CEN09LA284

NTSB accident investigation · Cessna 421B · Alpine, TX · May 8, 2009

Accident · Minor injuriesLimited investigationFinal report
Date
May 8, 2009, 10:30 local (15:30 UTC)
Place
Alpine, TX
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N60HGCessna 421B
Defining event
Initial climb: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report April 22, 2010
Report
Approved by Office Director
NTSB office
Central Region
Parties
Cessna Aircraft Company, FAA FSDO, Continental Aircraft Engines
FAA report
20090508053949A
Case key
73805

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The loss of engine power due to disengagement of the magneto idler gear support pin.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Engine (reciprocating)Aircraft › Aircraft power plant · MalfunctionCessna 421B: 2 casesAll aircraft: 497 casesProbable cause
Maintenance/inspectionsAircraft › Aircraft handling/service · Not specifiedCessna 421B: 3 casesAll aircraft: 103 cases
Ignition system: magneto/distributorAircraft › Aircraft power plant · MalfunctionCessna 421B: 1 caseAll aircraft: 101 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

Shortly after departure, when the airplane was about 400 feet in the air, the right engine stopped producing power. The pilot conducted a forced landing in a nearby field. An on-site inspection revealed that the airplane fuel tanks contained plenty of fuel. A post accident examination of the engines was conducted. An engine monitor was downloaded; a sudden decrease in cylinder head (CHT) and exhaust gas (EGT) temperature readings were observed for the right engine. A visual inspection of the engine revealed that the idler gear support pin, located on the rear of the engine, had backed out. The idler pin's retaining hardware (two nuts and lock-washers) were missing. The idler pin's movement allowed the idler gear to drop and become disconnected from the magnetos drive gear, resulting in a loss of engine ignition. Additionally, due to the mis-located idler gear, the accessory drive gears on the cam and crankshafts were either ground down or broken. Disassembly of the engine, found numerous metal pieces in the engine's oil sump.

Factual narrative

On May 8, 2009, approximately 1030 central daylight time, a twin-engine Cessna 421B, N60HG, was substantially damaged during a forced landing following the loss of engine power shortly after takeoff, near Alpine, Texas. The commercial pilot, sole occupant, received minor injuries during the forced landing. The airplane was registered and operated by O'Hara Flying Service, Amarillo, Texas. Visual meteorological conditions prevailed and a flight plan was not filed for the Title 14 Code of Federal Regulations Part (CFR) 91 positioning flight destined for the Rick Husband Amarillo International Airport (AMA), Amarillo, Texas. The pilot reported that, shortly after takeoff when the airplane was about 400 feet in the air, the right engine stopped producing power. As the pilot reached up to feather the right engine, the left engine "surged and sounded like it was going to quit." The pilot moved the engine controls forward, and looked for a place for a forced landing. The pilot added that he felt he did not have full power on the left engine. The airplane impacted several small bushes during the off-airfield landing. A Federal Aviation Administration (FAA) inspector who responded to the site reported that the airplane had plenty of fuel and that it appeared consistent with 100LL aviation grade fuel. An examination of the aircraft wreckage was conducted by the NTSB Investigator-in-Charge (IIC), along with technical representatives from the airframe and engine manufacturers, at Air Salvage of Dallas (ASOD) on 28 May, 2009. A JPI engine monitor was downloaded; a sudden decrease in cylinder head (CHT) and exhaust gas (EGT) temperature readings were observed for the right engine. A visual inspection of the engine revealed that the idler gear support pin, located on the rear of the motor, had backed out. The idler pin's retaining hardware (two nuts and lock-washers) were missing. The idler pin's movement allowed the idler gear to drop, and become disconnected from the magneto drive gears, resulting in a loss of engine ignition. The idler gear teeth were severely worn. Additionally, the accessory drive gears on the cam and crankshafts were either ground down or broken. Disassembly of the engine, found numerous metal pieces in the engine's oil sump. Examination of the left engine and engine monitor readings, revealed no apparent abnormalities. The engine was rotated to obtain thumb compression and drive train continuity. Each cylinder was borescoped; the sparkplugs were light gray in color and appeared "normal." The magnetos were removed and rotated by hand, producing spark at each terminal. The engine's oil filer was cut open, inspected, and was found to be clear of any metal.

Aircraft

Registration
N60HG
Reported as
Cessna 421B
Category
Airplane
Serial number
421B0534
Airframe hours
7,543
Engines
Cont Motor GTSIO-520-C, 340 horsepower, reciprocatingCont Motor GTSIO-520-C, 340 horsepower, reciprocating
Damage
Substantial damage
Flight
Positioning · Part 91
Operator
O'Hara Flying Service II Lp
Registered owner
O'Hara Flying Service II Lp
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · April 1, 2009
Departed
Alpine, TX
Destination
AMA · Amarillo, TX
Airport
E38 · Alpine-Casparis Municipal Apt

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
49
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
February 9, 2009
Seat
Left
Flight hours
8,818 total · 95 in this make and model · 8,060 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
230° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
88 °F, dew point 36 °F
Altimeter
29.94 inHg
Observed at
KE38

Docket · 5

The files NTSB released with the investigation on February 3, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.0 MB in all.

FAA reports on this event · 1

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