provide airport surveillance through visual observation. Facility runway incursion prevention strategies are highlighted in the Las Vegas HUB Operation and Administration Order, L30 7210.1D. Discrete radio communication frequencies are available at the facility for LC-1 (125.7/360.75), and GC (121.7). No radio communication frequencies are associated with the LA-1 position. During the interview of the local controller regarding his work schedule, he stated that he was exhausted from working overtime. ADDITIONAL INFORMATION The Piper Malibu Mirage pilot was credited with assisting the Piper Arrow pilot from the burning wreckage of his airplane. The Safety Board did not take possession of the wreckage from either airplane.

Probable Cause and Findings

the failure of the Federal Aviation Administration Air Traffic Control Tower local controller and local assist controller to effectively monitor the runway operation and ensure proper separation was maintained between aircraft on intersecting runways.

 

Source: NTSB Aviation Accident Database

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