North Las Vegas

The commercial pilot and private-rated copilot on board the low-wing airplane were performing a visual approach to their home airport at the end of an instrument-flight-rules flight. They were instructed by the approach controller to cross the destination airport over midfield and enter the left downwind leg of the traffic pattern for landing on runway 30L. Meanwhile, the flight instructor and student pilot on board the high-wing airplane were conducting takeoffs and landings in the right traffic pattern for runway 30R and were cleared to conduct a short approach for landing on runway 30R. Upon contacting the airport tower controller, the crew of the low-wing airplane was instructed to proceed to runway 30L, and the copilot acknowledged. The controller subsequently confirmed the landing approach to runway 30L, and the copilot again acknowledged with a correct readback of the landing clearance. Automatic Dependent Surveillance-Broadcast (ADS-B) flight track data indicated that, after crossing over the runway, the low-wing airplane performed a continuous, descending turn through the final approach path for runway 30L and rolled out aligned with the final approach path for runway 30R. The airplanes collided about ¼ nautical mile from the approach end of the runway. Although day visual meteorological conditions prevailed at the airport at the time of the accident, a visibility study determined that it would have been difficult for the pilots of the two airplanes to see and avoid one another given the size of each airplane in the other’s windscreen and the complex backgrounds against which they would have appeared. The pilot of the low-wing airplane would likely have had to move his head position in the cockpit (e.g., by leaning forward) in order to see the approach ends of the runways during most of the turn. If looking in the direction of the runways, he would have been looking away from the direction of the oncoming high-wing airplane, which was also obscured from view by aircraft structure during a portion of the turn, likely including the final seconds before the collision. The visibility study indicated that sun glare was not likely a factor. The high-wing airplane was not equipped with a cockpit display of traffic information (CDTI). The low-wing airplane was equipped with a CDTI, which may have generated a visual and aural traffic alert concerning the high-wing airplane before the collision; however, this may not have provoked concern from the flight crew, since other aircraft are to be expected while operating in the airport traffic pattern environment. The circumstances of this accident underscored the difficulty in seeing airborne traffic (the foundation of the “see and avoid” concept in visual meteorological conditions), even when pilots might be alerted to traffic in the vicinity by equipment such as CDTI. Given the low-wing airplane pilots’ familiarity with the airport, it is unlikely that they misidentified the intended landing runway; however, it is possible that they were unfamiliar with their issued instructions to overfly the airport and join the traffic pattern, as this was a fairly new air traffic control procedure for routing inbound traffic to the airport that had been implemented on a test basis, for a period of about one week, about two months before the accident. Their lack of familiarity with the maneuver may have resulted in a miscalculation that resulted in the airplane rolling out of turn farther to the right of runway 30L than expected. A performance study indicated that, during the turn to final approach, the airplane was between 38 knots (kts) and 21 kts faster than its nominal landing approach speed of 85 kts. This excess speed may have contributed to the pilots’ alignment with runway 30R instead of runway 30L. Analysis of the turn radius required to align the airplane with runway 30L indicated a required roll angle of between 32° and 37° at the speeds flown; at 85 kts. While the wrong runway line up by the low-wing airplane may have been the crew’s misidentification of the runway to which they were cleared to land, it may also have been a miscalculation in performing a maneuver that was relatively new and that they may have never conducted before. Thus, resulting in a fast, short, and tight continuous descending turn to final that rolled them out farther right than expected. The high-wing configuration of the Cessna in a right turn to final, and the low-wing configuration of the Piper in a left turn to final, only exacerbated the conflict by reducing the ability of the pilots to see the other aircraft. The pilot of the low-wing airplane had cardiovascular disease that increased his risk of experiencing an impairing or incapacitating medical event, such as arrhythmia or stroke. Although such an event does not leave reliable autopsy evidence if it occurs just before death, given that the airplane was in controlled flight until the collision, and had two pilots on board, one of whom was communicating with air traffic control, it is unlikely that an incapacitating medical event occurred. The pilot also had advanced hearing impairment, which may have made it more difficult for him to discern speech; however, the circumstances of the accident are not consistent with a pilot comprehension problem; the crew correctly read back the instruction to land on runway 30L. Whether the pilot’s hearing loss impacted his ability to detect cues such as the high-wing airplane’s landing clearance to the parallel runway or a possible CDTI aural alert could not be determined based on the available information. Although both the pilot and copilot’s ages and medical conditions were risk factors for cognitive impairment, there was no specific evidence available to suggest that either of the pilots on board the low-wing airplane had cognitive impairment that contributed to the accident. Autopsy of the flight instructor on board the high-wing airplane identified some dilation of his heart ventricles; while this may have been associated with increased risk of an impairing or incapacitating cardiovascular event, given the circumstances of the accident, it is unlikely that such an event occurred. The instructor also had hydronephrosis of the left kidney, with stones in the left renal pelvis. This may have been asymptomatic (kidney stone pain typically is associated with passage of a stone through the ureter, not with stones in the renal pelvis). The instructor’s vitreous creatinine and potassium elevation cannot be clearly attributed to hydronephrosis of a single kidney. Additionally, the instructor was producing urine and had no elevation of vitreous urea nitrogen. The vitreous chemistry results should be interpreted cautiously given the extent of thermal injury. The instructor’s heart and kidney issues are unlikely to have affected his ability to see and avoid the other airplane. The student pilot on board the high-wing airplane also had heart disease identified at autopsy, including moderate coronary artery disease and an enlarged heart with dilated ventricles. While his heart disease was associated with increased risk of an impairing or incapacitating cardiovascular event, given the circumstances of the accident, it is unlikely that such an event occurred. The student pilot’s vitreous chemistry test indicated hyponatremic dehydration; however, it is unlikely that dehydration contributed to the accident. The controller did not issue traffic advisory information to either of the airplanes involved in the collision at any time during their respective approaches for landing, even though the lowing airplane crossed about 500 ft over the high-wing airplane as it descended over the airport toward the downwind leg of the traffic pattern. His reasoning for not providing advisories to the airplanes as they entered opposing base legs was that he expected the high-wing airplane to be over the runway numbers before the low-wing airplane would be able to visually acquire it; however, this was a flawed expectation that did not account for the differences in airplane performance characteristics. After clearing both airplanes for landing, he communicated with two uninvolved aircraft and did not monitor the progress of the accident airplanes to the two closely-spaced parallel runways. This showed poor judgement, particularly given that in the months before the accident, there had been a series of events at the airport in which pilots had mistakenly aligned with, landed on, or taken off from an incorrect runway. Interviews with personnel at the air traffic control tower indicated that staffing was deficient, and most staff were required to work mandatory overtime shifts, reaching an annual average of 400 to 500 hours of overtime per controller. According to the air traffic manager (ATM), the inadequate staffing had resulted in reduced training discissions, and the management team was unable to appropriately monitor employee performance. The ATM stated that everyone on the team was exhausted, and that work/life balance was non-existent. It is likely that the cumulative effects of continued deficient staffing, excessive overtime, reduced training, and inadequate recovery time between shifts took a considerable toll on the control tower workforce.

The pilot receiving instruction conducted three full-stop landings without incident. After the fourth takeoff, the flight instructor simulated a prearranged left engine failure about 600 ft above ground level (agl). The pilot followed emergency procedures, used the checklist, and prepared to land. The pilot reported that, when the airplane was about 50 to 100 ft agl on final approach, he thought that it was a little too high, so he chose to initiate a go-around. He moved the throttle levers full forward, but neither engine responded. The flight instructor pushed the airplane's nose down, and the pilot continued the approach. On touchdown, the right main and nose landing gear collapsed. A postimpact fire ensued, which consumed most of the airplane. Postaccident examination of the landing gear revealed that it collapsed due to bending overload consistent with a hard landing. The reason for the failure of both engines to respond to power inputs could not be determined because of the postcrash fire damage.

The pilot reported that, immediately after touchdown, the airplane began “wavering” and moments later veered to the left. He attempted to regain directional control with the application of “full right rudder” and the airplane subsequently departed the right side of the runway. A witness reported that the airplane’s touchdown was “firm” but not abnormal. As the airplane approached the left side of the runway, it yawed right and skidded down the runway while facing right. As the airplane began moving to the right side of the runway, the witness heard the right engine increase to near full power. The airplane spun to the left, coming to rest facing the opposite direction from its approach to landing. Another witness reported seeing the propellers contact the ground. The pilot attributed the loss of directional control to a main landing gear malfunction. Post accident examination of the airplane revealed that the left propeller assembly was feathered and that the right propeller blades were bent forward, indicative of the right engine impacting terrain under high power. Both throttle levers were found in the aft/closed position, and both propeller control levers were in the full-forward position. The propeller control levers exhibited little friction and could be moved with pressure from one finger. The evidence suggested that the pilot inadvertently feathered the left propeller assembly during the accident sequence. The pilot did not report any pre accident malfunctions or failures with the airplane’s engines or propeller assemblies that would have precluded normal operation.

Radar data indicated that the airplane departed for a cross-country flight, climbed to a cruise altitude of 9,700 feet msl, and maintained a northeasterly course of 050 degrees magnetic direct to its destination. About 11 minutes after takeoff, the airplane entered a 1,000 foot-per-minute descent. The airplane continued to descend at this rate until it impacted terrain at an elevation of 4,734 feet. Examination of the accident site revealed that the airplane was still on its northeasterly course towards the destination at impact. Ground scars at the initial point of impact were consistent with the airplane being wings level in a slight nose-down pitch attitude. No mechanical anomalies with the airplane or engine were identified during the airplane wreckage examination. A postimpact fire destroyed all cockpit instrumentation, and no recorded or stored flight data could be recovered. Weather conditions at the time were clear, and light winds. The pilot had some moderate heart disease that was noted during the autopsy. He also had a history of stress and insomnia, which was documented in his FAA medical records. Toxicology findings noted the use of a sedating and impairing over-the-counter medication (chlorpheniramine) that was taken at some undetermined time prior to the accident. The investigation could not conclusively determine whether the pilot’s conditions or medication use were related to the accident. The reason for the airplane’s descent to ground impact could not be determined.

According to radar and Global Positioning System data, the pilot overflew the airport from the southwest and turned to the west to maneuver into position for landing on runway 9. Several witnesses observed the airplane to the west of the airport at a low altitude, appearing to enter a turn that was followed by a "rapid descent" and impact with the ground. The ground scars and
damage to the airplane were consistent with a near-vertical descent and impact. An examination of the airplane and its systems revealed no preaccident anomalies. The moon was obscured by an overcast sky and dark night conditions were prevalent.

During climb a few minutes after takeoff, a fire erupted in the airplane's right engine compartment. About 7 miles from the departure airport, the pilot reversed course and notified the air traffic controller that he was declaring an emergency. As the pilot was proceeding back toward the departure airport witnesses observed fire beneath, and smoke trailing from, the right engine and heard boom sounds or explosions as the airplane descended. Although the pilot feathered the right engine's propeller, the airplane's descent continued. The 12-minute flight ended about 1.25 miles from the runway when the airplane impacted trees and power lines before coming to rest upside down adjacent to a private residence. A fuel-fed fire consumed the airframe and damaged nearby private residences. The airplane was owned and operated by an airplane broker that intended to have it ferried to Korea. In preparation for the overseas ferry flight, the airplane's engines were overhauled. Maintenance was also performed on various components including the engine-driven fuel pumps, turbochargers, and propellers. Nacelle fuel tanks were installed and the airplane received an annual inspection. Thereafter, the broker had a ferry pilot fly the airplane from the maintenance facility in Ohio to the pilot's Nevada-based facility, where the ferry pilot had additional maintenance performed related to the air conditioner, gear door, vacuum pump, and idle adjustment. Upon completion of this maintenance, the right engine was test run for at least 20 minutes and the airplane was returned to the ferry pilot. During the following month, the ferry pilot modified the airplane's fuel system by installing four custom-made ferry fuel tanks in the fuselage, and associated plumbing in the wings, to supplement the existing six certificated fuel tanks. The ferry pilot held an airframe and powerplant mechanic certificate with inspection authorization. He reinspected the airplane, purportedly in accordance with the Piper Aircraft Company's annual inspection protocol, signed the maintenance logbook, and requested Federal Aviation Administration (FAA) approval for his ferry flight. The FAA reported that it did not process the first ferry pilot's ferry permit application because of issues related to the applicant's forms and the FAA inspector's workload. The airplane broker discharged the pilot and contracted with a new ferry pilot (the accident pilot) to immediately pick up the airplane in Nevada and fly it to California, the second ferry pilot's base. The contract specified that the airplane be airworthy. In California, the accident pilot planned to complete any necessary modifications, acquire FAA approval, and then ferry the airplane overseas. The discharged ferry pilot stated to the National Transportation Safety Board (NTSB) investigator that none of his airplane modifications had involved maintenance in the right engine compartment. He also stated that when he presented the airplane to the replacement ferry pilot (at most 3 hours before takeoff) he told him that fuel lines and fittings in the wings related to the ferry tanks needed to be disconnected prior to flight. During the Safety Board's examination of the airplane, physical evidence was found indicating that the custom-made ferry tank plumbing in the wings had not been disconnected. The airplane wreckage was examined by the NTSB investigation team while on scene and following its recovery. Regarding both engines, no evidence was found of any internal engine component malfunction. Notably, the localized area surrounding and including the right engine-driven fuel pump and its outlet port had sustained significantly greater fire damage than was observed elsewhere. According to the Lycoming engine participant, the damage was consistent with a fuel-fed fire originating in this vicinity, which may have resulted from the engine's fuel supply line "B" nut being loose, a failed fuel line, or an engine-driven fuel pumprelated leak. The fuel supply line and its connecting components were not located. The engine-driven fuel pump was subsequently examined by staff from the NTSB's Materials Laboratory. Noted evidence consisted of globules of resolidified metal and areas of missing material consistent with the pump having been engulfed in fire. The staff also examined the airplane. Evidence was found indicating that the fire's area of origin was not within the wings or fuselage, but rather emanated from a localized area within the right engine compartment, where the engine-driven fuel pump and its fuel supply line and fittings were located. However, due to the extensive pre- and post-impact fires, the point of origin and the initiating event that precipitated the fuel leak could not be ascertained. The airplane's "Pilot Operator's Handbook" (POH), provides the procedures for responding to an in-flight fire and securing an engine. It also provides single-engine climb performance data. The POH indicates that the pilot should move the firewall fuel shutoff valve of the affected engine to the "off" position, feather the propeller, close the engine's cowl flaps to reduce drag, turn off the magneto switches, turn off the emergency fuel pump switch and the fuel selector, and pull out the fuel boost pump circuit breaker. It further notes that unless the boost pump's circuit breaker is pulled, the pump will continuously operate. During the wreckage examination, the Safety Board investigators found evidence indicating that the right engine's propeller was feathered. However, contrary to the POH's guidance, the right engine's firewall fuel shutoff valve was not in the "off" position, the cowl flaps were open, the magneto switches were on, the emergency fuel pump switches and the fuel selector were on, and the landing gear was down. Due to fire damage, the position of the fuel boost pump circuit breaker could not be ascertained. Calculations based upon POH data indicate that an undamaged and appropriately configured airplane flying on one engine should have had the capability to climb between 100 and 200 feet per minute and, at a minimum, maintain altitude. Recorded Mode C altitude data indicates that during the last 5 minutes of flight, the airplane descended while slowing about 16 knots below the speed required to maintain altitude.

The airplane descended into the ground during takeoff-initial climb on a local fire reconnaissance flight. Witnesses reported that airplane became airborne, but was not climbing, and it continued down the runway in a nose-up attitude in ground effect until impacting terrain about 600 feet southeast from the departure end of the runway. The ambient temperature was about 107 degrees Fahrenheit, and the density altitude was calculated at 5,878 feet mean sea level. On scene examination found the flaps in the 30-degree position, which also corresponded to the flap actuator position. The cockpit indicator for the flaps also showed a 30-degree extension. A subsequent bench test of the combined flap/gear selector valve was conducted. During the initial inspection, both the gear selector and the flap selector valves were bent, but otherwise operational. The "stop-pin" on the flap selector lever was missing. There was no leakage of fluid during this test. Examination of both engines revealed no abnormalities, which would prevent normal operations. The aircraft flight manual specifies that the flaps should be set at 1/4 down (10 degrees) for normal takeoff.

The passenger flying the airplane made a hard landing after the pilot had experienced an incapacitating cardiac event. Shortly after takeoff the pilot turned the plane around to return to the departure airport. He started coughing and then went unconscious. The passenger in the right seat, who had no piloting experience, took control of the airplane and made several landing attempts. During the fourth landing attempt he stalled the airplane at a low altitude. The airplane impacted terrain, landing flat on its belly a few hundred feet short of the runway. The autopsy report attributed the pilot's cause of death to arteriosclerotic cardiovascular disease.

The airplane overran the runway after landing on runway 7. The passenger stated that he felt that the approach was "fast" and that the pilot was "behind the power curve" because of high
minimum en route altitudes in the area and that they had to "hustle down" during the descent. The passenger indicated that the flight crossed the runway threshold "maybe a bit more" that 10 knots above Vref and touched down about 10 knots above Vref. He said it was not a stabilized approach. Landing distance calculations and other evidence suggest that the lift dump panels did not extend after landing; however, the investigation did not determine the reason(s) for the lack of lift dump. No evidence was found of any failures affecting the lift dump or braking systems. Evidence and interview statements reveal that the pilot flew an unstabilized approach to the runway and landed well above target speed. The high landing speed was result of the pilot's excessive airspeed on the approach and a tailwind component of about 8 knots. Although the pilot landed the airplane within the touchdown area, the airplane's speed upon touchdown was about 17 knots above the prescribed speed. The flight's unstabilized approach and excessive speed should have prompted the pilot to initiate a missed approach.

The airplane collided with mountainous terrain during climb to cruise on a night departure. The pilot of the on-demand cargo flight was brought in off reserve to replace the scheduled pilot who was ill. The flight was behind schedule because the cargo was late. When the instrument flight release created further delay, the pilot opted to depart into the clear, dark night under visual flight rules (VFR) with the intention of picking up his instrument clearance when airborne. When clearing the flight for takeoff, the tower controller issued a suggested heading of 340 degrees, which headed the aircraft toward mountainous terrain 11 miles north of the airport. The purpose of the suggested heading was never stated to the pilot as required by FAA Order 7110.65L. After a frequency change to radar departure control, the controller asked the pilot 'are you direct [the initial (route) fix] at this time?' and the pilot replied, 'we can go ahead and we'll go direct [the initial fix].' A turn toward the initial fix would have headed the aircraft away from high terrain. The controller then diverted his attention to servicing another VFR aircraft and the accident aircraft continued to fly heading 340 degrees until impacting the mountain. ATC personnel said the 340-degree heading was routinely issued to departing aircraft to avoid them entering Class B airspace 3 miles from the airport. The approach control supervisor said this flight departs daily, often VFR, and routinely turns toward the initial fix, avoiding mountainous terrain. When the pilot said that he would go to the initial fix, the controller expected him to turn away from the terrain. Minimum Safe Altitude Warning (MSAW) was not enabled for the flight because the original, instrument flight plan did not route the aircraft through this approach control's airspace and the controller had not had time to manually enter the flight data. High terrain was not displayed on the controller's radar display and no safety alert was issued.