NTSB CAROL · Event
Event GAA15CA128
Aircraft involved
Probable cause & findings
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.
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. 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. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).
- C Personnel issues-Psychological-Attention/monitoring-Monitoring environment-Pilot - C
- F Organizational issues-Management-Communication (organizational)-Within group(s)/organization-ATC - F
- — Environmental issues-Conditions/weather/phenomena-Light condition-Dark-Contributed to outcome
- C Organizational issues-Support/oversight/monitoring-Oversight-Oversight of operation-ATC
- — Environmental issues-Physical environment-Object/animal/substance-Fence/fence post-Contributed to outcome
Verbatim from NTSB's published report. Source file
NTSB_2015_GAA15CA128.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (go-around). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- NASA NTRS 2025 · Conference Paper
A Training Study to Improve Monitoring During A Go-Around
As part of an FAA program to improve go-around (GA) safety, we were asked to determine if we could improve the performance of the Pilot Monitoring (PM) during a GA maneuver.
- Flight Safety Foundation 2024 · FSF / AeroSafety World
Go-Around Safety Forum Findings
Foundation Go-Around Safety Forum technical findings — examines why pilots fail to execute go-arounds when criteria are met (stabilized approach gate not met, energy state out of envelope, traffic con…
- Semantic Scholar 2022 · Article (Journal of Safety Research)
Go-around accidents and general aviation safety.
INTRODUCTION Changes in General Aviation (GA) accident rates, specifically in the go-around phase, are examined by comparing the number of accidents, the proportion of fatal accidents, and the proport…
- Semantic Scholar 2021 · Article (Aerospace)
Classification and Analysis of Go-Arounds in Commercial Aviation Using ADS-B Data
Go-arounds are a necessary aspect of commercial aviation and are conducted after a landing attempt has been aborted. It is necessary to conduct go-arounds in the safest possible manner, as go-arounds …
- NASA NTRS 2021 · Accepted Manuscript (Version with final changes)
Go-Around Criteria Refinement for Transport Category Aircraft
Presently, airline pilots are trained to go around if, when lower than 500 ft above the ground, they are outside of a handful of parameters such as airspeed, position, and rate of descent.
- NASA NTRS 2019 · Conference Paper
Validation of Proposed Go-Around Criteria Under Various Environmental Conditions
This paper evaluates the effects of environmental conditions on touchdown performance under varying approach states and validates proposed go-around criteria developed using data from a previously con…
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