1987-11-15: Cessna 441 Conquest (N2484B) — United States Government — Mexicali, Mexico

2 fatalitiesMexicali, MexicoFlight

A US Customs Services Cessna 441 crashed into a ridge during a night tactical mission, resulting in the deaths of both crew members.

What happened

During an authorized night tactical mission, a Cessna 441 operated by the US Customs Services struck terrain. The flight began during daylight hours and transitioned into astronomical twilight. While navigating through varying light levels caused by ambient conditions and terrain features, the aircraft impacted a small ridge that rose 300 feet abruptly. The accident resulted in two fatalities, as both occupants of the aircraft were killed in the collision.

Findings

Investigations into the crash identified several contributing factors related to crew performance and environmental conditions. A primary issue involved the lack of proper dark adaptation; the pilots failed to allow their vision to adjust to night conditions, a process that was further complicated by fluctuating light levels encountered during the flight. Additionally, the co-pilot lacked the necessary qualification for this specific aircraft type and did not meet the currency standards required by the operator.

Several operational failures were noted regarding the pilot in command, including inadequate altitude maintenance and an inability to properly judge the terrain's elevation. The crew also struggled with task overload and insufficient visual lookout procedures. The investigation concluded that the pilot in command failed to maintain proper altitude, misjudged the terrain, and suffered from excessive workload, while the co-pilot's lack of recent instrument training and inadequate transition training further compromised the safety of the flight.

Probable cause

The accident was caused by the pilot's failure to maintain proper altitude and judge terrain elevation during night operations, exacerbated by a lack of crew dark adaptation and unqualified flight crew members.