# NTSB LAX00FA014: Piper PA-31-350, N1024B, North Las Vegas, NV, October 15, 1999 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: October 14, 1999, 19:46 local (Oct 15, 1999, 02:46 UTC) - Place: North Las Vegas, NV - Coordinates: 36.220691, -115.170143 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.2207&lon=-115.1701&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report April 6, 2001 - Report: Approved by Office Director - NTSB case key (mKey): 47584 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX00FA014 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/47584/pdf - Page: https://openairdocs.org/ntsb/LAX00FA014 ## Probable cause The failure of the pilot-in-command to maintain separation from terrain while operating under visual flight rules. 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. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, climb - to cruise - terrain condition - mountainous/hilly - light condition - dark night - altitude/clearance - not obtained/maintained, pilot in command (cause) - atc clearance - improper, atc personnel(lcl/gnd/clnc) (contributing factor) - monitoring - inadequate, atc personnel(dep/apch) (contributing factor) - safety advisory - not issued, atc personnel(dep/apch) (contributing factor) ## Analysis 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. ## Factual narrative HISTORY OF FLIGHT On October 14, 1999, at 1946 hours Pacific daylight time, a Piper PA-31-350, N1024B, was destroyed by impact with mountainous terrain 11 miles north of North Las Vegas, Nevada. The airline transport pilot, the sole occupant, was fatally injured. The aircraft, transporting banking paperwork, was operated under the provisions of 14 CFR Part 135 by Ameriflight, Inc., as Flight 121, a nonscheduled on-demand cargo flight destined for Sacramento, California. An instrument flight plan was filed; however, the flight departed VFR from the North Las Vegas airport at 1941, and was operating under visual flight rules at the time of the accident. Night, visual meteorological conditions prevailed. The operator reported that the outbound freight, approximately 300 pounds of bank paperwork, arrived at the North Las Vegas airport about 1 hour late and the flight was departing behind schedule. Because his instrument flight release was not available when he was ready for takeoff, the pilot elected to depart under visual flight rules with the intention of picking up the flight's instrument clearance when airborne. Before issuing takeoff clearance, North Las Vegas Air Traffic Control Tower instructed the pilot to reset his transponder to a VFR code and issued a recommended heading after takeoff of 340 degrees. After takeoff on runway 7, the aircraft was observed to turn left and depart the airport area to the north in the direction of the accident site. The pilot was in radio and radar contact with Nellis approach control at the time radar contact was lost near the accident site. Local law enforcement pilots, patrolling the city in a helicopter, reported that the night was very dark with only a small (new) moon visible to the southwest. Gass Peak and the adjacent ridgeline were not visible in the night sky. As they were patrolling, they saw the bright flash of the fire when the aircraft impacted the mountain, and proceeded to the location. Their helicopter was equipped with a FLIR (forward looking infrared sensor), which they employed to locate the ridgeline. Recorded radar data was provided by Nellis ATCF, and was plotted onto a visual navigation chart by the Safety Board investigator (attached). The data shows the aircraft flying approximately a 340-degree course from the departure end of runway 7 to the accident site. The Las Vegas Class B airspace overlies the flight path and the terrain rises north of North Las Vegas. PERSONNEL INFORMATION The pilot was hired by Ameriflight in January 1999, and completed his most recent 14 CFR Part 135 check ride in the Piper PA-31-350 on June 25, 1999. He had been employed from June 1998 to January 1999 with a Grand Canyon tour operator, and flew in the Las Vegas area before being hired by the current operator. According to Ameriflight, the pilot had flown 176 hours in the last 90 days, including 24 at night. He had flown one daytime trip into North Las Vegas in the same period. According to the operator, the pilot who was scheduled to fly Flight 121 called in ill and unable to fly. The pilot involved in the accident was assigned from the evening reserve staff. The pilot was on evening reserve the previous day also, and was on stand-by at the operator's Burbank, California, facility from 1500 to 2300; however, no flying requirement developed that evening. The pilot was released at 2300 and had 16 hours off-duty time available for rest. The following day, the day of the accident, the dispatcher called the pilot at home about 1230 and told him to expect to come to Burbank at 1500 and then travel by commercial airline to Las Vegas to fly Flight 121. The pilot's father spoke with him by telephone about 1330 on the day of the accident. He said that his son told him he had walked his dog and was now going to Las Vegas to fly the trip. He made no comment about any reservations regarding flying the trip and seemed to be in good spirits and good health. AIRCRAFT INFORMATION According to the operator, the aircraft was dispatched with no deferred maintenance items (squawks). METEOROLOGICAL INFORMATION The scheduled weather observation taken at 1947 at North Las Vegas was clear skies and visibility 10 miles. A sun and moon illumination computer program used by the Safety Board calculated that, at the time of the accident, the sun was 19.7 degrees below the horizon on a bearing of 261.3 degrees (magnetic) from the accident site, and the moon was 19.3 degrees above the horizon on a bearing of 212 degrees. The moon's illumination was 27 percent of full moon illumination. The program makes no allowance for the shadowing effect of mountainous terrain to the west and southwest (non-level horizons). COMMUNICATIONS According to communications transcripts provided by North Las Vegas Tower, the pilot contacted ground control at 1853 and was issued an instrument clearance to Sacramento via the published instrument departure procedure and the flight planned route. The flight was originally cleared to maintain 4,000 feet and was to expect clearance to 12,000 feet 10 minutes after departure. At the pilot's request, the controller read the text of the published instrument departure. According to the operator, the initial fix on the company (canned) flight plan is the Beatty (Nevada) VORTAC located 83 miles west (280 degrees magnetic) of North Las Vegas. At 1935, the pilot again contacted ground control and requested taxi clearance for takeoff. The flight was cleared to taxi to runway 7. At 1938, the pilot contacted North Las Vegas Tower and advised he was ready for takeoff. The tower advised there would be a 10-minute delay for instrument departure and the pilot requested a "VFR clearance out." At 1939, the tower issued the pilot a suggested heading of 340 and provided a Nellis departure control frequency. At 1940, the tower instructed the pilot to squawk a VFR code (1200), said "we're going to alert Nellis of your request," and cleared Flight 121 for takeoff on runway 7. At 1942, the tower authorized a frequency change. According to communications transcripts provided by the U.S. Air Force, Nellis Air Traffic Control Facility (NATCF), at 1941, North Las Vegas Tower contacted Nellis by landline and told them "I've just sent you a strip on AMF121 to Sacramento. He's departing VFR: he'll call you for his IFR clearance in the air." At 1942, the pilot contacted Nellis Approach Control "three-thousand, two-hundred, climbing." After verifying the pilot was requesting his instrument clearance, and his destination, the controller said "roger standby, I need to see if I can pull it up." At 1943, Nellis issued the flight a transponder code of 7221. At 1944, Nellis Approach said, "AMF121 is radar contact 6 miles north of North Las Vegas. UH, are you direct Beatty at this time?" The pilot replied "Umm, 121 um we can go ahead and we'll go direct Beatty." At 1945, Nellis transmitted "AMF One-Twenty" and at 1946, transmitted "AMF121 radar contact lost you can, uh, maintain VFR, and uh, proceed to Beatty." Approximately 20 seconds later, the pilot of another aircraft reported observing a large flash over the mountains. Nellis Approach transmitted to Amflight 121 until 1949 without receiving a reply. The pilot did not communicate any distress message or report any flight irregularity to Air Traffic Control. WRECKAGE AND IMPACT INFORMATION The accident site was on the south face of Gass Peak in the Sheep Mountains about 11 miles north of the North Las Vegas airport. The site is at latitude 36 degrees 23.83 minutes north and longitude 115 degrees 12.26 minutes west, at approximately 5,200 feet msl (GPS). To the north of the site, the mountain slope rises steeply to a ridgeline top of approximately 6,000 feet msl. About 1 mile to the east, Gass Peak rises to 6,943 feet msl and to the west, along the ridge, the peak descends into a wide, open valley. To th ## Aircraft - Registration: [N1024B](https://openairdocs.org/deregistered/N1024B-2000-04-26), registration cancelled 2000-04-26, S/N 31-7652107 (OpenAirDocs) - Reported make and model: Piper PA-31-350 - Registry model: [Piper PA-31-350](https://openairdocs.org/model/piper-pa-31-350) (registry code 7103110) (OpenAirDocs) - Category: Airplane - Serial number: 31-7652107 - Airframe hours: 14048 - Engines: Lycoming TIO-540-J2BD 350 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Part 135 - Registered owner: Ameriflight, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, September 30, 1999, 26 hours before - Departed: VGT, NV - Destination: SAC, SACRAMENTO, CA - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 30; airline transport, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 2,103 total, 250 in this make and model, 1,956 as pilot in command, 176 in the last 90 days, 40 in the last 30 days ## Weather - Conditions: Visual (VMC), Night/dark - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 82 °F, dew point 19 °F - Altimeter: 29.00 inHg - Observed at: VGT, 11 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19991014031719A](https://openairdocs.org/incident/19991014031719A), Oct 14, 1999: Piper PA31350, North Las Vegas, NV, Destroyed, 1 fatal. (.19) On October 14, 1999 at 2000 hours pacific daylight time, a Piper PA-31-350, N1024B, was destroyed by impact with mountainous terrain, 11 miles north of… From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.