# NTSB LAX92FA033: Cessna 337F, N1734M, Bullhead City, AZ, November 2, 1991

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: November 1, 1991, 20:22 local (Nov 2, 1991, 03:22 UTC)
- Place: Bullhead City, AZ
- Location: 35.1478° N, 114.5683° W: Placed by OpenAirDocs: center of Bullhead City, AZ, within about 6 miles (OpenAirDocs)
- Nearby events: https://openairdocs.org/map.md?lat=35.1478&lon=-114.5683&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 3 fatal
- Status: Completed, report May 5, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 27389
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX92FA033
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/27389/pdf
- Page: https://openairdocs.org/ntsb/LAX92FA033

## 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

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- In flight collision with terrain/water, approach - vfr pattern - base leg/base to final
  - light condition - dark night (contributing factor)
  - airport facilities,visual apch slope ind(vasi) - not operating
  - proper descent rate - not maintained, pilot in command (cause)
  - altitude - misjudged, pilot in command (cause)
  - physical impairment(visual deficiency), pilot in command
  - notams - information insufficient, faa(airways facility personnel) (contributing factor)
  - inadequate substantiation process, faa(organization) (contributing 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](https://openairdocs.org/deregistered/N1734M-1992-03-19), registration cancelled 1992-03-19, S/N 33701334 (OpenAirDocs)
- Reported make and model: CESSNA 337F
- Registry model: [Cessna 337F](https://openairdocs.org/model/cessna-337f) (registry code 2075725) (OpenAirDocs)
- Category: Airplane
- Serial number: 33701334
- Airframe hours: 3264
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 68; 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 (OpenAirDocs).

- [Accident 19911101048799A](https://openairdocs.org/incident/19911101048799A), Nov 1, 1991: Cessna 337, Bullhead City, AZ, Destroyed, 3 fatal. Struck ridges short of airport on approach to new higher elevation runway. Attempting night landing.

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.

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