# NTSB LAX03FA298: Piper PA-28R-200, N8604N, North Las Vegas, NV, September 23, 2003 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Field investigation · Final report - Date: September 23, 2003, 12:55 local (19:55 UTC) - Place: North Las Vegas, NV - Coordinates: 36.212501, -115.196113 - Nearby events: https://openairdocs.org/map.md?lat=36.2125&lon=-115.1961&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed, report April 28, 2005 - Report: Approved by Office Director - Parties: Federal Aviation Administration, The New Piper Aircraft Co. - NTSB case key (mKey): 57987 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX03FA298 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/57987/pdf - Page: https://openairdocs.org/ntsb/LAX03FA298 ## Probable cause (aircraft 2) 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. ## Probable cause (aircraft 1) 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. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Collision between aircraft (other than midair), landing - roll - control tower service - improper, atc personnel(lcl/gnd/clnc) (cause) - visual separation - not maintained, atc personnel(lcl/gnd/clnc) (cause) - Collision between aircraft (other than midair), takeoff - roll/run - control tower service - improper, atc personnel(lcl/gnd/clnc) (cause) - visual separation - not maintained, atc personnel(lcl/gnd/clnc) (cause) ## Analysis (aircraft 2) 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. ## Analysis (aircraft 1) 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 narrative (aircraft 2) 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 Ve ## Factual narrative (aircraft 1) 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 Ve ## Aircraft 1 - Registration: [N8604N](https://openairdocs.org/deregistered/N8604N-2008-12-03), registration cancelled 2008-12-03, S/N 28R-7135124, built 1971 (OpenAirDocs) - Reported make and model: Piper PA-28R-200 - Registry model: [Piper PA-28R-200](https://openairdocs.org/model/piper-pa-28r-200) (registry code 7102811) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28R-7135124 - Airframe hours: 4524 - Engines: Lycoming IO-360 200 horsepower reciprocating - Damage: Substantial damage - Fire: On-Ground - Flight: Personal, Part 91 - Operator: West Air Aviation - Registered owner: J and P Holdings Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 1, 2003, 35 hours before - Departed: SGU, St. George, UT - Destination: VGT, N. Las Vegas, NV - Airport: VGT, North Las Vegas, runway 12R, 5,000 × 75 ft, asphalt ## Aircraft 2 - Registration: N146PM (not matched to a registry record) - Reported make and model: Piper PA-46-350P - Category: Airplane - Serial number: 4622160 - Airframe hours: 965 - Engines: Pratt & Whitney PT6A-35 560 horsepower turbo prop - Damage: Substantial damage - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Samuel Johnson - Registered owner: Sam Johnson - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 12, 2003, 68 hours before - Departed: VGT, N. Las Vegas, NV - Destination: SLC, Salt Lake City, UT - Airport: VGT, North Las Vegas, runway 7, 5,005 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot, aircraft N8604N; age 60; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, valid medical--no waivers/lim.; last flight review July 16, 2002; seat: left; flight hours: 412 total, 26 in this make and model, 335 as pilot in command, 6 in the last 90 days, 3 in the last 30 days - Pilot, aircraft N146PM; age 51; injuries: serious; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; last flight review February 14, 2003; seat: left; flight hours: 1,756 total, 88 in this make and model, 1,580 as pilot in command, 13 in the last 90 days, 68 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 130° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 86 °F, dew point 41 °F - Observed at: VGT ## FAA reports on this event (2) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20030923037051A](https://openairdocs.org/incident/20030923037051A), Sep 23, 2003: Piper PA28R200, Las Vegas, NV, Substantial damage. (-23) ATC had issued the pilot of N8604N a landing clearance for runway 12R and the pilot of N146PM a take off clearance for runway 7. The aircraft collided at… - [Accident 20030923037052A](https://openairdocs.org/incident/20030923037052A), Sep 23, 2003: Piper PA46350P, Las Vegas, NV, Substantial damage. (-23) ATC had issued the pilot of N146PM a take off clearance for runway 07 and a landing clearance for runway 12R to the pilot of N8604N. The aircraft… 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.