LAX87FA119

NTSB accident investigation · Cessna 441 · Flagstaff, AZ · February 21, 1987

Accident · FatalField investigationFinal report
Date
February 20, 1987, 18:45 local (Feb 21, 1987, 01:45 UTC)
Place
Flagstaff, AZ
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N6858SCessna 441
Weather
Instrument (IMC) · Night/dark
Status
Completed · report October 13, 1988
Report
Approved by Office Director
FAA report
19870220082019A
Case key
25381

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

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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.

Airframe/component/system failure/malfunctionApproach
Maintenance,recordkeeping - improper
Procedures/directives - not followed
Inadequate surveillance of operationCompany/operator mgmtFactor
Electrical system - undeterminedCause
Electrical system,inverter - inoperative
Flight/nav instruments,attitude indicator - inoperative
Loss of control - in flightApproach
Light condition - dark nightFactor
Weather condition - low ceilingFactor
Weather condition - snowFactor
Aircraft handling - not maintainedPilot in commandCause
Spatial disorientationPilot in commandCause
Lack of total experience in type of aircraftPilot in commandFactor
In flight collision with terrain/waterDescent - uncontrolled

Analysis

The acft was on an emerg med svc (ems/med-evac) flt with a plt & flt nurse aboard to transport a maternity patient fm Flagstaff to phoenix. Drg a ngt arrival, the plt bgn a vor-a apch in IMC, then he rprtd a problem with his avionics & elected to make a missed apch. Drg the missed apch, he said that he 'lost' an inverter, then rprtd the gyros were inop. Radar vectors were being provided when he stated 'we have big trouble here.' Soon thereafter, radar & radio ctc were lost & the acft crashed aprx 7 mi se of the arpt. Drg impact, the acft made a deep crater & was demolished. No preimpacteng or airframe failure was fnd. An inv revealed the #2 (coplt's) attitude indcr was inop on the prev flt. A discrepancyrprt was taken to the avionics dept, but the reqd entry was not made in the acft form-4. The plt tkof before corrective action was taken. The opns manual reqd 1000 hrs multi-eng time as PIC & trng by designated cfi's. the plt had aprx 837 hrs multi-eng time, recd 9 trng flts in N6858S with non-designated instructors, completed a part 135 flt chk on 2/17/88.

Aircraft

Registration
N6858S
Reported as
Cessna 441
Category
Airplane
Serial number
0253
Airframe hours
3,349
Engine
Airesearch TPE-331, 635 horsepower, turbo prop
Damage
Destroyed
Flight
Part 135
Operator
Samaritan Health Services
Registered owner
Cessna Finance Corp.
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · February 10, 1987 · 239 hours before
Departed
PHX · Phoenix, AZ
Destination
FLG · Flagstaff, AZ
Flight plan
IFR

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
27
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
2,311 total · 24 in this make and model · 256 in the last 90 days · 100 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
40° at 7 knots
Visibility
1 statute miles
Lowest ceiling
1,200 ft broken
Temperature
25 °F, dew point 21 °F
Altimeter
30.00 inHg
Observed at
FLG

FAA reports on this event · 1

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