CHI01FA329

NTSB accident investigation · Cessna 414 Riley Super-8 · Marshfield, WI · September 29, 2001

Accident · FatalField investigationFinal report
Date
September 29, 2001, 17:00 local (22:00 UTC)
Place
Marshfield, WI
Injuries
3 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N414NGCessna 414 Riley Super-8
Weather
Visual (VMC) · Day
Status
Completed · report November 25, 2003
Report
Approved by Office Director
Parties
Engine Components Inc., Federal Aviation Adminstration, Cessna Aircraft Company, Lycoming
FAA report
20010929026099A
Case key
53564

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 pilot's failure to maintain adequate airspeed (Vmc) which resulted in a loss of control. Contributing factors were the improper in-flight planning/decision not to land at a closer airport and the lack of recent experience in multiengine airplanes by the pilot-in-command, the cylinder head separation, the inadequate manufacturing process, and the lack of continued airworthiness instructions relating to the Riley Super-8 STC.

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 power(partial) - nonmechanicalClimb
Engine assembly - separationFactor
Facility inadequateManufacturerFactor
Inadequate surveillance of operationFaa(organization)Factor
Acft/equip,inadequate standard/requirementManufacturerFactor
Condition(s)/step(s) insufficiently definedManufacturerFactor
Engine assembly - service life exceededFactor
Loss of control - in flightApproach
Lack of recent experience in kind of aircraftPilot in commandFactor
In-flight planning/decision - inadequatePilot in commandFactor
Airspeed(vmc) - not maintainedPilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

The airplane was destroyed after an attempted landing following a reported partial power loss of the left engine while en route. The flight did not divert to the closest airport located about 27 nautical miles to the southwest while at an altitude of about 15,900 feet. This airport was a controlled field equipped with airport rescue and fire fighting (ARFF), and its longest runway was 9,005 feet. The flight diverted to the departure airport located about 93 nautical miles to the north. This airport was an uncontrolled field not equipped with ARFF, and its longest runway was 5,000 feet. No emergency was declared.

The airplane was reported by a witness to be too high and too fast to land on runway 34 at the airport. The winds were from 140 degrees at 6 knots. The wreckage distribution was consistent with an impact resulting from a Vmc (minimum control speed with the critical engine inoperative) roll to the left.

The pilot received a checkout from the right seat in the accident airplane by the airplane owner. The checkout was about 20 minutes in duration and did not include any single-engine flight maneuvers or emergency procedures. The owner did not hold a certified flight instructor certificate. The pilot had stopped flying for 12 years and just began giving flight instruction and flying in single-engine airplanes about a year prior to the accident. The pilot's recent multiengine flight experience was limited to a couple of non-revenue flights within the past year while seated in the right seat of a King Air. The King Air was used for commercial charter work which would involve one or two landings per flight. One landing was made on the day prior to the accident. The accident pilot asked the King Air pilot to accompany him along on the accident flight; the King Air pilot declined. A multiengine commercial rated pilot-rated passenger, who the accident pilot knew, was seated in the right front seat.

Examination of the airplane's supplemental type certificate (STC) revealed that the airplane had undergone numerous inspections by different maintenance personnel. The left engine's variable absolute pressure controller had safety wire around its control arm, which precluded its normal operation and a pressure relief valve that was not called for in the STC drawings. At the time of issuance, Federal Regulation's did not require STC instructions for continued airworthiness. Reliance on the airplane and engine maintenance manuals would not have provided enough information for continued airworthiness in accordance with the STC and could have yielded a setting exceeding those for which the STC parts were originally certificated to and thus increasing Vmc speed.

Examination of the left engine revealed a cylinder head separation on the number six cylinder assembly, which had accumulated an estimated time since installation of 240 hours. Visual inspection of the assembly revealed the presence of some undecipherable characters in its parts numbering. A cylinder head separation from another airplane was also examined. This cylinder assembly accumulated about 270 hours since installation. Both cylinder assembly examinations revealed the presence of additional material on the cylinder barrel threads and fatigue fracture on the cylinder head.

Factual narrative

On September 29, 2001, at 1700 central daylight time, a Cessna 414 Riley Super-8, N414NG, piloted by a commercial pilot, was destroyed on impact with terrain and fire near Marshfield Municipal Airport (MFI), Marshfield, Wisconsin. A report of a partial power loss on one engine was made to ATC during the en route phase of flight. Visual meteorological conditions prevailed at the time of the accident. The 14 CFR Part 91 flight was operating on an instrument flight rules flight plan. The pilot, pilot-rated passenger, and one other passenger were fatally injured. The flight departed from Alexander Field South Wood County Airport (ISW), Wisconsin Rapids, Wisconsin, en route to Poplar Bluff Municipal Airport (POF), Poplar Bluff, Missouri.

For full narrative please go to http://www.ntsb.gov/aviation/CHI01FA329_Factual_Narrative.pdf

Aircraft

Registration
N414NG
Reported as
Cessna 414 Riley Super-8
Category
Airplane
Serial number
414-0496
Engine
Lycoming IO-720-B1BD, 400 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Part 91
Registered owner
Potter and Son
Airworthiness certificate
Standard, Normal
Last inspection
Annual · November 1, 2000
Departed
ISW · Wisconsin Rapid, WI
Destination
POF · Poplar Bluff, MO
Flight plan
IFR
Airport
MFI · Marshfield Municipal

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
41
Injuries
Fatal
Certificates
Commercial, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1
Seat
Left
Toxicology
Performed

Weather

Conditions
Visual (VMC) · Day
Wind
140° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
59 °F, dew point 46 °F
Altimeter
30.35 inHg
Observed at
MFI

Docket · 133

The files NTSB released with the investigation on October 7, 2003, on NTSB’s docket system: statements, records, photos and specialists’ reports.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 401 KBMaterials Laboratory 15 - Factual Report 01-145Item 2 · .PDF · 1.4 MBMaterials Laboratory 15 - Factual Report 03-030Item 3 · .PDF · 1.7 MBWitness Statements and Record of InterviewItem 4 · .PDF · 1.2 MBWreckage DiagramItem 5 · .PDF · 27 KBWeather InformationItem 6 · .PDF · 63 KBATC TranscriptItem 7 · .PDF · 388 KBFederal Aviation Regulation 21.50Item 8 · .PDF · 133 KBCorrespondence with Family of Andrew MalyItem 9 · .PDF · 50 KBFuel ReceiptItem 10 · .PDF · 31 KBThe Advanced Pilot's Flight ManualItem 11 · .PDF · 837 KBPilot LogbookItem 12 · .PDF · 2.6 MBRadar Plot 1Item 13 · .GIF · 320 KBRadar Plot 2Item 14 · .GIF · 313 KBRadar Plot 3Item 15 · .GIF · 310 KBRadar Plot 4Item 16 · .GIF · 288 KBRadar Plot 5Item 17 · .GIF · 136 KBRadar Data 1Item 18 · .TXTRadar Data 2Item 19 · .TXT · 6 KBRadar Data 3Item 20 · .TXT · 6 KBRadar Data 4Item 21 · .TXT · 6 KBRadar Data 5Item 22 · .TXT · 6 KBRadar Data 6Item 23 · .TXT · 4 KBRiley Super 414-8 Flight Manual SupplementItem 24 · .PDF · 718 KBAirplane LogItem 25 · .PDF · 1.8 MBRight Engine LogItem 26 · .PDF · 1.4 MBLeft Engine LogItem 27 · .PDF · 808 KBCACIC Aviation InformationItem 28 · .PDF · 150 KBLeft Engine Cylinder Yellow TagsItem 29 · .PDF · 446 KBSTC SE4408SWItem 30 · .PDF · 69 KBWeight and BalanceItem 31 · .PDF · 69 KBAircraft Maintenance TechnologyItem 32 · .PDF · 273 KBCessna 414 Service ManualItem 33 · .PDF · 167 KBFAA-H-8083-3 Airplane Flying HandbookItem 34 · .PDF · 969 KBOther C414 Aircraft with IO-720 EnginesItem 35 · .PDF · 131 KBPilot Rated Passenger Airman Blue Ribbon ReportItem 36 · .PDF · 2.8 MBPilot Airman Blue Ribbon ReportItem 37 · .PDF · 2.2 MBToxicological ReportItem 38 · .PDF · 94 KBStatement of Party Representatives to NTSB InvestigationItem 39 · .PDF · 347 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 40 · .PDF · 68 KBPhoto 1. AirplaneItem 41 · .PDF · 155 KBPhoto 2. AirplaneItem 42 · .PDF · 117 KBPhoto 3. AirplaneItem 43 · .PDF · 180 KBPhoto 4. AirplaneItem 44 · .PDF · 194 KBPhoto 5. AirplaneItem 45 · .PDF · 200 KBPhoto 6. AirplaneItem 46 · .PDF · 217 KBPhoto 7. AirplaneItem 47 · .PDF · 209 KBPhoto 8. AirplaneItem 48 · .PDF · 195 KBPhoto 9. Propellers and Ground ScarItem 49 · .PDF · 297 KBPhoto 10. Ground Scar With Material Consistent With Red Navigation LightItem 50 · .PDF · 329 KBPhoto 11. Ground Scar With Material Consistent with The Windshield and Nose SectionItem 51 · .PDF · 292 KBPhoto 12. Ground Scar with Material Consistent with the Windshield and Nose SectionItem 52 · .PDF · 288 KBPhoto 13. Right EngineItem 53 · .PDF · 257 KBPhoto 14. Left EngineItem 54 · .PDF · 292 KBPhoto 15. PropellersItem 55 · .PDF · 150 KBPhoto 16. Right PropellerItem 56 · .PDF · 164 KBPhoto 17. Right PropellerItem 57 · .PDF · 148 KBPhoto 18. Left PropellerItem 58 · .PDF · 143 KBPhoto 19. Left PropellerItem 59 · .PDF · 141 KBLycoming Photo 1. Engine TeardownItem 60 · .PDF · 596 KB
All 133 files on NTSB’s docket

FAA reports on this event · 1

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