LAX96LA296

NTSB accident investigation · Cessna 421C · Avalon, CA · August 4, 1996

Accident · Serious injuriesLimited investigationFinal report
Date
August 4, 1996, 16:20 local (23:20 UTC)
Place
Avalon, CA
Injuries
4 serious, 3 minor
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N6209VCessna 421C
Weather
Visual (VMC) · Day
Status
Completed · report April 10, 1998
Report
Approved by Office Director
FAA report
19960804020799A
Case key
29528

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 pilot's failure to initiate a go-around when a landing overshoot became apparent. Factors which contributed to the accident were: the pilot's excessive airspeed and misjudged distance during landing, his lack of flying experience in the Cessna, and overconfidence in his personal ability.

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.

OverrunLanding - roll
Distance/speed - misjudgedPilot in commandFactor
Airspeed(vref) - not attainedPilot in commandFactor
Proper touchdown point - not attainedPilot in commandCause
Go-around - not performedPilot in commandCause
Lack of total experience in type of aircraftPilot in commandFactor
Overconfidence in personal abilityPilot in commandFactor
On ground/water encounter with terrain/waterLanding - roll
Terrain condition - drop-off/descending embankment
Terrain condition - rough/uneven

Analysis

According to the airport's acting tower manager, the airplane's landing approach 'looked good' but was 'a lot faster than most twin-engine airplanes.' The airplane 'appeared to float,' and it did not touchdown until reaching midfield on the 3,240-foot-long runway. A pilot-witness who was standing on the ramp similarly reported that the airplane's approach speed was fast, and also noted that as the airplane passed midfield its nose wheel had not been lowered to the pavement. The pilot report that after touchdown he applied brakes, and although the airplane slowed he was unable to stop before exiting off the runway's departure end. The airplane went down an embankment, collided with rough terrain, and came to rest approximately 120 feet southwest of the runway's end. The pilot previously had landed at the Santa Monica Municipal Airport. According to the FAA, at Santa Monica the airplane touched down about 1,000 feet prior to the end of that 4,987-foot-long runway. Three months earlier, the pilot received a multiengine class rating. At that time, he indicated his total multiengine flying experience was 23 hours of dual instruction.

Factual narrative

History of flight

On August 4, 1996, at 1620 hours Pacific daylight time, a Cessna 421C, N6209V, operated by the pilot, overran the departure end of runway 22 during landing rollout at the (uncontrolled) Catalina Airport, Avalon, California. The airplane went down an embankment, collided with rough terrain, and came to rest approximately 120 feet southwest of the runway's end. The airplane was substantially damaged. The private pilot and three passengers were seriously injured, and three additional passengers received minor injuries. Visual meteorological conditions prevailed at the time of the personal flight, and no flight plan was filed. The flight originated from the John Wayne Airport, Santa Ana, California, about 1500.

According to the Federal Aviation Administration (FAA), after departing from Santa Ana the pilot proceeded to the Santa Monica Municipal Airport, Santa Monica, California, and arrived there at 1529. The on-duty air traffic controller reported that when the pilot requested landing instructions, he gave him instructions to overfly the airport above 2,000 feet for right traffic to runway 21, and to report abeam the tower on the north side of the airport. The controller stated that the pilot did not comply with his instructions. The pilot descended on the south side of the airport and entered the left-hand traffic pattern.

The controller further reported that the pilot landed on runway 21, but he touched down long. The runway's length is 4,987 feet, and the airplane touched down at approximately the 1,000 foot distance remaining marker.

After passengers boarded the airplane, the pilot departed for Catalina at 1553. The controller reported that he instructed the pilot to make a right climbing 270-degree turn at the shoreline during climbout. The controller stated that, once again, the pilot did not comply with his instructions. Upon departure, the pilot made a left turn.

No further contact was made with the airplane until it approached the Catalina Airport. A pilot-witness, who was standing on the ramp at the Catalina Airport, reported observing the airplane's final approach. The witness stated it appeared that the pilot was flying at a fast airspeed, and he opined that the pilot would be unable to completely decelerate before reaching the runway's end. He stated that as the airplane passed the midfield location, its nose wheel had not been lowered to the pavement. As the airplane neared the departure end of the runway, no evidence of engine power application was heard.

Another witness, the acting tower manager, reported that the Cessna's approach "looked good" but it was "a lot faster than most twin-engine airplanes." The airplane "appeared to float," and it did not touchdown until reaching midfield on the 3,240-foot-long runway.

An officer from the Los Angeles Country Sheriff's Department responded to the accident site and interviewed the pilot. According to the officer, the pilot reported that he touched down about midfield, and the brakes felt like they were working. When he saw that the airplane was nearing the runway's end, all he could do was to keep applying the brakes because he would not be able to build up enough speed to take off prior to reaching the runway's end. The airplane rolled off the runway's end, floated about 50 feet down an embankment, and slid to a stop.

Wreckage examination

The FAA and a participant from the Cessna Aircraft Corporation inspected the accident site, the runway, and the airplane. Evidence of tire (rubber transfer) marks was observed on the runway surface which corresponded with the airplane's left and right main landing gear tires. The marks were nearly symmetrical in appearance (length and density). The marks were noted over an approximate 70-yard-long distance from near the runway's end to the southwestern edge of the airport, where the terrain elevation suddenly lowered by about 40 feet. No evidence of malfunctions was found during the examination of the tires, wheels, or brake assemblies.

Personnel information

The private pilot's flight time (hours) recorded in the Flight Time Matrix boxes in this factual report were obtained from FAA Form 8710-1, entitled Airman Certificate and/or Rating Application. The hours were reported by the pilot on April 26, 1996, upon his second application for the addition of a multiengine class rating. As indicated on the application form, the pilot reported that his total multiengine flight time (experience) was 23 hours, and the hours were all obtained during dual flight instruction. The flight test was conducted in a Piper PA-34-200 airplane.

On May 5, 1996, the pilot was issued a multiengine class rating. The National Transportation Safety Board was not able to determine the pilot's experience level (flight hours) in the Cessna 421C airplane.

Additional information

On August 8, 1996, the Safety Board mailed the pilot a letter requesting that he complete the required "Pilot/Operator Aircraft Accident Report" NTSB Form 6120.1/2. On October 22, 1996, the Safety Board requested to speak with the pilot via telephone and left a message at his residence. On October 30, 1996, the FAA mailed the pilot a letter requesting that he make his flight records available for examination. As of March 1997, the pilot has not responded to either the NTSB or the FAA's requests.

Aircraft

Registration
N6209V
Reported as
Cessna 421C
Category
Airplane
Serial number
421C0324
Engine
Continental GTSIO-520-B, 375 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Sarkis Badzhaksizyan
Registered owner
Tigran Svadjian, M.D.
Airworthiness certificate
Standard, Normal
Departed
SMO · Santa Monica, CA
Destination
AVX
Airport
AVX · Catalina, runway 22, 3,240 × 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
35
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
248 total · 134 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
66 °F
Altimeter
29.00 inHg
Observed at
AVX, 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.