# NTSB GAA15CA128: Beech C23, N24022, Long Beach, CA, June 19, 2015 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: June 18, 2015, 21:07 local (Jun 19, 2015, 04:07 UTC) - Place: Long Beach, CA - Coordinates: 33.822776, -118.141944 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.8228&lon=-118.1419&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report September 11, 2015 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 91409 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA15CA128 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91409/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91409 - Page: https://openairdocs.org/ntsb/GAA15CA128 ## Probable cause The pilot failed to maintain clearance from trees while maneuvering to land at night, which resulted in a collision with terrain/objects. A factor contributing to the accident was the lack of oversight by ATC; failing to insure that the fully operational VASI was turned on during the hours of darkness. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Attention/monitoring: monitoring environment](https://openairdocs.org/ntsb-findings/02021545): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Beech C23, 2 cases](https://openairdocs.org/ntsb-findings/02021545/cases.md?model=1151242), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/02021545/cases.md) - [Communication (organizational): within group(s)/organization](https://openairdocs.org/ntsb-findings/04025015): Organizational issues › Management · ATC (probable cause); cases with it: [Beech C23, 1 case](https://openairdocs.org/ntsb-findings/04025015/cases.md?model=1151242), [All aircraft, 4 cases](https://openairdocs.org/ntsb-findings/04025015/cases.md) - [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Contributed to outcome; cases with it: [Beech C23, 1 case](https://openairdocs.org/ntsb-findings/03036020/cases.md?model=1151242), [All aircraft, 448 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md) - [Oversight: oversight of operation](https://openairdocs.org/ntsb-findings/04032015): Organizational issues › Support/oversight/monitoring · ATC (probable cause); cases with it: [Beech C23, 1 case](https://openairdocs.org/ntsb-findings/04032015/cases.md?model=1151242), [All aircraft, 61 cases](https://openairdocs.org/ntsb-findings/04032015/cases.md) - [Object/animal/substance: fence/fence post](https://openairdocs.org/ntsb-findings/03022047): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Beech C23, 4 cases](https://openairdocs.org/ntsb-findings/03022047/cases.md?model=1151242), [All aircraft, 313 cases](https://openairdocs.org/ntsb-findings/03022047/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Beech C23, 3 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=1151242), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## Analysis The pilot reported that while on final approach for runway 25R during night conditions, the visual approach slope indicator (VASI) was not operational. The pilot stated that he was "too low" during the approach, so he applied full power in an attempt to go-around. The airplane impacted the top of trees about 530 feet east of the runway and then impacted the airport perimeter fence about 380 feet east of the runway. The pilot reported there were no pre-impact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation. The airplane sustained substantial damage to the fuselage and both wings. ## Factual narrative The pilot reported that while on final approach for runway 25R during night conditions, the visual approach slope indicator (VASI) was not operational. The pilot stated that he was "too low" during the approach, so he applied full power in an attempt to go-around. The airplane impacted the top of trees about 530 feet east of the runway and then impacted the airport perimeter fence about 380 feet east of the runway. The pilot reported there were no pre-impact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation. The airplane sustained substantial damage to the fuselage and both wings. ADDITIONAL INFORMATION According to the Federal Aviation Administration (FAA) Notice to Airman (NOTAM) Search archive, NOTAM 06/010 was issued for runway 25R VASI out of service, effective on 06/04/2015, at 2017 (UTC). The NOTAM 06/010 stated that the expiration date was 06/19/2015, at 2300 (UTC), but was canceled one day early on 06/18/2015 at 2241 (UTC). In a telephone conversation with a representative from the FAA Service Operations Center in the Southern California Terminal Radar Approach Control Facility, he stated that the VASI NOTAM was canceled because the equipment was returned to an operational status and the Long Beach Airport (LGB) air traffic control (ATC) tower was notified over the telephone. During the time of the accident, the LGB ATC tower Automatic Terminal Information Service was still broadcasting that the 25R VASI was out of service. ## Aircraft - Registration: [N24022](https://openairdocs.org/deregistered/N24022-2018-03-23), registration cancelled 2018-03-23, S/N M-1927, built 1977 (OpenAirDocs) - Reported make and model: BEECH C23 (NO SERIES) - Registry model: [Beech C23](https://openairdocs.org/model/beech-c23) (registry code 1151242) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: M-1927 - Year built: 1977 - Airframe hours: 4641 - Engines: LYCOMING O-360-A4K 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Ranjiv Priyantha Goonetilleke - Registered owner: Concord Trading Inc - Airworthiness certificate: Standard, Normal; Standard, Utility - Last inspection: 100 hour, May 4, 2015 - Departed: AJO, CORONA, CA - Destination: LGB, Long Beach, CA - Flight plan: VFR/IFR - Airport: LGB, Long Beach /Daugherty Field/, runway 25R, 6,191 × 150 ft, asphalt - Equipment: Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 67; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review August 24, 2014; seat: left; restraint: 3-point; flight hours: 1,427 total, 1,376 in this make and model, 1,291 as pilot in command, 53 in the last 90 days, 8.5 in the last 30 days, 0.6 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 320° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 66 °F, dew point 59 °F - Altimeter: 29.88 inHg - Observed at: KLGB, 1 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 20150618012079A](https://openairdocs.org/incident/20150618012079A), Jun 18, 2015: Beech C23, Long Beach, CA, Substantial damage. Upon approach/landing runway 25R at Long Beach airport on June 18, 2015 around 2102 PST, aircraft N24022 impacted a group of trees on approach, east of runway… ## Docket (1 files) The files NTSB released with the investigation on September 4, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91409. 242 KB in all. - Photo 1-View of substantial damage to the fuselage (photo courtesy of airport operations) (item 1, .PDF, 242 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431575&FileExtension=.PDF&FileName=Photo%201-View%20of%20substantial%20damage%20to%20the%20fuselage%20(photo%20courtesy%20of%20airport%20operations)%20-Master.PDF 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.