# NTSB ATL97LA022: Cessna 421C, N5195C, St. Petersburg, FL, December 8, 1996 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: December 8, 1996, 12:30 local (17:30 UTC) - Place: St. Petersburg, FL - Location: 27.7709° N, 82.6793° W: Placed by OpenAirDocs: center of St. Petersburg, FL, within about 6 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=27.7709&lon=-82.6793&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious, 2 minor - Status: Completed, report September 5, 1997 - Report: Approved by Office Director - NTSB case key (mKey): 3810 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL97LA022 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/3810/pdf - Page: https://openairdocs.org/ntsb/ATL97LA022 ## Probable cause improper installation of the new starter adapter by maintenance personnel. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, climb - to cruise - engine accessories,engine starter - flow restricted (cause) - maintenance,installation - improper, company maintenance personnel (cause) - Forced landing, emergency descent/landing - In flight collision with object, emergency 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](https://openairdocs.org/deregistered/N5195C-1998-06-10), registration cancelled 1998-06-10, S/N 421C0656 (OpenAirDocs) - Reported make and model: Cessna 421C - Registry model: [Cessna 421C](https://openairdocs.org/model/cessna-421c) (registry code 2076016) (OpenAirDocs) - Category: Airplane - Serial number: 421CO656 - Airframe hours: 4228 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 52; 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 (OpenAirDocs). - [Accident 19961208037549A](https://openairdocs.org/incident/19961208037549A), Dec 8, 1996: Cessna 421C, St Petersburg-C, FL, Substantial damage. Shortly after departure right engine quit, unable to make runway, crash landed se of airport. (.4)the flight departed the airport in visual meteorological… 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.