LAX92FA033

NTSB accident investigation · Cessna 337F · Bullhead City, AZ · November 2, 1991

Accident · FatalField investigationFinal report
Date
November 1, 1991, 20:22 local (Nov 2, 1991, 03:22 UTC)
Place
Bullhead City, AZ
Injuries
3 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N1734MCessna 337F
Weather
Visual (VMC) · Night/dark
Status
Completed · report May 5, 1993
Report
Approved by Office Director
FAA report
19911101048799A
Case key
27389

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilots failure to maintain a proper descent rate and to adequately judge the above ground altitude of the aircraft during the approach. Factors in the accident were: 1) the dark night conditions, 2) the pilot's degraded visual perceptive ability, and 3) the failure of the FAA to disseminate the airport elevation change information in a timely manner.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight collision with terrain/waterApproach - vfr pattern - base leg/base to final
Light condition - dark nightFactor
Airport facilities,visual apch slope ind(vasi) - not operating
Proper descent rate - not maintainedPilot in commandCause
Altitude - misjudgedPilot in commandCause
Physical impairment(visual deficiency)Pilot in command
Notams - information insufficientFaa(airways facility personnel)Factor
Inadequate substantiation processFaa(organization)Factor

Analysis

Drg an apch to a new rwy (34) at ngt, the acft dscndd into trrn abt 4000' short of the rwy. The old rwy (17/35) had recently been closed. The new rwy (16/34) was aprx 1400' east of the old rwy & abt 145' higher. The arpt operator had notified the FAA of the elev chg. The FAA NOTAM issued for the new rwy did not include the alt chg due to proc policy. The plt had lndd at the arpt svrl times, but this was to be his 1st lndg on the new rwy. The plt's logbook showed a total of 118 hrs of ngt time, but the last recorded ngt flt was 12 yrs bfr the acdnt. Two plts awaiting takeoff saw the apch & indcd the acft appeared low on dwnwnd & base leg. The plt's psn callouts sounded nml. The plt was on medication (med) for diabetes & hi blood pres, which was prescribed by his regular physician. None of the prescribed medications was detected in the plt's blood. An FAA rgnl flt surgeon stated that if the plt discontinued his medication, it could have caused hypertension and/or hyperglycemia, with a corresponding degredation in his ngt visual perceptive ability.

Aircraft

Registration
N1734M
Reported as
Cessna 337F
Category
Airplane
Serial number
33701334
Airframe hours
3,264
Engine
Continental IO-360-C, 210 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
Jerome Marcus
Registered owner
Jerome Marcus Trustee
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 11, 1991 · 35 hours before
Departed
PSP · Palm Springs, CA
Destination
P06 · Bullhead City, AZ
Flight plan
VFR
Airport
P06 · Laughlin Bullhead, runway 34, 7,500 × 100 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
68
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
1,792 total · 536 in this make and model · 1,701 as pilot in command · 9 in the last 90 days · 2 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/dark
Wind
360° at 10 knots
Visibility
15 statute miles
Lowest ceiling
None
Temperature
68 °F, dew point -0 °F
Altimeter
30.00 inHg
Observed at
P06, 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.