Date & Time:
Nov 15, 1987 at 1815 LT
Type of aircraft:
Cessna 441 Conquest
Operator:
United States Government
Registration:
N2484B
Flight Phase:
Flight
Flight Type:
Survey / Patrol / Reconnaissance
Survivors:
No
Site:
Plain, Valley
Schedule:
San Diego - Palm Springs
MSN:
441-0112
YOM:
1979
Country:
Mexico
Region:
Central America
Crew on board:
1
Crew fatalities:
1
Pax on board:
1
Pax fatalities:
1
Other fatalities:
0
Total fatalities:
2
Aircraft flight hours:
1461
Circumstances:
A Cessna 441 operated by the US Customs Services collided with terrain while on an authorized night tactical flight. The copilot did not meet the currency standards as required by USCS and was not qualified in the aircraft. The flight originated during the daylight hours and continued to astronomical twilight. The pilots did not dark adapt previous to the night conditions. Dark adaption was impeded by flight through various light conditions created by terrain and ambient light levels. With night vision impeded the pilot would not have been able to distinguish relief of the terrain. The acft collided with a small ridge that abruptly rose 300 feet. Both occupants were killed.
Probable cause:
Occurrence #1: in flight collision with terrain/water
Phase of operation: maneuvering
Findings
1. (f) terrain condition - uphill
2. (c) altitude - misjudged - pilot in command
3. (f) excessive workload (task overload) - pilot in command
4. (f) light condition - night
5. (c) proper altitude - not maintained - pilot in command
6. (f) visual lookout - inadequate - pilot in command
7. (f) visual/aural detection - pilot in command
8. (f) visual lookout - inadequate - copilot/second pilot
9. (f) visual/aural detection - copilot/second pilot
10. (f) lack of recent instrument time - copilot/second pilot
11. (f) inadequate transition/upgrade training - copilot/second pilot
12. (f) in-flight planning/decision - inadequate - pilot in command
13. (f) crew/group coordination - inadequate - pilot in command
Phase of operation: maneuvering
Findings
1. (f) terrain condition - uphill
2. (c) altitude - misjudged - pilot in command
3. (f) excessive workload (task overload) - pilot in command
4. (f) light condition - night
5. (c) proper altitude - not maintained - pilot in command
6. (f) visual lookout - inadequate - pilot in command
7. (f) visual/aural detection - pilot in command
8. (f) visual lookout - inadequate - copilot/second pilot
9. (f) visual/aural detection - copilot/second pilot
10. (f) lack of recent instrument time - copilot/second pilot
11. (f) inadequate transition/upgrade training - copilot/second pilot
12. (f) in-flight planning/decision - inadequate - pilot in command
13. (f) crew/group coordination - inadequate - pilot in command
Final Report:
N2484B.pdf89.35 KB
