# NTSB ATL05FA032: Cessna 421B, N421SD, Apison, TN, December 2, 2004 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 2, 2004, 13:24 local (18:24 UTC) - Place: Apison, TN - Coordinates: 35.081111, -85.009162 - Nearby events: https://openairdocs.org/map.md?lat=35.0811&lon=-85.0092&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 5 fatal, 1 serious - Status: Completed, report June 8, 2005 - Report: Approved by Office Director - Parties: Cessna Aircraft Company, Nashville FSDO-03, Teledyne Continental - NTSB case key (mKey): 60666 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL05FA032 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/60666/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=60666 - Page: https://openairdocs.org/ntsb/ATL05FA032 ## Probable cause The pilot's improper identification of a partial loss of engine power on initial takeoff climb resulting in a collision with trees and the ground. A factor was a partial failure of the left engine starter adapter due to overload. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(partial) - mech failure/malf, takeoff - initial climb - 1 engine (contributing factor) - engine accessories,engine starter - overload (contributing factor) - In flight collision with terrain/water, descent - emergency - emergency procedure - improper, pilot in command (cause) - object - tree(s) - terrain condition - ground ## Analysis The airline transport pilot (ATP) stated the airplane was between 200 to 300 feet on initial takeoff climb when the right engine lost power and the airplane yawed to the right. The pilot lowered the nose of the airplane to gain airspeed, pulled the right power lever rearward and nothing happened. The pilot did not feather the right propeller and started moving switches in the vicinity of the boost pump switches. The ATP passenger stated, he did not think the left engine was producing full power. He scanned the instruments with his eyes looking at the manifold pressure gauges. "One needle was at zero and the other was at 25-inches. The manifold pressure should have been 39-inches of manifold pressure. The ATP passenger observed trees to their front and thought the pilot was trying to make a forced landing in an open field to their left. The ATP passenger realized the airplane was going to collide with the trees. Just before the airplane collided with the trees, the pilot feathered the right engine. The ATP passenger observed the right propeller going into the feather position, and the propeller came to a complete stop. Examination of the right engine revealed no anomalies. Examination of the left engine revealed the starter adapter gear teeth had failed due to overload. ## Factual narrative HISTORY OF FLIGHT On December 2, 2004, at 1324 eastern standard time, a Cessna 421B, N421SD, registered to Georgia Cumberland Conference of Seventh Day Adventist, operating as a 14 CFR Part 91 business flight, collided with trees and the ground while attempting a forced landing in the vicinity of Apison, Tennessee. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed. The flight plan was not activated. The airplane was destroyed and there was a post-crash fire. The commercial pilot, and four passengers were fatally injured. The airline transport pilot-rated passenger (ATP) reported serious injuries. The flight originated from Collegedale Municipal Airport, Collegedale, Tennessee, on December 2, 2004, at 1318. The ATP passenger seated in the right front cockpit seat stated the pilot departed from runway 03 without completing an engine run-up. The airplane was between 200 to 300 feet on initial takeoff climb when the right engine lost power and the airplane yawed to the right. The pilot lowered the nose of the airplane to gain airspeed, pulled the right power lever rearward and nothing happened. The pilot did not feather the right propeller and started moving switches in the vicinity of the boost pump switches. At one point the ATP passenger stated, he did not think the left engine was producing full power. He scanned the instruments with his eyes looking at the manifold pressure gauges. "One needle was at zero and the other was at 25-inches. The manifold pressure should have been 39-inches of manifold pressure. I assumed the zero reading on the manifold pressure was the right engine." The ATP passenger observed trees to their front and thought the pilot was trying to make a forced landing in an open field to their left. The ATP passenger thought the airplane would skim the top of the trees and they would be able to complete the forced landing to the open field. He then realized the airplane was going to collide with the trees. Just before the airplane hit the trees, the pilot feathered the right engine. The ATP passenger observed the right propeller going into the feather position, and the propeller came to a complete stop. As soon as the airplane came to a stop he observed he pilot slumped over in his seat, and then observed the airplane was on fire. He immediately exited the airplane, and departed the crash site seeking assistance. A witness stated he was walking in his front yard when he heard an airplane approaching. " The engine sounded like it was surging." The airplane approached his home from the south going north, and was located above the tee line. The witness observed the airplane make a left bank estimated at 20-degres degrees. The airplane disappeared from view behind the trees and smoldering smoke pursued. The witness called the emergency 911 operators, and notified them of the accident. He then observed an individual coming from the direction of the crash site and saw a ball of fire when the airplane exploded. Another witness who lives near the airport stated he and his wife were in their home when they heard an airplane approaching. He assumed that the airplane had departed from Collegedale Municipal Airport. The airplane sounded like a twin-engine airplane and it sounded as if the airplane was flying low. He went outside and observed the airplane flying towards him. The left engine was turning but he could not see propeller blades as if it was idling, and the engine sounded like a Harley engine. The right engine was not running. It appeared the pilot was trying to start the right engine. The propeller would turn and stop. It did this about two times. The airplane was about 100 feet high and was descending fast. The airplane was observed to start a left turn towards an open field in the vicinity of Pine Hill Road and McDonald Road. The witness stated he knew the airplane was in trouble and he told his wife that the airplane was going to crash. The airplane disappeared from view and he heard it hit the ground and subsequently observed smoke rising in the general area of Pine Hill Road and McDonald Road. He called the airport to report the accident and his neighbor called the 911 emergency operators. PERSONNEL INFORMATION Review of information on file with the FAA Airman's Certification Division, Oklahoma City, Oklahoma, revealed the commercial pilot was issued a commercial pilot certificate on August 30, 1994, with ratings for airplane single engine land, airplane multiengine land, and instrument airplane. In addition, the pilot held a flight instructor certificate issued on May 30, 2003, with ratings for airplane single engine land, and instrument airplane. The pilot also held an advanced ground instructor instrument certificate issued on June 19, 1992. In addition, the pilot held a mechanic airframe and power plant certificate issued on June 30, 1989. The pilot held a first class medical certificate issued on April 6, 2004, with no limitations. The pilot's last biennial flight review was completed on September 1, 2004. Review of information on file with the FAA Airman's Certification Division, Oklahoma City, Oklahoma, revealed the airline transport pilot rated passenger was issued an airline transport pilot certificate on August 23, 2002. In addition, the pilot holds a commercial pilot certificate with ratings for airplane single engine land and rotorcraft helicopter issued on August 23, 2002. The pilot holds a ground instructor certificate for advanced instruments issued on June 2, 1993. In addition, the pilot holds a flight instructor certificate with ratings for airplane single engine land, rotorcraft helicopter, and instrument airplane issued on March 10, 2004. The pilot holds a first class medical with no restrictions issued on July 1, 2004, and the pilot's last biennial flight review was not determined. AIRCRAFT INFORMATION A review of the airframe maintenance records revealed the last annual inspection was performed on September 22, 2004, at Hobbs meter 6741.4 hours. According to the maintenance manger for Georgia Cumberland Conference of Seventh Day Adventist, the airplane had flown 67.2 hours since the annual inspection. The left engine had 832 hours at the time of the accident. The right engine had 1,084 hours at the time of the accident. The total airframe hours at the time of the accident was 6,808 hours. The Hobbs meter at the crash site was not recovered. The airplane was last refueled with 79.9 gallons of 100 low lead fuel on December 2, 2004, at Chattanooga, Tennessee. The main fuel tanks were topped off to 50 gallons per side, and the auxiliary fuel tanks contained 30 gallons of fuel per side. Review of the engine logbook revealed Teledyne Continental Motors had completed Critical Service Bulletin (CSB) SB 94-4, STARTER ADAPTER SHAFTGEAR AND CRANKSHAFT GEAR INSPECTION on the right engine and installed new gears on April 16, 2000. Teledyne Continental Motors completed CSB 94-4B on the left engine on April 24, 2001. The operator's maintenance personnel had not recorded as completed the CSB94-4D or the Cessna Multi-Engine Service Bulletin MEB94-7 during the100-hour inspection or annual inspection. The Critical Service Bulletin states in a WARNING, "Compliance with this bulletin is required to prevent possible failure of the starter adapter shaft gear and or crankshaft gear which can result in metal contamination and or engine failure." According to records on file with the Georgia-Cumberland Conference of Seventh-Day Adventist, the Conference entered into a contract agreement with an individual for his services to serve as Aviation Manager providing maintenance and service on N421SD and 4 days of pilot time each month. The Aviation Manager stated Chattanooga Aero Service and Star Avionics worked on the airplane allot, to include oil changes. Chattanooga Aero Service stated they had not performed any annual inspections on N421SD. In addition, t ## Aircraft - Registration: [N421SD](https://openairdocs.org/deregistered/N421SD-2005-03-21), registration cancelled 2005-03-21, S/N 421B0386, built 1973 (OpenAirDocs) - Reported make and model: Cessna 421B - Registry model: [Cessna 421B](https://openairdocs.org/model/cessna-421b) (registry code 2076014) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 421BO386 - Airframe hours: 6808 - Engines: Lycoming GTSIO-520-H 375 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Business, Part 91 - Operator: Georgia Cumberland Conference of Seventh Day - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 22, 2004, 67 hours before - Departed: 3M3, Collegedale, TN - Destination: TYS, Knoxville, TN - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 36; injuries: fatal; commercial, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; last flight review September 1, 2004; seat: left; toxicology performed; flight hours: 4,475 total, 2,000 in this make and model, 4,250 as pilot in command, 120 in the last 90 days, 40 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: variable at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 52 °F, dew point 32 °F - Altimeter: 30.10 inHg - Observed at: CHA, 10 nm away ## 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 20041202034429A](https://openairdocs.org/incident/20041202034429A), Dec 2, 2004: Cessna 421B, Apison, TN, Destroyed, 5 fatal. (-23) On December 2, 2004 at 1324 east a Cessna 421B, was departing on runway 03 at collegedale municipal airport. The aircraft altitude was between 200 to 300… ## Docket (45 files) The files NTSB released with the investigation on March 31, 2005, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=60666. 27.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 393 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409416&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Supplement A (item 2, .PDF, 210 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40222852&FileExtension=.PDF&FileName=Supplement%20A-Master.PDF - Supplement B (item 3, .PDF, 227 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40222613&FileExtension=.PDF&FileName=Supplement%20B-Master.PDF - Supplement E (item 4, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409422&FileExtension=.PDF&FileName=Supplement%20E-Redacted.PDF - Supplement S (item 5, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40222615&FileExtension=.PDF&FileName=Supplement%20S-Master.PDF - Emergency 911 Log (item 6, .PDF, 142 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40222593&FileExtension=.PDF&FileName=Emergency%20911%20Log-Redacted.PDF - Left Engine Logbook (item 7, .PDF, 880 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409412&FileExtension=.PDF&FileName=Left%20Engine%20Logbook-Redacted.PDF - Right Engine Logbook (item 8, .PDF, 932 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409413&FileExtension=.PDF&FileName=Right%20Engine%20Logbook-Redacted.PDF - Propeller Logbook (item 9, .PDF, 449 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409419&FileExtension=.PDF&FileName=Propeller%20Logbook-Redacted.PDF - Airframe Logbook (item 10, .PDF, 605 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409423&FileExtension=.PDF&FileName=Airframe%20Logbook-Redacted.PDF - Other Code Sheet (item 11, .PDF, 83 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40222596&FileExtension=.PDF&FileName=Other%20Code%20Sheet-Master.PDF - Police Report (item 12, .PDF, 744 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409415&FileExtension=.PDF&FileName=Police%20Report-Redacted.PDF - Refueling Records (item 13, .PDF, 923 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409421&FileExtension=.PDF&FileName=Refueling%20Records-Redacted.PDF - Excerpt Cessna Owner's Manual (item 14, .PDF, 676 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40222853&FileExtension=.PDF&FileName=Excerpt%20Cessna%20Owner%27s%20Manual-Master.PDF - Statements (item 15, .PDF, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409424&FileExtension=.PDF&FileName=Statements-Redacted.PDF - Extract DUATS Flight Plan N421SD (item 16, .PDF, 206 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224226&FileExtension=.PDF&FileName=Extract%20DUATS%20Flight%20Plan%20N421SD-Master.PDF - Teardown Inspection of Propellers and Govenors (item 17, .PDF, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409425&FileExtension=.PDF&FileName=Teardown%20Inspection%20of%20Propellers%20and%20Govenors-Redacted.PDF - Materials Laboratory 15 - Factual Report 05-003 starter adapter gear (item 18, .PDF, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224461&FileExtension=.PDF&FileName=Materials%20Laboratory%2015%20-%20Factual%20Report%2005-003%20starter%20adapter%20gear-Master.PDF - Cessna's Ground Handling Servicing and Inspection extract (item 19, .PDF, 456 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225161&FileExtension=.PDF&FileName=Cessna%27s%20Ground%20Handling%20Servicing%20and%20Inspection%20extract-Master.PDF - Maps or Charts of Accident Area, Wreckage Diagrams (item 20, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225163&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20Wreckage%20Diagrams-Master.PDF - Aviation Management Contract (item 21, .PDF, 174 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409426&FileExtension=.PDF&FileName=Aviation%20Management%20Contract-Redacted.PDF - Engine Reports (item 22, .PDF, 363 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409427&FileExtension=.PDF&FileName=Engine%20Reports-Redacted.PDF - Cessna's Engineering Test Memo (item 23, .PDF, 211 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409429&FileExtension=.PDF&FileName=Cessna%27s%20Engineering%20Test%20Memo-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 24, .PDF, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409414&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 25, .PDF, 206 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409430&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report (item 26, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409431&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Photo 1 View of crash site and forced landing area (item 27, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224207&FileExtension=.PDF&FileName=Photo%201%20View%20of%20crash%20site%20and%20forced%20landing%20area-Master.PDF - Photo 2 View looking back down crash debris line (item 28, .PDF, 476 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224208&FileExtension=.PDF&FileName=Photo%202%20View%20looking%20back%20down%20crash%20debris%20line-Master.PDF - Photo 3 Tree branch with v-cut (item 29, .PDF, 475 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224209&FileExtension=.PDF&FileName=Photo%203%20Tree%20branch%20with%20v-cut-Master.PDF - Photo 4 Large tree with v-cut (item 30, .PDF, 460 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224210&FileExtension=.PDF&FileName=Photo%204%20Large%20tree%20with%20v-cut-Master.PDF - Photo 5 View of left wing and crach site (item 31, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224211&FileExtension=.PDF&FileName=Photo%205%20View%20of%20left%20wing%20and%20crach%20site-Master.PDF - Photo 6 Left wing fire damage (item 32, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224212&FileExtension=.PDF&FileName=Photo%206%20Left%20wing%20fire%20damage-Master.PDF - Photo 7 Right nacelle and cockpit inverted (item 33, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224213&FileExtension=.PDF&FileName=Photo%207%20Right%20nacelle%20and%20cockpit%20inverted-Master.PDF - Photo 8 View looking rearward (item 34, .PDF, 474 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224214&FileExtension=.PDF&FileName=Photo%208%20View%20looking%20rearward-Master.PDF - Photo 9 Left and right engine (item 35, .PDF, 493 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224215&FileExtension=.PDF&FileName=Photo%209%20Left%20and%20right%20engine-Master.PDF - Photo 10 Right nacelle inverted with fire damage (item 36, .PDF, 455 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224216&FileExtension=.PDF&FileName=Photo%2010%20Right%20nacelle%20inverted%20with%20fire%20damage-Master.PDF - Photo 11 Right side of fuselage and horizontal stablizer at rest inverted (item 37, .PDF, 482 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224217&FileExtension=.PDF&FileName=Photo%2011%20Right%20side%20of%20fuselage%20and%20horizontal%20stablizer%20at%20rest%20inverted-Master.PDF - Photo 12 Left rear view inverted (item 38, .PDF, 450 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224218&FileExtension=.PDF&FileName=Photo%2012%20Left%20rear%20view%20inverted-Master.PDF - Photo 13 Cockpit (item 39, .PDF, 496 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224219&FileExtension=.PDF&FileName=Photo%2013%20Cockpit-Master.PDF - Photo 14 Right side view (item 40, .PDF, 456 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224220&FileExtension=.PDF&FileName=Photo%2014%20Right%20side%20view-Master.PDF - Photo 15 Left engine and propeller assembly (item 41, .PDF, 465 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224221&FileExtension=.PDF&FileName=Photo%2015%20Left%20engine%20and%20propeller%20assembly-Master.PDF - Photo 16 Left engine (item 42, .PDF, 473 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224222&FileExtension=.PDF&FileName=Photo%2016%20Left%20engine-Master.PDF - Photo 17 Left propeller (item 43, .PDF, 494 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224223&FileExtension=.PDF&FileName=Photo%2017%20Left%20propeller-Master.PDF - Photo 18 Right engine (item 44, .PDF, 457 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224224&FileExtension=.PDF&FileName=Photo%2018%20Right%20engine-Master.PDF - Photo 19 Right Propeller (item 45, .PDF, 491 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224225&FileExtension=.PDF&FileName=Photo%2019%20Right%20Propeller-Master.PDF From the NTSB's public API. 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