# NTSB CHI98FA187: Cessna 421, N541N, Little Falls, MN, June 1, 1998 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 1, 1998, 18:31 local (23:31 UTC) - Place: Little Falls, MN - Coordinates: 45.969646, -94.360519 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=45.9696&lon=-94.3605&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report March 31, 2000 - Report: Approved by Office Director - NTSB case key (mKey): 10743 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI98FA187 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/10743/pdf - Page: https://openairdocs.org/ntsb/CHI98FA187 ## Probable cause the pilot's continued operation with a known deficiency in equipment. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, takeoff - maintenance - improper, owner/pilot mechanic - fuel system - contamination,water - operation with known deficiencies in equipment - continued, owner/pilot mechanic (cause) - Forced landing, descent - uncontrolled - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis A witness reported the airplane did not climb above 200 feet and reported seeing the airplane 'wobbling up and down' as it attempted to climb. He reported the airplane went into a sharp left bank and nose dived down. The airplane burned upon impact. The wreckage was located in a wooded area about 3/4 mile from the approach end of runway 30. Numerous open farm fields were located near the airplane's flight path. The winds were reported at 240 degrees at 22 knots gusting to 29 knots. The wreckage path was on a 040 heading and covered about 190 feet from initial tree impact to the location of the main wreckage. The engine inspection did not reveal any anomalies to either engine. The flight was the first maintenance check flight after the airplane had not been flown for 14 months. During maintenance the pilot had put about 100 gallons of water in the left main and left auxiliary fuel tanks to locate a fuel leak. A plug was installed in the left auxiliary fuel drain valve and the fuel tank could not be checked during preflight for fuel contamination without removing the plug. ## Factual narrative History of Flight On June 1, 1998, at 1831 central daylight time, a Cessna 421, N541N, was destroyed after takeoff when it impacted the ground about 1/2 mile from the airport. The airplane had difficulty climbing to about 200 feet above ground level. It made a sharp left bank and nosed down into trees and impacted the ground. The airplane was engulfed in flames after impact. The commercial pilot was fatally injured. The 14 CFR Part 91 flight departed Little Falls-Morrison County Airport, Little Falls, Minnesota, on a local maintenance flight. Visual meteorological conditions prevailed and no flight plan had been filed. No one witnessed the airplane departing runway 30, but a witness reported he was about 1/2 mile from the departure end of runway 30 when he saw an airplane flying above the tree line, about 100 feet above ground level (agl). He then saw the smoke from the airplane accident a "couple of minutes" later. A witness reported he observed the airplane while he was doing field work about 1/2 mile east of the airport. He reported the airplane was flying to the east and that it never climbed more than 200 feet agl, "not a 100 feet above the trees." He reported the airplane tried to gain 20 feet in altitude, but then would lose it. He reported the airplane's flight path was "... wobbling up and down." He reported he could see the whole top of the airplane as it went into a sharp left bank and nose dived down. He reported seeing black smoke and flames immediately upon impact. He did not hear the engines or the explosion since he was riding on a tractor. The airplane impacted the ground in a wooded area approximately 3/4 mile east of the approach end of runway 30. Rescue personnel found the pilot's body about 15 feet to the left of the main wreckage. Personnel Information The pilot was a commercially rated pilot with single and multi-engine land ratings. He held a second class medical certificate. He had a total of about 6,000 hours of flight time. 4,000 hours were in multi-engine airplanes with approximately 1,500 hours in the accident airplane. The pilot received a type rating in a North American Sabreliner, N-265, seven months prior to the accident. The pilot's logbook was not obtained. Witnesses reported the pilot owned five airplanes and was an active pilot who flew frequently. A witness reported the pilot flew his twin engine Piper Aztec on Sunday afternoon, May 31, 1998. The pilot held Airframe and Powerplant mechanic (A&P) licenses. He also held a maintenance Inspection Authorization license. Witnesses reported the pilot had performed maintenance on the airplanes he owned to include engine overhauls, painting aircraft and control surfaces, and refurbishing aircraft interiors. Aircraft Information The airplane was a twin engine Cessna 421, serial number 4210161. The airplane seated seven and had a maximum gross weight of 6,840 pounds. The engines were 375 horsepower Continental GTSIO-520-D engines. The aircraft logbooks were not obtained and were reportedly kept in the airplane. The date of the last annual inspection was unknown. Witnesses reported the airplane had not flown for approximately 14 months. They reported that the pilot had inspected the right engine and had determined that an alternator gear tooth was chipped and needed repair. The witnesses reported the pilot repaired the engine himself. The witnesses reported that the pilot also repainted the aircraft and refurbished the interior of the airplane during the 14 months the airplane did not fly. Witnesses reported the pilot had performed a ground engine run on both engines after the right engine had been repaired and reinstalled on the airplane. A fuel leak to the left auxiliary fuel tank, a bladder type fuel tank, was discovered. Witnesses reported the pilot used water as a means of determining where the bladder tank was leaking fuel. The witnesses estimated that between 50 to 100 gallons of water were put into the left main and left auxiliary fuel tanks. A witness reported the fuel leak was fixed but he was uncertain how it was accomplished. He reported the pilot intended to install a new fuel drain valve in the left auxiliary fuel tank, but since he had the wrong one, he put a plug in it instead. The witness reported that there was no way to sump the left auxiliary tank for water. A witness reported the pilot painted the exterior of the airplane. He reported that the control surfaces were not removed from the airplane when they were painted. A witness reported the pilot accomplished about 90% of the work done on the interior when it was refurbished. He reported all the seats and seatbelts were installed. He reported that all of the interior work, except for installing a couple screws, was completed by noon on Sunday, May 31, 1998. The witness reported the pilot attempted to start both engines on May 31, 1998, but neither would start. The witness reported the pilot charged the airplane's battery after the engines did not start. The witness reported that he fueled the airplane with 100 to 104 gallons of fuel on Sunday night, May 31, 1998. He reported the tanks were "bone dry" and that he put in 25 gallons of fuel in each fuel tank. The witness reported the pilot had called him at about 1730 on Monday, June 1, 1998, to ask him to go fly on the maintenance check flight. The witness was reported he was unable to fly because of a schedule conflict, but the pilot intended to fly the airplane on Monday evening. Meteorological Conditions At 1753, weather conditions reported at Brainerd, Minnesota, located about 30 miles north of Little Falls, Minnesota, were VFR. The sky was clear with ten miles visibility. The temperature was 70 degrees Fahrenheit. The winds were 240 degrees at 22 knots gusting to 29 knots. Wreckage and Impact Information The airplane impacted the trees on a 040 heading before coming to rest about 190 feet from the initial tree impact. The front of the airplane was heading approximately 220 degrees. An area approximately 100 feet long and 40 feet wide from 90 feet along the wreckage path to the main wreckage had been burned. The trees and other foliage had been burned or received fire damage. Impact marks on trees indicated the airplane first hit trees at about 40 to 50 feet high. Numerous branches with propeller slashes and paint transfer were found about 45 feet after the initial tree impact. Two trees that were 12 feet apart and located about 90 feet from the initial impact had impact marks. The right tree had an impact mark at about 34 feet high, and the left tree had an impact mark at about 22 feet high. The left wing tip tank was found between the two trees about 90 feet along the wreckage path. The left propeller and spinner had separated from the engine and were found about 125 feet along the wreckage path. Three ground impact craters which measured 6 to 10 feet long and 3 to 7 feet wide were located in line from about 130 feet to 160 feet along the wreckage path. A five foot section of the left outboard wing was found between the first and second impact craters and offset to the right of the wreckage path centerline. Numerous plexiglass pieces were found in and to the left of the second impact crater. The right engine's oil dipstick was found in the third impact crater. A blade tip from the right propeller was found northeast of the third impact crater. The main wreckage came to rest approximately 30 feet beyond the third impact crater. The wreckage was partially inverted and folded over. The right wing and right engine were located in front and to the left of the main wreckage along the wreckage path. The right wing section inboard of the engine was destroyed by fire. The left wing section inboard of the engine was destroyed by fire, but components from the left inboard wing section were found in the a ## Aircraft - Registration: [N541N](https://openairdocs.org/deregistered/N541N-2000-03-31), registration cancelled 2000-03-31, S/N 421-0161 (OpenAirDocs) - Reported make and model: Cessna 421 - Registry model: [Cessna 421](https://openairdocs.org/model/cessna-421) (registry code 2076010) (OpenAirDocs) - Category: Airplane - Serial number: 4210161 - Engines: Continental GTSIO-520-D 375 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Part 91 - Registered owner: George Fortier III - Airworthiness certificate: Standard, Normal - Departed: LXL - Airport: LXL, Little Falls-Morrison ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 6,000 total, 1,500 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 240° at 22 knots, gusting 29 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 70 °F, dew point 52 °F - Altimeter: 29.00 inHg - Observed at: BRD, 30 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 19980601026769A](https://openairdocs.org/incident/19980601026769A), Jun 1, 1998: Cessna 421, Little Falls, MN, Destroyed, 1 fatal. Witnesses reported that the aircraft was not gaining altitude shortly after take-off. The wings were dipping up then down. The pilot was then seen trying to… 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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.