# NTSB DEN91FA056: Cessna 421C, N3851C, Cortez, CO, March 29, 1991

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: March 29, 1991, 11:25 local (18:25 UTC)
- Place: Cortez, CO
- Coordinates: 37.350418, -108.569572 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=37.3504&lon=-108.5696&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 5 fatal
- Status: Completed, report May 5, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 18018
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DEN91FA056
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/18018/pdf
- Page: https://openairdocs.org/ntsb/DEN91FA056

## 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

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- In flight encounter with weather, approach - faf/outer marker to threshold (ifr)
  - weather condition - snow
  - preflight briefing service - not used, pilot in command (contributing factor)
  - weather condition - obscuration (contributing factor)
- In flight collision with terrain/water, missed approach (ifr)
  - terrain condition - mountainous/hilly
  - ifr procedure - improper, pilot in command (cause)

## 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](https://openairdocs.org/deregistered/N3851C-1992-01-13), registration cancelled 1992-01-13, S/N 421C0119 (OpenAirDocs)
- Reported make and model: CESSNA 421C
- Registry model: [Cessna 421C](https://openairdocs.org/model/cessna-421c) (registry code 2076016) (OpenAirDocs)
- Category: Airplane
- Serial number: 421C0119
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 42; 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 (OpenAirDocs).

- [Accident 19910329007879A](https://openairdocs.org/incident/19910329007879A), Mar 29, 1991: Cessna 421C, Cortez, CO, Destroyed, 5 fatal. Off course VOR inbound,hit rising mesa terrain. No wx briefing. Below minimum,low time in type and low IFR experience

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.

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