CEN15LA050

NTSB accident investigation · Cessna 401A · Fulton, MO · November 17, 2014

Accident · Serious injuriesLimited investigationFinal report
Date
November 17, 2014, 17:20 local (23:20 UTC)
Place
Fulton, MO
Injuries
3 serious
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N401MECessna 401A
Defining event
Takeoff: Loss of engine power (partial)
Weather
Visual (VMC) · Dusk
Status
Completed · report June 20, 2017
Report
Approved by Office Director
NTSB office
Central Region
Parties
Textron Aviation, Continental Motors Inc, FAA Kansas City FSDO
FAA report
20141117020969A
Case key
90400

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

A failure of the right engine magneto distributor drive gears, which resulted in a total loss of engine power during takeoff. Contributing to the accident was the operator’s failure to inspect and maintain the magnetos in accordance with the engine manufacturer’s specifications.

Findings · 2

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 · Fatigue/wear/corrosionCessna 401A: 1 caseAll aircraft: 497 casesProbable cause
Action: lack of actionPersonnel issues › Action/decision · Owner/builderCessna 401A: 1 caseAll aircraft: 792 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

The private pilot reported that, immediately after takeoff in the multi-engine airplane, the right engine experienced a total loss of power. The pilot aborted the takeoff; the airplane exited the end of the runway surface, impacted rough terrain, and came to rest upright. Examination of the right engine showed that the magneto distributor drive gears were not turning. Both damaged magnetos were removed and replaced with a slave set of magnetos. The right engine was installed in an engine test cell, and subsequently started and performed normally throughout the test cell procedure. The damaged magnetos from the right engine were disassembled. Both nylon magneto distributor gears exhibited missing gear teeth and brown discoloration. A review of maintenance records showed that the right engine had been operated for about 8 years and an estimated 697 hours since the most recent magneto overhauls had been completed. According to maintenance instructions from the engine manufacturer, the magnetos should be inspected every 500 hours and should be overhauled or replaced at the expiration of five years since the last overhaul. Guidance also indicated that discoloration of the drive gear is an indication that the gear had been exposed to extreme heat and should be replaced.

Factual narrative

On November 17, 2014, at 1720 central daylight time, a Cessna 401A, multi-engine airplane, N401ME, was substantially damaged after impacting terrain following a loss of engine power during takeoff at Elton Hensley Memorial Airport (FTT), Fulton, Missouri. The two pilots and the passenger all sustained serious injuries. The airplane was registered to and operated by Heartland Air, LLC; Mablelvale, Arkansas. Evening dusk visual meteorological conditions (VMC) prevailed at the time of the accident and an instrument flight rules (IFR) flight plan had been filed for the 14 Code of Federal Regulations Part 91 business flight. The intended destination was Memorial Field Airport (HOT), Hot Springs, Arkansas. The pilot reported that immediately after takeoff the right engine suddenly lost power and he aborted the takeoff. When the pilot saw he would not be able to stop on the runway he shut down the opposite engine. The airplane exited the end of the runway surface, impacted rough terrain, and came to rest upright. Fuel tanks were impact breached which resulted in a significant fuel spill, however there was no postimpact fire. Several witnesses called 9-1-1 emergency and ran to the wreckage location to provide aid to the three injured persons. An on-scene examination of the wreckage revealed no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. Both engines were removed and examined at the facilities of Continental Motors, Inc. in Mobile, Alabama. The left engine was installed in an engine test cell, and it performed normally throughout the test cell procedure. The right engine was installed in a test cell and several attempts to start the engine were unsuccessful. Examination showed that the magneto distributor drive gears were not turning. Both magnetos were removed and replaced with a slave set of magnetos. The right engine then started and preformed normally throughout the test cell procedure. The original magnetos from the right engine were then disassembled and both nylon magneto distributor gears had missing gear teeth and were observed to have discolored to a brown color. They were compared to a new nylon magneto distributor gear, which was white. A review of aircraft maintenance records for the right engine showed that the At the time of the accident, the right engine had been operated for about 8-years and an estimated 697 hours since the most recent magneto overhauls had been completed. At 1653 the automated weather observing system at Columbia Regional Airport (COU), Columbia, Missouri, located about 10 miles west from the accident location, reported wind from 290° at 19 knots gusting to 24 knots, visibility of 10 miles, scattered clouds at 5,000 feet, temperature minus 7° C, dew point minus 17° C, with an altimeter setting of 30.20 inches of Mercury. Data from the U.S. Naval Observatory showed that sundown occurred at 1653 and the end of evening civil twilight occurred at 1721. ADDITIONALINFORMATION According to the Continental Service Bulletin SB643B (April 6, 2005) Paragraph 3. A. "Magnetos … must be inspected every 500 hours …" Paragraph 4. C. "Magnetos must be overhauled or replaced at the expiration of five years since … the last overhaul … without regard to accumulated operating hours" According to the Continental S-20/S-200 Series High Tension Magneto Service Support Manual (August 31, 2011) Page 7-3. When servicing the magneto " … If the color of the gear has turned brown or the gear teeth are turning brown, the gear has been exposed to extreme heat, discard and replace the gear".

Aircraft

Registration
N401ME
Reported as
Cessna 401A
Category
Airplane
Serial number
401A0085
Built
1969
Airframe hours
6,434
Engines
Continental TSIO 520 E9, 300 horsepower, reciprocatingContinental TSIO 520 E8, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Business · Part 91
Operator
Heartland Air LLC
Registered owner
Heartland Air LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 1, 2014 · 241 hours before
Departed
FTT · Fulton, MO
Destination
HOT · Hot Springs, AR
Flight plan
IFR
Airport
FTT · Elton Hensley Memorial, runway 24, 3,203 × 50 ft, asphalt
Equipment
Stall warning system, Handheld GPS, Auto-pilot, Data recorder

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
63
Injuries
Serious
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
October 2, 2014
Seat
Left
Restraint
Lap only
Flight hours
2,949 total · 304 in this make and model · 41 in the last 90 days
Role
Pilot
Age
72
Injuries
Serious
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
October 3, 2013
Seat
Right
Restraint
Lap only
Flight hours
8,675 total · 1,850 in this make and model · 150 in the last 90 days

Weather

Conditions
Visual (VMC) · Dusk
Wind
290° at 19 knots, gusting 24
Visibility
10 statute miles
Lowest ceiling
None
Temperature
19 °F, dew point 1 °F
Altimeter
30.20 inHg
Observed at
KCOU, 10 nm away

Docket · 14

The files NTSB released with the investigation on May 2, 2017, on NTSB’s docket system: statements, records, photos and specialists’ reports. 11.6 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.