North Las Vegas

On July 17, 2022, about 1204 pacific daylight time, a Piper PA-46-350P airplane, N97CX, and a Cessna 172N airplane, N160RA, were destroyed when they were involved in an accident near Las Vegas, Nevada. The two pilots in the PA-46, and the flight instructor and student pilot in the Cessna 172, were fatally injured. The PA-46 was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight, and the Cessna 172 was operated as a Title 14 CFR Part 91 instructional flight. Both airplanes were maneuvering to land at North Las Vegas Airport (VGT), Las Vegas Nevada, when the accident occurred. N97CX had been instructed by air traffic control (ATC) to fly left traffic for runway 30L and N160RA had been instructed to fly right traffic for runway 30R. The airplanes collided about 0.25 nautical miles from the approach end of runway 30R. Figure 1 shows a simplified flight path diagram for the accident flights based on Federal Aviation Administration Automatic Dependent Surveillance – Broadcast (ADS-B) data. N97CX was operating as an instrument flight rules (IFR) flight and had departed from Coeur d'Alene Airport - Pappy Boyington Field (COE), Coeur d'Alene, Idaho about 0943, destined for VGT. N160RA was operating as a visual flight rules (VFR) training flight at VGT. N160RA was in the VFR traffic pattern for runway 30R, flying a right-hand traffic pattern and communicating with the VGT local controller. N97CX was inbound from the north on an IFR flight plan from COE. At 1156:08, the Nellis Radar Approach Control air traffic controller cleared N97CX for the visual approach and instructed the pilot to overfly VGT at midfield for left traffic to runway 30L. Air traffic control responsibility for the flight was transferred from Nellis Radar Approach Control to VGT at 1158:26. At 1158:43, the pilot of N97CX contacted the VGT local controller and reported “descending out of 7,600 feet msl for landing on three zero left and ah Nellis said to cross midfield.” The VGT local controller responded, “continue for three zero left.” The pilot acknowledged and stated, “okay continue for runway three zero left nine seven charlie x-ray we will cross over midfield.” At 1200:03, the pilot of N160RA requested a “short approach.” The VGT local controller transmitted “zero romeo alpha short approach approved runway three zero right cleared for the option,” which was acknowledged by N160RA. This information is preliminary and subject to change. At 1201:36, the VGT local controller transmitted “november seven charlie x-ray runway three zero left cleared to land.” The pilot of N97CX responded “three zero left cleared to land nine seven charlie x-ray.” At 1201:57, the VGT local controller transmitted “seven charlie x-ray I think I said it right runway three zero left seven charlie x-ray runway three zero left.” At 1202:02 the pilot of N97CX transmitted “yeah affirmative runway three zero left that’s what i heard nine seven charlie x-ray”. There were no further transmissions from either airplane. Examination of N97CX revealed that the airplane impacted in a nose low, right wing down attitude. The landing gear was down, and the right main landing gear was displaced outboard. The right wing displayed an impact separation around wing station (WS) 93. The right inboard wing section remained attached to the fuselage but was canted aft. The right wing flap was fractured about midspan; the inboard section remained attached to the wing and was found in the extended position. The outboard half of the flap was found about 10 ft forward of the right wing. The right wing leading edge displayed a series of crush impressions to the leading edge about 2.5 ft outboard of the wing root. The impressions contained flakes of green primer, and cuts to the de-ice boot. The outboard right wing section remained attached to the inboard wing by the aileron control cables. The aileron remained attached to the outboard wing section but was impact damaged. The outboard leading edge was crushed up and aft. The right wingtip fairing and pitot tube were also impact separated. Longitudinal scratches were visible along the right side of the fuselage. Examination of N160RA revealed that, the airplane had impacted terrain in a left-wing and nose-low attitude before coming to rest inverted on a 304°magnetic heading. Both inboard portions of the wings sustained thermal damage in the areas surrounding the fuel tanks, and the cabin and fuselage, except for the cabin roof, were consumed by a post-impact fire. Blue paint transfer was observed on the lower surface of the separated outboard left wing and the lower surface of the left wing flap. Black de-ice boot material transfer was observed on the lower surface of the separated outboard left wing, the lower surface of the attached portion of the left wing at approximately WS 100, and for an approximate 5 ft long distance outboard of the strut attach point, along the lower leading edge. About 4 ft of the left wing, which included the left aileron, was separated from the left wing, and was found on the edge of a culvert just south of the main wreckage. The left outboard wing section aft of the forward spar was found to be separated near the aileron-flap junction. The left wing flap was found to be separated from the wing.

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.