LAX95LA315

NTSB accident investigation · Cessna 421C · Chinle, AZ · August 28, 1995

Accident · No injuriesLimited investigationFinal report
Date
August 27, 1995, 20:03 local (Aug 28, 1995, 03:03 UTC)
Place
Chinle, AZ
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N745CACessna 421C
Weather
Visual (VMC) · Night/dark
Status
Completed · report March 21, 1996
Report
Approved by Office Director
FAA report
19950827027079A
Case key
29203

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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Probable cause

the pilot's selection of a runway inappropriate for the tailwind condition and his resultant failure to achieve a touchdown point which would allow the aircraft to stop prior to over running the departure end. The rough condition of the dirt runway, the lack of lighted wind indicators, and the operator's failure to develop procedures for night operations at the airport are factors in the accident.

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.

OverrunLanding - roll
Light condition - dark nightFactor
Airport facilities,runway/landing area condition - high obstruction(s)
Airport facilities,runway/landing area condition - rough/uneven
Weather condition - tailwind
Wind information - not availableAirport personnelFactor
Insufficient standards/requirementsCompany/operator mgmtFactor
Wrong runway - selectedPilot in commandCause
Proper touchdown point - not attainedPilot in commandCause
On ground/water collision with objectLanding - roll
Terrain condition - ditch
Object - pole
Gear collapsedLanding - roll
Landing gear - overload

Analysis

The aircraft is based at the dirt airstrip to provide aeromedical evacuation capability for the Navajo Nation. The pilot landed on runway 17 to avoid obstacles on the approach end of runway 35 during the night landing. The Navajo authorities said the winds were southerly at about 30 knots when the aircraft attempted to land. The windsock is not illuminated, and neither the airport nor the CTAF are attended after dark. The pilot said that after touchdown as the aircraft passed the hangar he observed the windsock sticking straight out indicating a tailwind. The pilot said he applied maximum braking, but could not stop prior to over running the departure end of the runway. The aircraft traveled down an embankment, through a ditch, and collided with two steel irrigation posts before coming to rest. FAA inspectors traveled to the accident site and examined both the runway and the aircraft. The touchdown point for the aircraft was identified as about the midpoint of the runway. Tire marks were apparent from that point to where the aircraft left the departure end of the runway and went through a cattle guard. A ditch was associated with the cattle guard. The FAA inspector said the ground distance traveled from the touchdown point was about the normal ground roll for the aircraft under the reported 20- to 30-knot tailwind condition. No discrepancies were identified with the aircraft.

Factual narrative

On August 27, 1995, at 2003 mountain standard time, a Cessna 421C, N745CA, overran the departure end of the runway while landing at Chinle, Arizona, and collided with ground obstructions and terrain. The aircraft was owned and operated by Critical Air Medicine, Inc., of San Diego, California, and was on a positioning flight returning from an aeromedical patient evacuation mission. Visual meteorological conditions prevailed at the time and no flight plan was filed. The aircraft sustained substantial damage. The certificated airline transport pilot and the flight nurse, the sole occupants, were not injured. The flight originated at Phoenix, Arizona, on the day of the accident at 1845.

According to information obtained from the Federal Aviation Administration (FAA), the operator and the Navajo Nation authorities, the aircraft is based at Chinle to provide medical evacuation capability for the Navajo community. The pilot and nurse had taken a patient to Phoenix and were returning to Chinle in a second company aircraft which had completed a maintenance inspection at Phoenix. The pilot landed on runway 17 to avoid obstacles on the approach end of runway 35 during the night landing. The pilot told local Navajo authorities immediately after the accident that after touchdown as the aircraft passed the hangar he observed the windsock "sticking straight out indicating a tailwind." The pilot said he applied maximum braking, but could not stop prior to over running the departure end of the runway. The aircraft traveled down an embankment, through a ditch, and collided with two steel irrigation posts before coming to rest.

The Navajo authorities said the winds were southerly at about 30 knots when the aircraft attempted to land. The windsock is not illuminated.

FAA operations and airworthiness inspectors from the Scottsdale, Arizona, Flight Standards District Office, traveled to the accident site on August 28, 1995. Both the runway and the aircraft were examined. The airport does not have any wind indicators which would be visible during the hours of darkness. The touchdown point for the aircraft was identified as about the midpoint of the runway. Tire marks were apparent from that point to where the aircraft left the departure end of the runway and went through a cattle guard. A ditch was associated with the cattle guard. According to the operations inspector, the ground distance traveled from the touchdown point was about the normal ground roll for the aircraft under the reported 20- to 30-knot tailwind condition.

The aircraft was observed in the company hangar at the airport. The landing gear had collapsed. Examination of the landing gear and the ditch associated with the cattle guard revealed evidence and ground scars that the gear collapsed as a result of overload when the aircraft went through the ditch. The encounter with the ditch and the resultant collapse disrupted the brake hydraulic lines. No discrepancies were identified with the aircraft.

Aircraft

Registration
N745CA
Reported as
Cessna 421C
Category
Airplane
Serial number
421C-1043
Airframe hours
4,087
Engine
Continental GTSIO-520N, 375 horsepower, reciprocating
Damage
Substantial damage
Flight
Positioning · Part 91
Registered owner
Critical Air Medicine, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · June 28, 1995 · 89 hours before
Departed
PHX · Phoenix, AZ
Destination
Q32
Airport
Q32 · Chinle Airport, runway 35, 4,200 × 60 ft, dirt

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
33
Certificates
Airline transport, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
2,500 total · 40 in this make and model · 1,500 as pilot in command · 40 in the last 90 days · 4 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/dark
Wind
160° at 12 knots, gusting 30
Visibility
10 statute miles
Lowest ceiling
None
Temperature
77 °F, dew point 55 °F
Altimeter
30.00 inHg
Observed at
Q32

FAA reports on this event · 1

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