CHI99FA163

NTSB accident investigation · Cessna 421B · Jefferson City, MO · May 27, 1999

Accident · FatalField investigationFinal report
Date
May 27, 1999, 18:26 local (23:26 UTC)
Place
Jefferson City, MO
Injuries
4 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N34TMCessna 421B
Weather
Visual (VMC) · Day
Status
Completed · report August 14, 2001
Report
Approved by Office Director
FAA report
19990527005849A
Case key
46403

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 failed to maintain control of the airplane. A factor was the partial loss of power due to the exhaust valve fatigue failure.

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) - mech failure/malfApproach - vfr pattern - final approach
Engine assembly,valve,exhaust - failure,totalFactor
Engine assembly,piston - failure,total
Loss of control - in flightApproach - vfr pattern - final approach
Aircraft control - not maintainedPilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled

Analysis

The airplane impacted the ground in a nose low, inverted attitude. The pilot reported, 'Jeff Tower, N34TM, I've just lost power on the right engine, eh, left engine.' The airplane's altitude was approximately 200 to 400 feet when the airplane's wings wobbled back and forth. The airplane's wings banked approximately 90 degrees to the left, and then the airplane nosed over and impacted the ground. White smoke was seen coming from the belly of the airplane for 1 to 2 seconds about 20 seconds prior to it impacting the ground. The terrain was a flat, hard packed field used for growing grass sod. Both the left and right propellers were found 12 to 18 inches under the hard packed soil. Rotational paint transfer patterns from the propeller blades onto the hard packed soil were evident. The left and right propeller blades exhibited chordwise scratching and leading edge polishing. The #2 cylinder piston was broken and the piston pin was still attached to the piston rod. The NTSB Materials Laboratory examination revealed the fracture face of the #2 exhaust valve stem was consistent with a bending fatigue separation. Both #2 and #6 exhaust valve guides showed heavy wear that ovalized the bores. The annual inspection conducted on March 15, 1999, indicated the compression on the left engine was 80/64, 50, 67, 70, 69, and 62.

Factual narrative

History of flight

On May 27, 1999, at 1826 central daylight time, a Cessna 421B, N34TM, was destroyed when it impacted the ground approximately 1.6 miles northwest of the approach end of runway 12 at the Jefferson City Memorial Airport, Jefferson City, Missouri. The private pilot and three passengers received fatal injuries. The 14 CFR Part 91 flight had departed Poplar Bluff Municipal Airport (POF), Poplar Bluff, Missouri, at approximately 1730 en route to Jefferson City (JEF), Missouri. Visual meteorological conditions prevailed and the flight was on an IFR flight plan. The airplane was on the final segment of a visual approach to runway 12 when the pilot indicated he had a loss of power. The airplane was seen making a left turn to the northeast. It continued to roll and it impacted the ground in a nose low, inverted attitude.

Records indicate the pilot contacted the Federal Aviation Administration's (FAA) St. Louis Automated Flight Service Station (AFSS) at 1711 to obtain a weather brief and file a flight plan. The filed flight plan showed the flight was a direct flight from POF direct to JEF with a time en route of 45 minutes. Fuel on board was listed as 4.5 hours.

At 1820:09, N34TM contacted the JEF control tower. N34TM had been given a visual approach to runway 12 by approach control, and was instructed by the JEF control tower to enter the right traffic pattern for runway 12.

At 1823:24, N34TM reported entering the right downwind for runway 12. N34TM was sequenced as the number two aircraft for landing.

At 1824:20, N34TM acknowledged that he was cleared to land.

At 1825:47, N34TM reported, "Jeff Tower, N34TM, I've just lost power on the right engine, eh, left engine." No further radio transmissions were made by N34TM to the tower.

Witnesses reported seeing the airplane flying toward the airport. Then they reported seeing the airplane turn left to the north as it passed over highway 63. The witnesses reported the airplane's altitude was approximately 200 to 400 feet. They reported seeing the airplane's wings rock back and forth. They reported seeing the airplane wings banked approximately 90 degrees to the left. Then the airplane nosed over and impacted the ground.

One witness reported seeing white smoke coming from the belly of the airplane for one to two seconds. He reported seeing the airplane's wings wobble before it went into the sharp left bank. He reported it was approximately 20 seconds from the time that he saw the white smoke until it impacted the ground. He reported the landing gear was not extended.

One witness reported that he heard power being applied to the engines. He reported the airplane was in a left bank, and then it entered a "drastic upward climb" before nosing over and going straight down. He reported that he thought both engines were running.

The JEF airport manager, who was in the control tower at the time of the accident, reported the airplane, "... appeared to be north of the extended centerline and proceeding northbound at a low altitude. The aircraft appeared to be in a shallow left bank, and was approximately 1 mile northwest of the airport. The aircraft also appeared to level out once, but then returned to the shallow left turn, and continued to lose altitude. Within a few seconds the aircraft suddenly rolled into a steep left turn, (approximately 90 degrees) the nose pointed down to vertical, and the aircraft descended behind the treeline. We then observed smoke from that location."

The witnesses reported the airplane burst into flames immediately after impacting the ground.

Personnel information

The pilot was a private pilot with single and multi-engine land ratings, and an instrument rating. He held a Third Class medical certificate. The pilot's flight logbook was not obtained. An insurance form dated March 9, 1999, indicated the pilot had approximately 1,850 hours of total flight time and 850 hours of time in make and model aircraft.

The pilot purchased N34TM in 1997. The total hours on the airplane when he purchased the airplane was approximately 5303 hours. The airplane had been flown approximately 227 hours since the pilot purchased the airplane.

Aircraft information

The airplane was a twin engine Cessna 421B, serial number 421B-0965. The airplane seated eight and had a maximum gross weight of 7,450 pounds. The engines were 375 horsepower Continental GTSIO-520-H engines. The last annual inspection was conducted on March 15, 1999. The airplane had flown about 35 hours since the last inspection and had a total time of about 5,530 hours.

The annual inspection conducted on March 15, 1999, indicated the compression on the left engine was 80/64, 50, 67, 70, 69, and 62. The right engine compression was 80/64, 64, 71, 62, 66, and 68.

The left propeller logbook indicated that on May 18, 1999, the left propeller was removed from the left engine for repair. The logbook indicated that nicks to one of the blades were filed and the propeller was balanced. The propeller was re-installed on the airplane on May 24, 1999.

Meteorological information

The JEF weather at 1753 was reported as: Winds 000 at 6 knots, sky clear, visibility 10 miles, temperature 74 degrees Fahrenheit, dew point 46 degrees Fahrenheit, altimeter 30.10.

Wreckage and impact information

The aircraft wreckage was located at coordinates N 42 degrees 36.786 minutes, W 92 degrees, 10.651 minutes. The location was approximately 1.6 nautical miles and 324 degrees from the approach end of runway 12. The terrain was a flat, hard packed field used for growing grass sod. The direction of the wreckage path was about 355 degrees. (See Wreckage Diagram and Photographs)

The left and right propellers were located at the initial impact site and were found on a line perpendicular to the wreckage path. The left propeller was found on the right side of the wreckage path, and the right propeller was found on the left side of the wreckage path. Both the left and right propellers were found 12 to 18 inches under the hard packed soil. Rotational paint transfer patterns from the propeller blades onto the hard packed soil were evident.

The left propeller blades exhibited chordwise scratching and leading edge polishing. The #3 blade exhibited blade polishing for more than a fourth of the blade. The #2 and #3 blade were bent aft.

The right propeller blades exhibited chordwise scratching and the #2 and #3 blades were bent aft. The #1 blade tip was curled aft with a slight bend aft. Both #2 and #3 blades exhibited blade polishing.

The fuselage, cockpit, and the left and right wings were destroyed by fire. All flight controls were found attached to their respective hinges. Control cables were traced throughout the wreckage to their respective hinges. Cable fractures exhibited "broom straw" features.

The left and right wingtip fuel tanks had impacted the terrain on the same line as the propellers. Fan shaped burn patterns in the direction of the wreckage path emanated from the impact marks made by the wingtip fuel tanks.

The on-site examination of the left engine revealed that the number two cylinder spark plugs' electrodes were damaged. The number two cylinder piston was broken and the piston pin was still attached to the piston rod.

Medical and pathological information

The autopsy on the pilot was performed at Office of the Medical Examiner, Columbia, Missouri.

A Forensic Toxicology Fatal Accident Report was prepared by the FAA Civil Aeromedical Institute. The report indicated the following results:

Carbon monoxide: Not performed

Cyanide: Not performed

No Ethanol detected in urine.

Ephedrine detected in liver fluid.

Pseudoephedrine detected in liver fluid.

Phenylopropanolamine detected in liver fluid.

Ephedrine detected in urine.

Pseudoephedrine detected in urine.

Phenylpropanolamine detect

Aircraft

Registration
N34TM
Reported as
Cessna 421B
Category
Airplane
Serial number
421B-0965
Airframe hours
5,530
Engine
Continental GTSIO-520-H, 375 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Business · Part 91
Registered owner
Robert E. Linville
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 15, 1999 · 35 hours before
Departed
POF · Poplar Bluff, MO
Destination
JEF
Flight plan
IFR
Airport
JEF · Jefferson City Memorial, runway 12, asphalt

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
43
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
1,850 total · 850 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
0° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
73 °F, dew point 46 °F
Altimeter
30.00 inHg
Observed at
JEF, 1 nm away

Docket · 41

The files NTSB released with the investigation on May 31, 2000, on NTSB’s docket system: statements, records, photos and specialists’ reports. 20.0 MB in all.

Supplement AItem 1 · .PDF · 250 KBSupplement BItem 2 · .PDF · 389 KBSupplement SItem 3 · .PDF · 77 KBMaterials Laboratory Factual ReportItem 4 · .PDF · 21 photos · 3.8 MBWitness Statement and Record of InterviewsItem 5 · .PDF · 402 KBMap of Accident Area and Wreckage DiagramsItem 6 · .PDF · 148 KBFAA ReportItem 7 · .PDF · 737 KBCallaway County Sheriff's Office ReportItem 8 · .PDF · 906 KBFuel Sample ResultsItem 9 · .PDF · 184 KBTeledyne Continental Motors Airsafety Investigation ReportItem 10 · .PDF · 483 KBAllied Signal Aerospace Teardown ReportItem 11 · .PDF · 597 KBMcCauley Propeller Systems Teardown ReportItem 12 · .PDF · 99 KBAircraft LogbooksItem 13 · .PDF · 8.5 MBN34TM Logbook Entries Maintained by Devine Aircraft Engines, Inc.Item 14 · .PDF · 77 KBInsurance Policy Indicating Pilots Flight TimeItem 15 · .PDF · 108 KBMetallurgical Analysis of Superior PistonItem 16 · .PDF · 56 KBStatement of Party Representatives to NTSB InvestigationItem 17 · .PDF · 537 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 18 · .PDF · 217 KBToxicological ReportItem 19 · .PDF · 77 KBCorrespondence and Copy of Wreckage Release FormItem 20 · .PDF · 303 KBPhoto 1. View of Wreckage Path Heading 355 Degrees. Note the Burn Residue on the Ground Spreading Out From the Wingtip Tanks.Item 21 · .PDF · 67 KBPhoto 2. View of Wreckage Path Heading 355 Degrees. The Right Propeller is on the Left and the Left Propeller is on the Right of the Photograph.Item 22 · .PDF · 76 KBPhoto 3. View of Initial Impact Looking to the Northwest. The Aircraft Impacted Inverted. Note the Right Wingtip, Right Propeller, Nose Ground Scar, Left Propeller, and Left Wingtip Impact Marks.Item 23 · .PDF · 82 KBPhoto 4. View of the Right Wing, Right Engine, and Cabin. The Left Wing and Fuselage in Background.Item 24 · .PDF · 106 KBPhoto 5. View of the Cockpit and Cabin From the Rear of the Aircraft. Note the Left Wing on the Left of the Photograph.Item 25 · .PDF · 116 KBPhoto 6. Left Wing and Left Nacelle. The Left Wing Outboard of the Nacelle is Visible Bent Back from the Nacelle.Item 26 · .PDF · 102 KBPhoto 7. View of Left Wing, Left Nacelle, and Left Engine.Item 27 · .PDF · 114 KBPhoto 8. View of Left Engine Upside Down on the Ground. Note the Oil Pan Had Exhibited Fire Damage and Melting.Item 28 · .PDF · 121 KBPhoto 9. View of the Cabin, Fuselage, and Tailcone.Item 29 · .PDF · 130 KBPhoto 10. View of the Empennage. Note the Displacement of the Rudder and Elevator Trim.Item 30 · .PDF · 71 KBPhoto 11. Right Engine.Item 31 · .PDF · 122 KBPhoto 12. View of Right Turbocharger in Wreckage.Item 32 · .PDF · 107 KBPhoto 13. View of Right Engine Nacelle, Right Wing, and Right Engine.Item 33 · .PDF · 112 KBPhoto 14. Right Propeller and Ground Scar.Item 34 · .PDF · 93 KBPhoto 15. Closer View of Right Propeller Ground Scar.Item 35 · .PDF · 93 KBPhoto 16. Left Propeller and Ground Scar.Item 36 · .PDF · 104 KBPhoto 17. Right Propeller After Ground Extraction.Item 37 · .PDF · 104 KBPhoto 18. Left Propeller After Ground Extraction.Item 38 · .PDF · 102 KBPhoto 19. Right Turbocharger.Item 39 · .PDF · 103 KBPhoto 20. Right Engine Exhaust Duct.Item 40 · .PDF · 92 KBPhoto 21. Left Engine #2 Cylinder Top and Bottom Spark Plugs.Item 41 · .PDF · 38 KB

FAA reports on this event · 1

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