National Transportation Safety Board

Aviation Accident Final Report

Location: North Las Vegas, Nevada Accident Number: WPR20FA034

Date & Time: November 26, 2019, 17:30 Local Registration: N7GA
Aircraft: Cirrus SR-22 Aircraft Damage: Destroyed
Controlled flight into terr/obj
Defining Event: Injuries: 3 Fatal
(CFIT)
Flight Conducted
Part 91: General aviation - Personal
Under:

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

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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

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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.

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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 west-
northwesterly 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

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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 Engine Model/Series: IO-550-N
not aid in locating accident
Registered Owner: Rated Power: 310 Horsepower
Operator: On file Operating Certificate(s) None
Held:

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.

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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 None / None
Forecast/Actual:
Wind Direction: 110° Turbulence Severity N/A / N/A
Forecast/Actual:
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 Unknown
Condition:
Runway Used: IFR Approach: None
Runway VFR Approach/Landing: None
Length/Width:

Wreckage and Impact Information

Crew Injuries: 1 Fatal Aircraft Damage: Destroyed
Passenger 2 Fatal Aircraft Fire: None
Injuries:
Ground Injuries: Aircraft None
Explosion:
Total Injuries: 3 Fatal Latitude, 36.400001,-115.18083
Longitude:

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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.

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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.

Administrative Information
Investigator In Charge (IIC):
Additional Participating
Persons:
Original Publish Date:
Note:
Investigation Docket:
Cawthra, Joshua
John C Waugh; Federal Aviation Administration; Las Vegas, NV
Brad Miller; Cirrus Aircraft; Duluth, MN
Chris Lang; Continental Motors; Mobile, AL
March 9, 2022 Investigation Class: 3
https://data.ntsb.gov/Docket?ProjectID=100631

The National Transportation Safety Board (NTSB), established in 1967, is an

independent federal agency mandated by Congress through the
Independent Safety Board Act of 1974 to investigate transportation
accidents, determine the probable causes of the accidents, issue safety
recommendations, study transportation safety issues, and evaluate the
safety effectiveness of government agencies involved in transportation. The
NTSB makes public its actions and decisions through accident reports,
safety studies, special investigation reports, safety recommendations, and
statistical reviews.

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b),

precludes the admission into evidence or use of any part of an NTSB report
related to an incident or accident in a civil action for damages resulting from
a matter mentioned in the report. A factual report that may be admissible
under 49 U.S.C. § 1154(b) is available here.

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