# NTSB CHI91LA173: Gulfstream American AA1A, N5675L, Evansville, IN, May 28, 1991

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Limited investigation · Final report
- Date: May 28, 1991, 16:30 local (21:30 UTC)
- Place: Evansville, IN
- Coordinates: 37.969043, -87.569076 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=37.9690&lon=-87.5691&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Highest injury: Serious injuries
- Injuries: 2 serious
- Status: Completed, report March 31, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 15080
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI91LA173
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/15080/pdf
- Page: https://openairdocs.org/ntsb/CHI91LA173

## Probable cause

THE FAILURE BY MAINTENANCE PERSONNEL TO IDENTIFY THE PROPER REPLACEMENT CYLINDER.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of engine power(total) - mech failure/malf, takeoff - initial climb
  - engine assembly,cylinder - improper
  - maintenance,replacement - improper, other maintenance personnel (cause)
  - engine assembly,piston - seized
- Forced landing, descent - emergency
- Hard landing, descent - emergency
  - object - wire,transmission
  - proper glidepath - not possible

## Analysis

THE SINGLE ENGINE AIRPLANE DEPARTED ON ITS FIRST FLIGHT AFTER MAINTENANCE INVOLVING REPLACEMENT OF A CYLINDER. PASSING 200 FEET ON CLIMBOUT, THE PILOT IN COMMAND OBSERVED ENGINE RPM AND POWER DECREASING.  UNABLE TO RETURN TO THE FIELD, THE PILOT EXECUTED AN OFF AIRPORT FORCED LANDING. ENGINE EXAMINATION AFTER THE ACCIDENT REVEALED A USED CYLINDER WITH A STANDARD SIZE BORE HAD BEEN INSTALLED AS A REPLACEMENT.  THE REMAINING CYLINDERS AND ALL PISTONS WERE 0.010 INCH OVERSIZE.

## Aircraft

- Registration: [N5675L](https://openairdocs.org/deregistered/N5675L-1992-05-21), registration cancelled 1992-05-21, S/N AA10075 (OpenAirDocs)
- Reported make and model: GULFSTREAM AMERICAN AA1A
- Registry model: [American AA-1](https://openairdocs.org/model/american-aa-1) (registry code 0630610) (OpenAirDocs)
- Category: Airplane
- Serial number: 0075
- Engines: LYCOMING O-235-C2C 100 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Operator: Fireside Gallery, Inc.
- Registered owner: Fireside Gallery, Inc.
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, May 28, 1991

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 62; commercial, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: right; flight hours: 5,765 total, 17 in this make and model, 5,578 as pilot in command, 79 in the last 90 days, 42 in the last 30 days, 1 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 170° at 7 knots
- Visibility: 10 statute miles
- Lowest ceiling: 25,000 ft broken
- Temperature: 88 °F, dew point 75 °F
- Altimeter: 30.00 inHg
- Observed at: EVV, 6 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 19910528017589A](https://openairdocs.org/incident/19910528017589A), May 28, 1991: Gulstm AA1A, Evansville, IN, Substantial damage. Engine quit on climbout. Nosed over landing. Just out of annual. Standard cylinder installed on oversize piston.

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.