# NTSB CHI05FA212: Cessna 421C, N421KC, Wheeling, IL, August 5, 2005 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Field investigation · Final report - Date: August 5, 2005, 12:25 local (17:25 UTC) - Place: Wheeling, IL - Coordinates: 42.130001, -87.914443 - Nearby events: https://openairdocs.org/map.md?lat=42.1300&lon=-87.9144&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed, report February 26, 2007 - Report: Approved by Office Director - Parties: FAA-DuPage FSDO, Teledyne Continental Motors, Cessna Aircraft Company - ADs cited in the narratives: [AD 2005-20-04](https://openairdocs.org/ad/2005-20-04) (OpenAirDocs) - NTSB case key (mKey): 62190 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI05FA212 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/62190/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=62190 - Page: https://openairdocs.org/ntsb/CHI05FA212 ## Probable cause The pilot's improper in-flight decision to execute a go-around without raising the landing gear and raising the flaps to the full UP position, resulting in low airspeed and the airplane stalling. Contributing factors to the accident included the pilot's failure to comply with the manufacturer's mandatory service bulletin and the failure of the starter adapter shaft gear which resulted in the loss of power to the left engine, and the collision with the building. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, takeoff - initial climb - maintenance,service bulletin/letter - not complied with, pilot in command (contributing factor) - engine assembly,other - failure (contributing factor) - Loss of control - in flight, go-around (vfr) - go-around - attempted, pilot in command (cause) - in-flight planning/decision - improper, pilot in command (cause) - airspeed - low, pilot in command (cause) - stall - encountered, pilot in command - flight control,flap - extended (cause) - landing gear - extended (cause) - In flight collision with object, descent - uncontrolled - object - building(nonresidential) (contributing factor) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - dirt bank/rising embankment ## Analysis The twin-engine airplane sustained substantial damage when it impacted the top of a single-story industrial building and then impacted a landscape embankment and trees during an attempted single-engine go-around. The pilot reported that the left engine failed during initial climb. He feathered the left propeller and returned to the airport to execute an emergency landing. The pilot reported that he had "excessive speed" on final approach and "overshot the runway." When the airplane was at mid-field, the pilot elected to do a go-around. He did not raise the landing gear and the flaps remained about 15-degrees down. The airplane lost altitude and impacted the terrain about .5 miles from the airport. A witness reported seeing the airplane attempt to land on the runway twice during the same approach, but ballooned both times before executing the go-around. The Pilot's Operating Handbook (POH) "Rate-of-Climb One Engine Inoperative" chart indicated that about a 450-foot rate-of-climb was possible during the single-engine go-around if the airplane was in a clean configuration. The chart also indicated that a 350-foot penalty would be subtracted from the rate-of-climb if the landing gear were in the DOWN position, and additionally, a 200-foot penalty would be subtracted from the rate-of-climb if the flaps were in the 15-degree DOWN position. Inspection of the left engine revealed that the starter adapter shaft gear had failed. Inspection of the engine maintenance logbooks revealed that the Teledyne Continental Motors Service Bulletin CSB94-4, and subsequent revisions including the Mandatory Service Bulletin MSB94-4F, issued on July 5, 2005, had not been complied with since the last engine overhaul on July 17, 1998. The service bulletin required a visual inspection of the starter adapter every 400 hours. The engine logbook indicated that the engine had accumulated about 1,270 hours since the last overhaul. The service bulletin contained a WARNING that stated, "Compliance with this bulletin is required to prevent possible failure of the starter adapter shaft gear and/or crankshaft gear which can result in metal contamination and/or engine failure." ## Factual narrative HISTORY OF FLIGHT On August 5, 2005, at 1225 central daylight time, a Cessna 421C, N421KC, was destroyed when it impacted a commercial building and terrain while attempting a go-around about 0.5 miles northwest of the Palwaukee Municipal Airport (PWK), Wheeling, Illinois. The pilot and passenger received minor injuries. The Title 14 Code of Federal Regulations Part 91 personal flight departed from PWK at 1220 and was en route to Mackinac Island, Michigan. Shortly after takeoff, the pilot reported a loss of power to the left engine and circled southeast of the airport to land on runway 34. The pilot attempted to land on runway 34, but executed a go-around. Visual meteorological conditions prevailed at the time of the accident. No flight plan was filed. The pilot reported that he performed a preflight and departed to the northeast. At 600 feet above ground level (agl) he reduced power to 32.5 inches of manifold pressure (MAP) and 1,900 RPM. The pilot reported that an engine failed. He reported that he identified that the left engine failed and confirmed that the airplane was in a "clean" configuration. He contacted PWK tower and reported that he was returning to PWK for landing. The pilot reported that he was northeast of PWK when the engine lost power, and that the tower cleared him to land on runway 34. The pilot reported that while he was on the base leg for runway 34, he lowered the flaps to 30 degrees. He reported that he turned on to the final approach course, the airspeed was 115 knots and he planned to "cross the fence" at 100 knots. He lowered the landing gear and lowered the flaps to 45 degrees. The pilot reported, "Although the descent on final was not too steep, Gear Down, Flaps 45 degrees, and the throttle was in Idle position; I was unable to slow down the aircraft at all. I crossed the fence at 118 KIAS. Because of the excessive airspeed, I overshot the runway. At mid-field, when I realized that a safe landing can not be made, I push the Right throttle full forward and retracted the flaps to 15 degree and then to zero degree. I applied right rudder to maintain directional control and bank 5 degree to the Right. Right after retracting the flaps, I remember moving the landing gear to the UP position. (Although I realized later that the aircraft crashed with the gear in the down position.)" The pilot reported the when the airplane crossed the fence at the northwest side of the airport, he verified that the mixture, propeller, and throttle were fully forward, and the airplane was in the clean configuration. The pilot reported, "It felt like the RIGHT engine does not produce full power." The pilot reported that the airspeed continued to decrease and he was not able to gain any altitude. The airplane collided with the roof of a one story industrial building at 15-20 feet, and then impacted a landscape embankment and pine trees. The airplane came to rest on its belly. The pilot reported that he and the passenger evacuated the airplane immediately with only minor injuries. A witness reported that he observed the airplane attempt to land on runway 34 two times during the same approach. He observed the airplane first attempt to land near the intersection of runway 34 and runway 30, but the airplane ballooned up. The airplane attempted to land again but it ballooned up a second time. The witness heard the pilot add power and attempt a go-around. He reported that the airplane cleared the airport fence, but he lost sight of the airplane behind a tree line. He reported that the landing gear was down during the go-around. PERSONNEL INFORMATION The pilot held a private pilot's certificate with single-engine land, multiengine land, and airplane instrument ratings. The pilot reported that he had a total of 728 flight hours with 28 hours in make and model. He held a second-class medical certificate that was issued on September 22, 2004. The pilot purchased N421KC in May 2005. AIRCRAFT INFORMATION The airplane was a twin-engine Cessna 421C, serial number 421C-0028. The airplane seated 8 and had a maximum gross weight of 7,450 pounds. The engines were 375 horsepower Continental GTSIO-520-L engines. The last annual inspection was conducted on March 24, 2005. The airplane had flown about 35 hours since the last inspection and had a total time of about 6,870 hours. The engine maintenance logbooks indicated that the left and right engines were replaced with overhauled engines on July 17, 1998. As part of the engine overhauls, both engines had the starter adapter shaft gear and crankshaft gear inspection complied with per the Teledyne Continental Motors (TCM) Service Bulletin CSB94-4 along with the installation of the Service Kit EQ6642. The TCM Service Bulletin CSB94-4 was first issued on June 13, 1994, and the CSB94-4D was reissued as a Mandatory Service Bulletin, MSB94-4E. The latest revision of the Service Bulletin was Mandatory Service Bulletin MSB94-4F, issued on July 5, 2005. CSB94-4D states the following in GENERAL INFORMATION: "Continued operation of the GTSIO-520 and GIO-550 series engines with starter adapter viscous dampers that have been overheated can lead to distress and possible failure of the starter adapter shaft gear and crankshaft teeth." A "WARNING" in the Service Bulletin states: "Compliance with this bulletin is required to prevent possible failure of the starter adapter shaft gear and/or crankshaft gear which can result in metal contamination and/or engine failure." To comply with the Service Bulletin, the following procedures were required to be followed: 1. Unscheduled maintenance inspection due to rough engine operation (Part 1). 2. At every 100 hour or annual inspection (which ever occurs first) perform the inspections detailed in Part 2, "STARTER ADAPTER VISCOUS DAMPER and SHAFTGEAR BACKLASH INSPECTION". 3. Starter adapters with less than 400 hours total time in service must be inspected in accordance with the "VISUAL INSPECTION PROCEDURE" set forth in Part 3 of this bulletin upon the accumulation of 400 hours total time in service and every 400 hours time in service thereafter. 4. Starter adapters with more than 400 hours total time in service must be inspected in accordance with the "VISUAL INSPECTION PROCEDURES" set forth in Part 3 of this bulletin within the next 25 hours of operation and every 400 hours thereafter. 5. If needle bearing P/N 537721 is installed in the crankcase, it must be removed and replaced with the bushing P/N 654472. Refer to Part 3, paragraph 9 and also Part 4 on page 10 for installation instruction. Order bushing P/N 654472 separately, if required. 6. If service kit P/N EQ 6642R has not been installed prior to engine overhaul it must be installed at the next engine overhaul or at the time of starter adapter replacement, whichever occurs first. Refer to the latest revision of TCM SB97-6 or mandatory replacement parts. Refer to Part 5 for instructions for installing service kit EQ 6642R. NOTE: Both the crankshaft gear and the starter adapter assembly, included in EQ 6642R, must be replaced at the same time if the tooth wear of either the crankshaft gear or the starter adapter shaft gear is unacceptable in accordance with this bulletin. The left and right engine logbooks indicated that neither the TCM Service Bulletin CSB94-4 nor Mandatory Service Bulletin CSB94-4E had been complied with since the engines had been overhauled on July 17, 1998. The engines had accumulated about 1,272 hours since the last overhaul. The Federal Aviation Administration (FAA) issued Airworthiness Directive (AD) 2005-20-04 on November 1, 2005. The AD stated, "We are issuing this AD to prevent failure of the starter adapter assembly and or crankshaft gear, resulting in failure of the engine and possible forced landing." The AD further stated, "You must use TCM Mandatory Service Bulletin No. ## Aircraft - Registration: [N421KC](https://openairdocs.org/deregistered/N421KC-2013-06-13), registration cancelled 2013-06-13, S/N 421C-0028, built 1976 (OpenAirDocs) - Reported make and model: Cessna 421C - Registry model: [Cessna 421C](https://openairdocs.org/model/cessna-421c) (registry code 2076016) (OpenAirDocs) - Registry engine: [Continental GTSI0-520-F-K](https://openairdocs.org/engine/continental-gtsi0-520-f-k) (registry code 17031, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 421C-0028 - Airframe hours: 6835 - Engines: Continental GTSIO-520-L 375 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Goldeneagleco Ltd. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 1, 2005, 15 hours before - Departed: PWK, Wheeling, IL - Destination: MCD, Mackinac Island, MI - Flight plan: Unknown - Airport: PWK, Palwaukee Municipal Airport, runway 34, 5,000 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 51; injuries: minor; private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2; seat: left; flight hours: 728 total, 28 in this make and model, 15 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 70° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: 5,000 ft overcast - Temperature: 79 °F, dew point 61 °F - Altimeter: 30.23 inHg - Observed at: PWK ## 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 20050805024219A](https://openairdocs.org/incident/20050805024219A), Aug 5, 2005: Cessna 421C, Chicago/Wheelin, IL, Substantial damage. (-23) After takeoff from pwk, aircraft experienced left engine failure. Pilot declared an emergency and attempted to land on runway 34. Before touch down the… ## Docket (31 files) The files NTSB released with the investigation on November 24, 2005, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=62190. 15.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 295 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420311&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Witness Statement & Record of Interview (item 2, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270964&FileExtension=.PDF&FileName=Witness%20Statement%20%26%20Record%20of%20Interview-Master.PDF - Pilot Information (item 3, .PDF, 91 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270967&FileExtension=.PDF&FileName=Pilot%20Information-Master.PDF - Pilot Operating Handbook Information (item 4, .PDF, 186 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270968&FileExtension=.PDF&FileName=Pilot%20Operating%20Handbook%20Information-Master.PDF - Airworthiness Directive 2005-20-04 (item 5, .PDF, 311 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270969&FileExtension=.PDF&FileName=Airworthiness%20Directive%202005-20-04-Master.PDF - TCM Mandatory Service Bulletin MSB 94-4F (item 6, .PDF, 4 photos, 5.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270971&FileExtension=.PDF&FileName=TCM%20Mandatory%20Service%20Bulletin%20MSB%2094-4F-Master.PDF - Engine Information (item 7, .PDF, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270972&FileExtension=.PDF&FileName=Engine%20Information-Master.PDF - Excerpts From TCM Engine Teardown & Metallurgical Reports (item 8, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270973&FileExtension=.PDF&FileName=Excerpts%20From%20TCM%20Engine%20Teardown%20%26%20Metallurgical%20Reports-Master.PDF - TCM Analytical Department Engine/Component Release Form (item 9, .PDF, 36 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270974&FileExtension=.PDF&FileName=TCM%20Analytical%20Department%20Engine%2FComponent%20Release%20Form-Master.PDF - Airframe Maintenance Records (item 10, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420312&FileExtension=.PDF&FileName=Airframe%20Maintenance%20Records-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 11, .PDF, 290 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270976&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 12, .PDF, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420313&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo 1. View of Cockpit (item 13, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270978&FileExtension=.PDF&FileName=Photo%201.%20%20View%20of%20Cockpit-Master.PDF - Photo 2. Fuel Selectors (item 14, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270979&FileExtension=.PDF&FileName=Photo%202.%20%20Fuel%20Selectors-Master.PDF - Photo 3. Gear Handle in the Down Position (item 15, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270980&FileExtension=.PDF&FileName=Photo%203.%20%20Gear%20Handle%20in%20the%20Down%20Position-Master.PDF - Photo 4. Power Quadrant (item 16, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270981&FileExtension=.PDF&FileName=Photo%204.%20%20Power%20Quadrant-Master.PDF - Photo 5. View of Airplane From Above (item 17, .PDF, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270982&FileExtension=.PDF&FileName=Photo%205.%20%20View%20of%20Airplane%20From%20Above-Master.PDF - Photo 6. View of Airplane, Impacted Building, and Wreckage Path (item 18, .PDF, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270983&FileExtension=.PDF&FileName=Photo%206.%20%20View%20of%20Airplane,%20Impacted%20Building,%20and%20Wreckage%20Path-Master.PDF - Photo 7. View of Front of Airplane (item 19, .PDF, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270984&FileExtension=.PDF&FileName=Photo%207.%20%20View%20of%20Front%20of%20Airplane-Master.PDF - Photo 8. View of Right Engine and Propeller Blade (item 20, .PDF, 82 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270985&FileExtension=.PDF&FileName=Photo%208.%20%20View%20of%20Right%20Engine%20and%20Propeller%20Blade-Master.PDF - Photo 9. Flap Handle and Indicator (item 21, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270986&FileExtension=.PDF&FileName=Photo%209.%20%20Flap%20Handle%20and%20Indicator-Master.PDF - Photo 10. Engine Case and Missing Idler Gear Pin (item 22, .PDF, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270987&FileExtension=.PDF&FileName=Photo%2010.%20%20Engine%20Case%20and%20Missing%20Idler%20Gear%20Pin-Master.PDF - Photo 11. Idler Gear Pin (item 23, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270988&FileExtension=.PDF&FileName=Photo%2011.%20%20Idler%20Gear%20Pin-Master.PDF - Photo 12. Right Propeller (item 24, .PDF, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270989&FileExtension=.PDF&FileName=Photo%2012.%20%20Right%20Propeller-Master.PDF - Photo 13. Right Propeller Blade (item 25, .PDF, 69 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270990&FileExtension=.PDF&FileName=Photo%2013.%20%20Right%20Propeller%20Blade-Master.PDF - Photo 14. Left Viscous Damper in Vise (item 26, .PDF, 69 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270991&FileExtension=.PDF&FileName=Photo%2014.%20%20Left%20Viscous%20Damper%20in%20Vise-Master.PDF - Photo 15. Left Viscous Damper Components (item 27, .PDF, 77 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270992&FileExtension=.PDF&FileName=Photo%2015.%20%20Left%20Viscous%20Damper%20Components-Master.PDF - Photo 16. Right Viscous Damper Components (item 28, .PDF, 76 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270993&FileExtension=.PDF&FileName=Photo%2016.%20%20Right%20Viscous%20Damper%20Components-Master.PDF - Photo 17. Exemplar Viscous Damper in Vise (item 29, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270994&FileExtension=.PDF&FileName=Photo%2017.%20%20Exemplar%20Viscous%20Damper%20in%20Vise-Master.PDF - Photo 18. Exemplar Viscous Damper Components (item 30, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270995&FileExtension=.PDF&FileName=Photo%2018.%20%20Exemplar%20Viscous%20Damper%20Components-Master.PDF - Photo 19. Exemplar Viscous Damper Components (item 31, .PDF, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270996&FileExtension=.PDF&FileName=Photo%2019.%20%20Exemplar%20Viscous%20Damper%20Components-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.