ATL97LA022

NTSB accident investigation · Cessna 421C · St. Petersburg, FL · December 8, 1996

Accident · Serious injuriesLimited investigationFinal report
Date
December 8, 1996, 12:30 local (17:30 UTC)
Place
St. Petersburg, FL
Injuries
1 serious, 2 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N5195CCessna 421C
Weather
Visual (VMC) · Day
Status
Completed · report September 5, 1997
Report
Approved by Office Director
FAA report
19961208037549A
Case key
3810

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

improper installation of the new starter adapter by maintenance personnel.

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.

Loss of engine powerClimb - to cruise
Engine accessories,engine starter - flow restrictedCause
Maintenance,installation - improperCompany maintenance personnelCause
Forced landingEmergency descent/landing
In flight collision with objectEmergency descent/landing
Object - tree(s)Cause

Analysis

The flight departed the airport in visual meteorological conditions. Shortly after takeoff, the pilot experienced a rough running right engine and a subsequent total loss of right engine power. The pilot elected to return to the airport for an emergency landing. The pilot stated he immediately shut down the right engine and feathered the propeller. The airplane collided with some trees and the ground as he maneuvered for the emergency landing. Service Bulletin, CSB 94-4, was issued on June 13, 1994, regarding starter adapter shaft gear and crank gear inspections. This bulletin required inspection and/or replacement of the starter adapter and crankshaft gear teeth. The right engine inspection disclosed that the holes of the starter adapter displayed marks typical of misalignment during installation of the adapter.

Factual narrative

On December 8, 1996, at 1230 eastern standard time, a Cessna 421C, N5195C, collided with the ground during an emergency landing attempt a mile southeast of the Clearwater Airport in St. Petersburg, Florida. The personal flight operated under the provisions of Title 14 CFR Part 91 with no flight plan filed. Visual meteorological conditions prevailed at the time of the accident. The airplane sustained substantial damage. The pilot received serious injuries and the two passengers received minor injuries. The flight departed St. Petersburg, Florida at 1225.

Shortly after takeoff, the pilot experienced a rough running right engine and a subsequent total loss of right engine power. The pilot elected to return to the airport for an emergency landing on runway 09. The pilot stated he immediately shut down the right engine and feathered the propeller. The tower advised him that runway 09 was closed and would have to land runway 35. After entering a downwind for 35, the pilot realized that he was unable to make the runway. He was then directed to land runway 04. He lost a significant amount of altitude through this maneuvering and subsequently collided with some trees and the ground.

Service Bulletin, CSB 94-4, was issued on June 13, 1994, regarding starter adapter shaftgear and crankgear inspections. This bulletin required inspection and/or replacement of the starter adapter and crankshaft gear teeth, of the TCM GTSIO-520 model engines. Compliance with this bulletin is required to prevent possible failure of the starter adapter shaftgear and/or crankshaft gear which can result in engine failure and/or metal contamination. Service Bulletin, CSB 94-4, was complied with, by installing a new starter adapter, part number 643259A17 and crankshaft gear.

Teledyne Continental Motors personnel performed a tear down of both engines. According to their Analytical Inspection Report, of the right engine, "Viewing the dowel holes of the starter adapter you can see marks that indicate the adapter was not straight when it was installed. If the adapter is not installed straight, the front pilot shaft could damage the needle bearing upon installation. The starter adapter needle bearing was broken up and the starter adapter shaft moved around, mutilating the needle bearing bore, contaminating the engine lubrication system with debris. Debris damaged and held the oil pressure relief valve off its seat allowing oil to bypass within the oil pump, and not supply oil flow downstream, which caused oil starvation to the engine." The number of hours accumulated on the engine, since Service Bulletin compliance, has not been determined.

Aircraft

Registration
N5195C
Reported as
Cessna 421C
Category
Airplane
Serial number
421CO656
Airframe hours
4,228
Engine
Continental GTSIO-520-L, 375 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
James L. Kingston
Registered owner
Haddad Restaurant Group, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 2, 1995
Departed
PIE
Destination
OJC · Olathe, MO
Airport
PIE · Clearwater, runway 17, 8,500 × 150 ft, asphalt

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
52
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
4,294 total · 1,577 in this make and model · 88 in the last 90 days · 30 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
330° at 12 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
64 °F, dew point 48 °F
Altimeter
30.00 inHg
Observed at
PIE

FAA reports on this event · 1

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