DEN91FA056

NTSB accident investigation · Cessna 421C · Cortez, CO · March 29, 1991

Accident · FatalField investigationFinal report
Date
March 29, 1991, 11:25 local (18:25 UTC)
Place
Cortez, CO
Injuries
5 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N3851CCessna 421C
Weather
Instrument (IMC) · Day
Status
Completed · report May 5, 1993
Report
Approved by Office Director
FAA report
19910329007879A
Case key
18018

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot's improper IFR procedures. Factors were: the existing weather conditions and the pilot's failure to obtain a preflight briefing.

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.

In flight encounter with weatherApproach - faf/outer marker to threshold (ifr)
Weather condition - snow
Preflight briefing service - not usedPilot in commandFactor
Weather condition - obscurationFactor
In flight collision with terrain/waterMissed approach (ifr)
Terrain condition - mountainous/hilly
Ifr procedure - improperPilot in commandCause

Analysis

The flight departed without a flight plan or weather brief. En route deteriorating weather was encountered and an IFR flight plan was filed to a revised destination. Clearance was received for a VOR approach and the pilot was advised of 1/2 mile visibility in snow and fog. A missed approach was reported over the UNICOM frequency. Impact occurred with a heading of about 170 degrees at 7,700 feet MSL in mountainous terrain on the 173 degree radial, 7.3 miles from the VOR. The inbound course to the final approach fix was 170 degrees with an inbound final approach course of 196 degrees. Airport elevation was 5,914 feet MSL. The airport was located on the 196 degree radial, 5.5 miles from the VOR final approach fix. The VOR approach to runway 21 called for a missed approach to be executed at 5.5 DME from the VOR and a minimum descent altitude of 6,600 feet.

Aircraft

Registration
N3851C
Reported as
Cessna 421C
Category
Airplane
Serial number
421C0119
Engine
Continental GTSIO-520-L, 375 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Operator
George Mehl
Registered owner
George Mehl
Departed
TUS · Tucson, AZ
Flight plan
IFR
Airport
CEZ · Cortez-Montezuma County, runway 21, 7,105 × 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
42
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--no waivers/lim.
Toxicology
Performed
Flight hours
530 total · 40 in this make and model · 10 in the last 90 days · 5 in the last 30 days

Weather

Conditions
Instrument (IMC) · Day
Wind
330° at 12 knots, gusting 25
Lowest ceiling
800 ft
Temperature
-0 °F, dew point -0 °F

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.