# NTSB LAX87FA119: Cessna 441, N6858S, Flagstaff, AZ, February 21, 1987

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: February 20, 1987, 18:45 local (Feb 21, 1987, 01:45 UTC)
- Place: Flagstaff, AZ
- Location: 35.1981° N, 111.6513° W: Placed by OpenAirDocs: center of Flagstaff, AZ, within about 6 miles (OpenAirDocs)
- Nearby events: https://openairdocs.org/map.md?lat=35.1981&lon=-111.6513&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 2 fatal
- Status: Completed, report October 13, 1988
- Report: Approved by Office Director
- NTSB case key (mKey): 25381
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX87FA119
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/25381/pdf
- Page: https://openairdocs.org/ntsb/LAX87FA119

## Sequence of events

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

- Airframe/component/system failure/malfunction, approach
  - maintenance,recordkeeping - improper
  - procedures/directives - not followed
  - inadequate surveillance of operation, company/operator mgmt (contributing factor)
  - electrical system - undetermined (cause)
  - electrical system,inverter - inoperative
  - flight/nav instruments,attitude indicator - inoperative
- Loss of control - in flight, approach
  - light condition - dark night (contributing factor)
  - weather condition - low ceiling (contributing factor)
  - weather condition - snow (contributing factor)
  - aircraft handling - not maintained, pilot in command (cause)
  - spatial disorientation, pilot in command (cause)
  - lack of total experience in type of aircraft, pilot in command (contributing factor)
- In flight collision with terrain/water, descent - 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](https://openairdocs.org/deregistered/N6858S-1988-07-15), registration cancelled 1988-07-15, S/N 4410253 (OpenAirDocs)
- Reported make and model: CESSNA 441
- Registry model: [Cessna 441](https://openairdocs.org/model/cessna-441) (registry code 2076020) (OpenAirDocs)
- Category: Airplane
- Serial number: 0253
- Airframe hours: 3349
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 27; 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 (OpenAirDocs).

- [Accident 19870220082019A](https://openairdocs.org/incident/19870220082019A), Feb 20, 1987: Cessna 441, Flagstaff, AZ, Destroyed, 2 fatal. Pilot missed VOR approach due to avionic problems. Reported no gyro. Lost control and crashed in densely wooded area

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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