CEN23LA267

NTSB accident investigation · Cessna 421 · Rockport, TX · June 24, 2023

Accident · No injuriesClass 3 · LimitedFinal report
Date
June 24, 2023, 16:15 UTC
Place
Rockport, TX
Injuries
4 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N123SMCessna 421
Defining event
Enroute: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
FAA, Continental Aerospace Technologies
FAA report
20230624010359A
Case key
192468

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 failure of the left engine starter adapter gear, which resulted in catastrophic damage to other engine components, and the subsequent loss of engine power.

Findings · 1

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): recip eng rear sectionAircraft › Aircraft power plant · FailureCessna 421: 1 caseAll aircraft: 42 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 pilot reported that, while climbing through 6,000 ft above mean sea level (msl), the left engine tachometer generator went offline but the engine was still operating normally. He stated that about 2 minutes later, the left engine lost power and the airplane banked left. He attempted to stabilize the airplane with aileron and rudder control, but the airplane entered a spin. The pilot was able to regain control, but after the spin the right engine’s propeller was stopped and the left engine’s propeller was windmilling. The pilot executed a forced landing to a field and the airplane sustained substantial damage to the horizontal stabilizer. During a postaccident engine test run, the right engine operated normally. Examination of the left engine revealed the starter adapter gear had failed, which resulted in damage to other engine components that rendered the engine inoperable. The starter adapter was subject to an FAA Airworthiness Directive (AD), and an associated manufacturer mandatory service bulletin (SB). Maintenance records indicated that the AD and SB had been complied with less than 1 month and 10 operating hours before the accident. The mechanic that performed the SB inspection reported that he had performed this test numerous times in the past and did not find the procedures difficult but required patience. He recalled that the backlash on both starter adapter assemblies were well within the limits specified in the SB.

Factual narrative

On June 24, 2023, about 1615 central daylight time, a Cessna 421 airplane, N123SM, was substantially damaged when it was involved in an accident near Rockport, Texas. The pilot and three passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he had flown the airplane from the West Houston Airport (IWS), Houston, Texas, to the Corpus Christi International Airport (CRP), Corpus Christi, Texas, where he picked up the airplane owner and his friends for a return flight to IWS. He stated that they loaded 130 gallons of fuel while at CRP. Recorded ADS-B data indicated that the airplane departed CRP about 1545 and headed northeast. The pilot reported that once the airplane reached 6,000 ft msl, the left engine tachometer generator went offline but the engine still operated normally. However, about 2 minutes later, the left engine lost power and the airplane banked left. The pilot attempted to stabilize the airplane with aileron and rudder control, but the airplane entered a spin. He moved both throttles to idle, applied right rudder, and was able to regain control of the airplane. After leveling off, the right engine had stopped and the propeller was not windmilling. The left engine was not producing power but the propeller was windmilling. The pilot activated the left engine boost pump to the high setting and looked for areas to land while turning toward the nearest suitable airport; he then executed a forced landing to a field. After the accident, a test run of the right engine was performed; the right engine was able to run and produced rated engine power during the test run. A teardown examination of the left engine revealed that the starter adapter gear had failed. The failure stripped the teeth off the accessory gears, including the camshaft drive gear. The starter adapter was the subject of FAA Airworthiness Directive 2007-05-15, which was issued “to prevent failure of the starter adapter assembly and or crankshaft gear, resulting in failure of the engine and possible forced landing.” The AD required compliance with Continental Motors Mandatory Service Bulletin (SB) MSB94-4H. The SB detailed inspection and replacement procedures for the starter adapter assembly and crankshaft gear. Part 1 of the SB required various inspections if rough engine operation was detected. Part 2 of the SB detailed a visual backlash check of the viscous damper installed on the starter adapter while the starter adapter was still installed on the engine. Part 2 was to be complied with every 100 hours of engine operation and was to ensure that excessive wear was not present on the gears of the crankshaft or starter adapter gears. Part 3 of the SB required removal and visual inspection of the starter adapter and gear at 400 hour intervals. During the engine examinations, the backlash check described in part 2 of the SB was performed on the airplane’s intact right engine and excessivebacklash was not detected. Damage precluded performing the check on the left engine. Examination of the airplane’s maintenance records showed that part 2 of the SB had been complied with on June 2, 2023, on both engines during the airplane’s annual inspection. According to recorded engine monitor data, the airplane had completed 7 flights and 10 hours of flight time since the annual inspection. On the right engine, part 3 of the SB was complied with by replacement of the starter adapter on June 10, 2020. On the left engine, the starter adapter was removed, inspected and placed back in service on June 20, 2020, about 100 hours before the accident. There was no maintenance record for 2022 in the maintenance records reviewed. The mechanic that performed the SB reported that on the most recent annual inspection he performed part 2 of the SB and the readings were well within the specified limits listed in the SB. He noted that he had performed this check many times in the past and did not find the procedure difficult, just that it required patience to perform the checks.

Aircraft

Registration
N123SM
Reported as
Cessna 421
Category
Airplane
Serial number
421-0193
Built
1968
Airframe hours
6,831
Engines
Continental GTSIO-520D, 300 horsepower, reciprocatingContinental GTSIO-520D, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Fernair LLC
Registered owner
Fernair LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 2, 2023 · 10 hours before
Departed
CRP · Corpus Christi, TX
Destination
IWS · West Houston, TX
Flight plan
VFR
Equipment
ADS-B, Stall warning system, Auto-pilot

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
48
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
October 31, 2022
Seat
Left
Restraint
Lap only
Flight hours
1,171 total · 59 in this make and model · 983 as pilot in command · 105 in the last 90 days · 85 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
140° at 14 knots
Visibility
9 statute miles
Lowest ceiling
None
Temperature
91 °F, dew point 77 °F
Altimeter
29.92 inHg
Observed at
KRKP, 4 nm away
METAR
KRKP 242053Z AUTO 14014KT 9SM CLR 33/25 A2992 RMK AO2 SLP134 T03330250 56009 $

Docket · 10

The files NTSB released with the investigation on July 16, 2025, on NTSB’s docket system: statements, records, photos and specialists’ reports. 40.3 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.

Other investigations on N123SM · 2

Matched to the same aircraft by N-number and date.