NTSB CAROL · Event
Event LAX92FA033
Aircraft involved
Probable cause & findings
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.
Factual narrative
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. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_1991_LAX92FA033.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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