NTSB Factual Report

History of the Flight

On May 3, 1996, at 2107 hours Pacific daylight time, a Cessna 310D, N6780T, collided with the surface of the Pacific Ocean about 3 miles west of the Los Angeles International Airport (LAX), Los Angeles, California, after a go-around from runway 25L. The airplane was destroyed by impact forces. Two certificated commercial pilots and two passengers received fatal injuries. The airplane was rented by the pilot for a personal cross-country flight. The flight originated in Phoenix, Arizona, at 1934. Night visual meteorological conditions prevailed at the time and an instrument flight rules (IFR) flight plan was filed.

At 2059, the LAX air traffic control tower local controller cleared the pilot to land on runway 25L. At 2103, the pilot indicated he was executing a go-around and that he did not have the "green lights" for the landing gear. At this time, the airplane was at a position about 3,400 feet west of the runway 25L threshold about 75 feet above the ground. The local controller asked the pilot if he needed any assistance. The pilot indicated, "we're going to find the error." The local controller told the pilot that all three landing gear appeared down and cleared the pilot to climb to 2,000 feet mean sea level (msl), turn to a heading of 200 degrees, and to remain on frequency. The pilot acknowledged the clearance stating, "climbing to two thousand."

At 2104, the local controller instructed the pilot to turn left heading 220 degrees, climb and maintain 2,000 feet msl, and contact Southern California departure control. The local controller received no response from the pilot and issued the clearance again. The local controller again issued the clearance with no response. The local controller then referred to the D-Brite radar display in the tower cab and observed the target about 1/2 mile offshore at a displayed altitude of 800 feet msl. According to the local controller, after the next sweep of the radar antennae the target disappeared.

Radar data depicted the airplane in the last 9 seconds climbing to 1,400 feet msl, and then descending to 1,300 feet msl, when it disappeared from radar. Eye witnesses positioned on Dockweiler Beach about 1/2 mile from the accident site indicated they saw the airplane descend in a near vertical nose-down attitude until it hit the water. One witness who first observed the airplane stated she saw the airplane first descend out of a cloud. A scheduled record weather observation taken about 45 minutes after the accident indicated a 1,300 foot broken ceiling at LAX.

Pilot Information

First Pilot

The first pilot held a commercial pilot certificate which was issued on February 15, 1996. The pilot upgraded his single engine airplane rating from private pilot privileges to commercial pilot privileges on the above date. The pilot completed his commercial pilot rating and multiengine airplane rating at the same time on January 23, 1996.

The Safety Board examined portions of the first pilot's logbook, which was found floating in the water in the area of the accident, and the pilot's airman records, maintained by the FAA Airman Certification Branch in Oklahoma City, Oklahoma. According to his logbook, the first pilot's total aeronautical experience consisted of about 346 hours, of which 36 hours were accrued in multiengine airplanes. The pilot indicated on his application for a multiengine airplane rating that he had flown 10.1 hours in a Piper PA-30, which was the type aircraft used for the pilot's multiengine airplane flight test.

Second Pilot

The second pilot held a commercial pilot certificate which was issued on February 23, 1996. The second pilot also held a private pilot certificate with single and instrument airplane privileges before applying for the commercial flight test. The pilot completed his commercial pilot rating and multiengine airplane rating flight tests simultaneously on the above date.

Portions of the second pilot's logbook were found floating in the vicinity of the accident scene. The last date entered in the recovered portions of the logbook was March 29, 1996. The aeronautical experience listed in this report was obtained from a review of available logbook pages and of airmen FAA records on file in Oklahoma City. The pilot's total aeronautical experience consisted of about 330 hours, of which about 29 were accrued in multiengine airplanes. The pilot's airmen records indicate he had flown about 13 hours in the Piper PA-44-180 before completing his multiengine airplane flight test. The pilot received about 1 hour of dual instruction on March 1, 1996, and then logged another 10 hours in the Cessna 310 over the next 5 days.

Airplane Information

The airplane was manufactured in 1960, and had accumulated a total time in service of 4,605 flight hours. Examination of the maintenance records revealed that the most recent annual inspection was accomplished on July 2, 1995, about 418 flight hours before the accident. In addition, a 100-hour inspection was completed on March 13, 1996, about 22 flight hours before the accident.

Two Teledyne Continental IO-470-D engines were installed in the airframe. The total time in service for both engines could not be determined from examination of maintenance records. Since major overhaul, the left engine had accrued about 1,140 flight hours, and the right engine about 990 flight hours. Annual and 100-hour inspections were accomplished on the dates specified above for the airframe.

Review of the airplane's maintenance records revealed that on April 15, 1996, the right main gear down indicator switch actuator was replaced. The airplane's landing gear was cycled three times and the emergency extension system was tested after the part was replaced. The airplane was then returned to service.

On April 17, 1996, the return spring for the squat switch on the left main landing gear strut was found broken. The squat switch, which actuates the hobbs meter in-flight, was replaced. The landing gear was again cycled three times and the airplane was returned to service.

Meteorological Information

The closest official weather observation station is the Los Angeles International Airport, which is located about 3 nautical miles northeast of the accident site. The elevation of the observation station is 126 feet above sea level.

At 2050, a record surface observation was reporting in part: sky condition and ceiling measured 1,300 feet broken; visibility 7 statute miles; temperature 62 degrees Fahrenheit; dew point 59 degrees Fahrenheit; winds 200 degrees at 6 knots; altimeter 29.91 inHg.

In addition, at 2231, a special surface observation was reporting in part: sky condition and ceiling1,500 scattered; visibility 10 statute miles; temperature 61 degrees Fahrenheit; dew point 58 degrees Fahrenheit; winds 230 degrees at 4 knots; altimeter 29.94 inHg.

Airport and Ground Facilities

The Los Angeles International Airport is owned and operated by the City of Los Angeles. The published elevation of the airport 126 feet msl. The airport is a 14 CFR 139 Index D facility.

Runway 25L is 11,096 feet long by 200 feet wide, and is equipped with high intensity runway lights, centerline lights, and a category II configuration high intensity approach lighting system. Review of the FAA daily record of facility operation revealed there were no reports of difficulties with runway 25L lighting systems at the time of the accident.

The airport is served by a Terminal Radar Service Area, and the tower cab is equipped with a BRITE radar repeater display. The BRITE System is designed to display primary and secondary (transponder) radar returns of aircraft and alphanumeric target symbology generated by the Automatic Radar Terminal System (ARTS) to positions in the ATC tower. The equipment is specifically intended to present a usable visual display in the tower of the traffic inbound/outbound to the respective runways during both day and night conditions. The radar display augments visual observations by tower personnel of arrival, departure, and overflight aircraft. The BRITE System was used by the local controller at the time of the accident and there were no reported difficulties with the system.

Wreckage and Impact Information

The wreckage was found on May 5, 1996, in 61 feet of water at 33 degrees 55.37 minutes north latitude, and 118 degrees 26.96 minutes west longitude. The fuselage was destroyed. A debris field surrounded the airplane. The outboard sections of the wings and the engines had separated and were found in the debris field. The main landing gear and nose gear were found out of the gear wells and separated from the structure. The landing gear actuator was found in the retracted position.

The wreckage was recovered and transported to Compton Airport, Compton, California, where it was examined. During the recovery the flight control cables to the elevator and rudder were observed to be continuous. The rudder trim was found fully deflected to the right stop. The elevator trim tab actuator screw was found extended 1.4 inches. According to Cessna Aircraft Company, this measurement equates to a 5-degree tab down position.

The flap panels were destroyed. The flaps position was determined by length of the flap drive chain and its position on the drive sprocket. The drive chain was found with 5.5 rollers past the top center of the right flap drive socket. According to Cessna Aircraft Company, this chain position equates to a 5-degree flap down position, which is an intermediate position between flaps up position and a 15-degree flap down position.

Both engines and propellers were recovered. The left propeller and hub were found attached to the engine. The right propeller blades separated from the engine at a break in the hub. Both blades were found in wreckage area on the ocean floor. All four propeller blades were bowed forward and bent about 90 degrees aft. The shape of the aft bending conformed to the shape of the engine cowling. Damage to the blades was found on the propeller blade face. The damaged areas also conformed to contact with the engine cowling.

Medical and Pathological Information

Post mortem examinations were conducted by the Los Angeles County Coroner's Office, with specimens retained from both pilots for toxicological examination.

The specimens were sent to the Federal Aviation Administration (FAA) Civil Aeromedical Institute (CAMI) for analysis. According to the CAMI report, the specimens from both pilots were found unsuitable for analysis for carbon monoxide and cyanide test.

The results of the toxicological analysis for the first pilot were negative for routine drug and alcohol screens.

The results of the toxicological analysis for the second pilot were positive for ethanol in muscle and lung fluids and positive for acetaldehyde in lung fluid. Salicylate was also detected in liver fluid.

Tests and Research

Pilot's Checklist

A non-standard pilot's check list was found in the floating debris in the vicinity of the airplane's wreckage. The checklist was found with the go-around procedure page open. Review of the go-around procedure revealed four items listed. The go-around procedure listed in the airplane's owner manual published by the airplane manufacturer lists five items. Comparison of the two checklists revealed the third item listed in the manufacturer's owners manual was omitted on the checklist found near the wreckage. The third item in the go-around procedure in the owner's manual specifies the pilot should trim the airplane for climb.

Wake Turbulence Study

Radar data revealed that a Boeing 737 departed on runway 25R about 3 minutes before the Cessna 310 pilot elected to perform a go-around on runway 25L. The Safety Board completed a "Recorded Radar Study" to determine the relative flight paths of the two aircraft. According to the study, the closest possible wake vortex from the Boeing 737 occured near the end of the Cessna 310 flight path. The study states, "In this case the possible wake vortex is assumed to be very weak (3 minutes and 10 seconds old) and the vertical separation between the predicted wake vortex and the accident airplane is 400+ feet."

Additional Information

Wreckage Release

The wreckage was released to the representatives of the owner on June 19, 1996.

NTSB Probable Cause

failure of the pilot to maintain aircraft control due to spatial disorientation. Factors were clouds and dark night light conditions, and the pilot's diverted attention due to a landing gear problem.