# NTSB CHI02LA060: Cessna 414A, N6560C, Sturgis, MI, January 6, 2002 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: January 6, 2002, 12:30 local (17:30 UTC) - Place: Sturgis, MI - Coordinates: 41.80091, -85.419776 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.8009&lon=-85.4198&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious, 1 minor, 1 uninjured - Status: Completed, report August 28, 2002 - Report: Approved by Office Director - Parties: Teledyne Continental Motors, Federal Aviation Administration, Cessna Aircraft Company - NTSB case key (mKey): 53993 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI02LA060 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/53993/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=53993 - Page: https://openairdocs.org/ntsb/CHI02LA060 ## Probable cause the inadequate in-flight emergency planning/decision, the checklist not followed and excessive approach altitude by the pilot. Contributing factors were the loose oil return line and weather. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, climb - lubricating system,oil hose - loose (contributing factor) - In flight collision with terrain/water, missed approach (ifr) - in-flight planning/decision - inadequate, pilot in command (cause) - weather condition - other (contributing factor) - checklist - not followed, pilot in command (cause) - altitude - excessive, pilot in command (cause) ## Analysis The pilot attempted a single engine missed approach to the departure airport following a loss of right engine power during the departure climb phase of flight. The pilot reported that he was high on the approach and then feathered the propeller when the missed approach was executed. Instrument meteorological conditions prevailed at the time of the accident. Graphical performance data for the airplane shows a positive climb rate, at field conditions, of approximately 340 fpm based upon the airplanes checklist configuration for single engine flight. The data also shows a loss of single engine climb performance of 400 fpm if the propeller is not feathered in addition to a loss of 200 fpm with a flap setting of 15 degrees. Examination of the right engine revealed that the oil return line from the turbocharger to the scavenge oil pump was disconnected and did not exhibited stripping of the connectors threads. Removal of the engine’s oil pan also revealed the presence of metallic debris. Engine logbook information indicates that the last recorded maintenance performed on the engine was the engine's installation 31.7 hours prior to the accident. ## Factual narrative On January 6, 2002, at 1230 eastern standard time, a Cessna 414A, N6560C, piloted by a commercial pilot, was substantially damaged during an emergency landing on a frozen snow covered agricultural field following a single engine missed approach to the Kirsch Municipal Airport (IRS), Sturgis, Michigan. Instrument meteorological conditions prevailed at the time of the accident. The 14 CFR Part 91 personal flight was operating on an instrument rules flight plan. The pilot sustained minor injuries, one passenger sustained serious injuries and the remaining passenger was uninjured. The flight originated from IRS, at 1210, en route to the New Braunfels Municipal Airport (BAZ), New Braunfels, Texas. The pilot reported that the right engine lost power during a departure climb from IRS approximately 4,300 feet msl. He then received radar vectors for a return to the airport during which time the airplane began to lose altitude at a rate of 100-150 feet per minute. The pilot added that he flew the NDB 18 approach and found himself in a position too high to land, so he executed a missed approach and feathered the right engine's propeller. After finding that he was unable to avoid obstructions along the flight path, he elected to execute an emergency landing in a corn field. The pilot reported in a written statement, "...While the aircraft was hangared, 3 suitcases weighing [less than] 30 lbs each were placed into the aft section of the nose baggage compartment. Light weight Christmas gifts had been pre-loaded on [January 5, 2002]. A picnic basket [and] thermos bottle were secured inside the cabin." "Pre-flight, external walk-around inspection was accomplished inside the hangar and was unremarkable. The [right and left] engines showed 10 qts of oil [and] no oil was added from the previous flight on [January 2, 2002]. The aircraft was towed from the hangar [and] hangar secured." "The checklist before starting engines was completed. The engines started normally [and] easily." "Taxi for run-up [and] brake checks were unremarkable." "Before [Takeoff] checklist was accomplished on the taxiway. There were no abnormalities or irregularities." "...Following release, brakes were applied, final [directional gyro] check, flaps up, prop synchrophaser off, fuel pump ON determined. Throttles were advanced slowly, fuel flows [right and left] engines advanced normally [and] symmetrically. Engine gauges showed all needles in green arcs. Brakes released at 25" [manifold pressure]. Throttles advanced to full power. There was no abnormal power [right] or [left] engine on roll out. No braking was required. Lift off was at a point estimated to be 2000 - 2500' from runway threshold. Leveled off aircraft at 50', speed increased to 110 KIAS (blue line) [and] wheels (gear) was retracted when runway insufficient for landing. Climb out was at blue line (110 KIAS) to 500' AGL where first power reduction was made to top of green MP [and propeller] reduction to 2500 RPMs. The climb was continued at 120 KIAS. Power appeared normal in both engines. Entered bottom of overcast at 1550' MSL." "At 4000-4300' MSL, still in overcast layer, the [right] engine changed tone (no explosion or loud bang), the [right propeller] RPM decreased progressively [and] with moderate rapidity. Manifold pressure (MP) decrease similar to RPM decrease. Throttles, [propellers and] mixture controls were advanced full forward. Fuel selector switches were determined to be on [right and left] main tanks, respectively [and] fuel pumps were still on. I leveled the aircraft, determined the inoperative engine to be the [right] engine. I set up a [left] 5 [degree] bank into the good engine [and] applied [right] rudder to maintain direction." "A20 [air traffic control] was advised of [right engine power loss]. Continued stabilization was effected." "N6560C requested vectors for NDB 10 [approach] at IRS, Kirsh [Municipal] Airport. Shortly, thereafter, maximum [right] rudder was necessary to maintain vectored course heading." "I set up for NDB 18 with a 170 [degree] course heading. [Approach] plates were still mounted on the yoke clip. Gear was lowered [and] descent started. At 1500' the airport runways were not evident ( airport was covered with snow uniformly). Five clicks on 123.05 gave little to no help from lighting as it related to identification of runways. At the time [runway] 18 was identified, aircraft was too high to effect a normal or near normal transition for landing." "Next, I made a decision to attempt a go-around to avoid houses in the airport vicinity [and] downtown Strugis which was ahead of the aircraft. I applied full [left] throttle, [propeller and] mixture controls. At that time, the [right propeller] was feathered from its windmilling profile [and] I closed the [right] throttle [and right] mixture to idle/cut off. When in level flight, flaps were retracted from 15 [degrees] (1 notch)(maximum extension). Then when stable the gear was retracted. A [right] turn was then effected to avoid downtown Sturgis [and] surrounding city. I could not maintain level flight in a [right] bank. Altitude loss on the [vertical speed indicator] was 150-200 fpm. At full [left] engine throttle, [propeller and] mixture settings, clean." "After clearing one tree row with minimum clearance [and vertical speed indicator] still indicating 150-200 fpm descent, it was evident that the aircraft would not be above tree [and] telephone lines, which were visible ahead of me." "Next, I determined that a bank of the degree required to change direction in order to avoid the rapidly approaching trees [and] telephone lines, would probably result in a stall at low altitude with no means to recover before ground impact. I was approaching agricultural land." "Summarily, I changed course to miss an agricultural sprinkler [and] at the same time direct the aircraft course toward a relative decreased density of trees in the next tree row." Next, I closed down the [left] engine throttle, [propeller] to feather [and] mixture to off. Switched tanks to [right and left] off positions. [Magnetos] to off [and] then maintained 300 fpm descent to touchdown." "The terrain was previously plowed agricultural land. The snow, unfortunately, provided less friction on the fuselage. The aircraft slid across US-12 and came to rest approximately 20' from the road with the nose between two trees which were approximately 20' apart." "The passengers were advised to exit the aircraft, immediately and they did so under their own power..." The pilot reported sustaining a laceration to his lower lip and the passenger seated in the aft facing seat behind the right front seat sustained a fracture of the second lumbar vertebrae. The remaining passenger who was seated in the right front seat did not receive any injuries. The IRS automated weather observing system recorded: at 1201, an overcast ceiling 500 feet agl, visibility of 1 1/4 sm in mist, temperature of 1 C, and altimeter setting of 29.75 inches of Hg. at 1221, an overcast ceiling 500 feet agl and visibility of 1 1/2 sm in mist, temperature of 1 C, and altimeter setting of 29.75 inches of Hg. at 1238, an overcast of 700 feet agl, visibility of 2 sm in mist, temperature of 1C, and altimeter setting of 29.75 inches of Hg. The NDB 18 approach at IRS has approach minimums of 1500 feet msl and 1 sm visibility for category A and B aircraft. The touchdown zone elevation and the airport elevation were 915 msl and 925 feet msl, respectively. Runway 18 was equipped with a visual slope approach indicator and pilot controlled runway end identifier lights. The engine inoperative procedure for an engine failure during flight at a speed above air minimum control speed is listed in the Cessna 414A pilot's operating handbook as: 1. Inoperative Engine - DETERMINE. Idle engine same side as idle foot. 2. Operative ## Aircraft - Registration: [N6560C](https://openairdocs.org/deregistered/N6560C-2010-03-25), registration cancelled 2010-03-25, S/N 414A0013, built 1977 (OpenAirDocs) - Reported make and model: Cessna 414A - Registry model: [Cessna 414A](https://openairdocs.org/model/cessna-414a) (registry code 2075907) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 414A0013 - Airframe hours: 2570.7 - Engines: Continental TSIO-520N 310 horsepower reciprocating; Continental TSIO-520N 310 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Mid Continent Aire LTD - Airworthiness certificate: Standard, Utility - Last inspection: Annual, January 19, 2001, 39.4 hours before - Departed: IRS, Sturgis, MI - Destination: BAZ, New Braunfels, TX - Flight plan: IFR - Airport: IRS, Kirsch Municipal Airport, runway 18, 5,700 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: minor; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; last flight review August 20, 2001; seat: left; flight hours: 2,051 total, 723 in this make and model, 1,956 as pilot in command, 23 in the last 90 days, 10 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Day - Wind: 340° at 6 knots - Visibility: 2 statute miles - Lowest ceiling: 700 ft overcast - Temperature: 34 °F, dew point 30 °F - Altimeter: 29.75 inHg - Observed at: IRS, 2 nm away ## 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 20020106000789A](https://openairdocs.org/incident/20020106000789A), Jan 6, 2002: Cessna 414A, Sturgis, MI, No damage. (.19) On January 6, 2002, at 1230 eastern standard time, a Cessna 414A, N6560C, piloted by a commercial pilot, was substantially damaged during an emergency… ## Docket (19 files) The files NTSB released with the investigation on August 2, 2002, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=53993. 18.3 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 764 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40378359&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Record of Interview (item 2, .PDF, 383 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40378360&FileExtension=.PDF&FileName=Record%20of%20Interview-Redacted.PDF - Map of Accident Area (item 3, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40163779&FileExtension=.PDF&FileName=Map%20of%20Accident%20Area-Master.PDF - Weather Information (item 4, .PDF, 423 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40163780&FileExtension=.PDF&FileName=Weather%20Information-Master.PDF - Radar Data (item 5, .PDF, 441 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40163781&FileExtension=.PDF&FileName=Radar%20Data-Master.PDF - Approach Information (item 6, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40163782&FileExtension=.PDF&FileName=Approach%20Information-Master.PDF - Cessna 414A Aircraft Information (item 7, .PDF, 156 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40163783&FileExtension=.PDF&FileName=Cessna%20414A%20Aircraft%20Information-Master.PDF - Maintenance Log Excerpts (item 8, .PDF, 195 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40378361&FileExtension=.PDF&FileName=Maintenance%20Log%20Excerpts-Redacted.PDF - Turbocharger Parts Manual Excerpt (item 9, .PDF, 196 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40163785&FileExtension=.PDF&FileName=Turbocharger%20Parts%20Manual%20Excerpt-Master.PDF - Airplane Flight Manual Supplement (item 10, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40378362&FileExtension=.PDF&FileName=Airplane%20Flight%20Manual%20Supplement-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 11, .PDF, 327 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40378365&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Photo 1. Aircraft Wreckage (item 12, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40163943&FileExtension=.PDF&FileName=Photo%201.%20%20Aircraft%20Wreckage-Master.PDF - Photo 2. Aircraft Wreckage (item 13, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40163999&FileExtension=.PDF&FileName=Photo%202.%20%20Aircraft%20Wreckage-Master.PDF - Photo 3. Aircraft Wreckage (item 14, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40164000&FileExtension=.PDF&FileName=Photo%203.%20%20Aircraft%20Wreckage-Master.PDF - Photo 4. Aircraft Wreckage (item 15, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40164001&FileExtension=.PDF&FileName=Photo%204.%20%20Aircraft%20Wreckage-Master.PDF - Photo 5. Aircraft Wreckage (item 16, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40164002&FileExtension=.PDF&FileName=Photo%205.%20%20Aircraft%20Wreckage-Master.PDF - Photo 6. Aircraft Wreckage (item 17, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40164003&FileExtension=.PDF&FileName=Photo%206.%20%20Aircraft%20Wreckage-Master.PDF - Photo 7. Aircraft Wreckage (item 18, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40164004&FileExtension=.PDF&FileName=Photo%207.%20%20Aircraft%20Wreckage-Master.PDF - Photo 8. Aircraft Wreckage (item 19, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40164005&FileExtension=.PDF&FileName=Photo%208.%20%20Aircraft%20Wreckage-Master.PDF 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.