# NTSB LAX95LA315: Cessna 421C, N745CA, Chinle, AZ, August 28, 1995 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: August 27, 1995, 20:03 local (Aug 28, 1995, 03:03 UTC) - Place: Chinle, AZ - Coordinates: 36.229499, -109.56919 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.2295&lon=-109.5692&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report March 21, 1996 - Report: Approved by Office Director - NTSB case key (mKey): 29203 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX95LA315 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/29203/pdf - Page: https://openairdocs.org/ntsb/LAX95LA315 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Overrun, landing - roll - light condition - dark night (contributing factor) - airport facilities,runway/landing area condition - high obstruction(s) - airport facilities,runway/landing area condition - rough/uneven - weather condition - tailwind - wind information - not available, airport personnel (contributing factor) - insufficient standards/requirements, company/operator mgmt (contributing factor) - wrong runway - selected, pilot in command (cause) - proper touchdown point - not attained, pilot in command (cause) - On ground/water collision with object, landing - roll - terrain condition - ditch - object - pole - Gear collapsed, landing - 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](https://openairdocs.org/aircraft/N745CA), registered now, S/N 421C1043 (OpenAirDocs) - Reported make and model: CESSNA 421C - Registry model: [Cessna 421C](https://openairdocs.org/model/cessna-421c) (registry code 2076016) (OpenAirDocs) - Registry engine: [NONE](https://openairdocs.org/engine/none) (registry code 00000, none) (OpenAirDocs) - Category: Airplane - Serial number: 421C-1043 - Airframe hours: 4087 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 33; 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 (OpenAirDocs). - [Accident 19950827027079A](https://openairdocs.org/incident/19950827027079A), Aug 27, 1995: Cessna 421C, Chinle, AZ, Substantial damage. Overran runway landing with a 30 knot tailwind. Touchdown midway. Wanted to avoid obstacles for landing on 35. 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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.