# NTSB DFW05LA045: Cessna 421C, N369RK, Henderson, TX, December 21, 2004 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: December 21, 2004, 13:30 local (19:30 UTC) - Place: Henderson, TX - Coordinates: 32.138889, -94.851669 - Nearby events: https://openairdocs.org/map.md?lat=32.1389&lon=-94.8517&mi=10 - Phase of flight: [Taxi](https://openairdocs.org/ntsb-phases/250) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report February 24, 2005 - Report: Approved by Office Director - Parties: Federal Aviation Administration - NTSB case key (mKey): 60764 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DFW05LA045 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/60764/pdf - Page: https://openairdocs.org/ntsb/DFW05LA045 ## Probable cause The failure of the nose landing gear trunnion lug. A contributing factor was the non-compliance of the service bulletin by maintenance personnel. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - on ground/water, taxi - from landing - landing gear,nose gear attach point - failure (cause) - Nose gear collapsed, taxi - from landing - maintenance,service bulletin/letter - not complied with, other maintenance personnel (contributing factor) ## Analysis While on a maintenance flight, a rough running engine developed and the pilot elected to make a precautionary landing at Rusk County Airport (F12), near Henderson, Texas. After a "normal" landing on runway 16, he back taxied and was turning onto taxiway bravo, when the airplane made an uncontrolled right turn, followed by the collapse of the nose landing gear. Examination of the aircraft revealed that the nose gear trunnion lug had fractured, resulting in the nose landing gear collapse and structural damage to the nose gear well. A review of the airplane logbooks revealed that Service Bulletin, MEB88-5 Revision 2, that addresses trunnion lug failure, had not been complied with. ## Factual narrative On December 21, 2004, about 1330 central standard time, a Cessna 421C twin-engine airplane, N369RK, was substantially damaged when the nose landing gear collapsed during taxi, following a landing at the Rusk County Airport (F12), near Henderson, Texas. The two instrument-rated commercial pilots were not injured. The airplane was registered to Yates Air LLC, of Henderson, Texas. Visual meteorological conditions prevailed, and a flight plan was not filed for the 14 Code of Federal Regulations Part 91 maintenance flight. The local flight originated from the Tyler Pounds Regional Airport (TYR), near Tyler, Texas, approximately 20 minutes earlier. According to the pilot, while on a maintenance flight, a rough running engine developed and he elected to make a precautionary landing at Rusk County Airport. After a "normal" landing on runway 16, he back taxied and was turning onto taxiway bravo, when the airplane made an uncontrolled right turn, followed by the collapse of the nose landing gear. The pilot proceeded to shut down and secure the engines, and both pilots exited the airplane. A witness, who observed the incident, reported the airplane was taxiing at a slow speed when the nose landing gear collapsed. An aircraft mechanic (A&P) from the Waco Regional Airport inspected the airplane. The A&P reported that the nose gear trunnion lug had fractured, resulting in the nose gear collapse and structural damage to the nose gear well. Inspection of the failed nose gear trunnion lug was addressed in Cessna Service Bulletin MEB88-5 Revision 2. The stated purpose of the Service Bulletin is as follows: "Field reports of cracks in the nose landing gear trunnion lugs on some airplanes indicate the need for an inspection of the trunnion to ensure cracks are not present. Non-compliance with this service bulletin may result in failure of the nose landing gear trunnion which could cause substantial damage to the airplane and possible injury to the airplane occupants and/or ground personnel." A review of the airplane logbooks by an A&P mechanic on behalf of the National Transportation Safety Board (NTSB), revealed that Service Bulletin, MEB88-5 Revision 2, had not been complied with. At 1353, the weather observation facility at Tyler Pounds Regional Airport, located approximately 30.7 miles northwest of the accident site, reported wind from 190 degrees at 18 knots gusting to 22 knots, visibility 10 statute miles, clouds scattered at 3,400 feet, temperature 72 degrees Fahrenheit, dew point 55 degrees Fahrenheit, and a barometric pressure setting of 29.81 inches of Mercury. ## Aircraft - Registration: [N369RK](https://openairdocs.org/aircraft/N369RK), registered now, S/N 421C0072, 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: 0072 - Airframe hours: 3805 - Engines: Continental GTSIO-520-L 375 horsepower reciprocating; Continental GTSIO-520-L 375 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Yates Air LLC - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 7, 2004, 66 hours before - Departed: TYR, TYLER, TX - Airport: F12, Rusk County ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 26; injuries: none; flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; last flight review December 14, 2004; seat: left; flight hours: 1,080 total, 5 in this make and model, 908 as pilot in command, 134 in the last 90 days, 26 in the last 30 days, 0 in the last 24 hours - Co-pilot; age 46; injuries: none; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1; last flight review July 31, 2004; seat: rear; flight hours: 7,000 total, 800 in this make and model, 150 in the last 90 days, 25 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 190° at 18 knots, gusting 22 - Visibility: 10 statute miles - Lowest ceiling: 4,500 ft broken - Temperature: 72 °F, dew point 55 °F - Altimeter: 29.80 inHg - Observed at: TYR, 30 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 20041221032739A](https://openairdocs.org/incident/20041221032739A), Dec 21, 2004: Cessna 421C, Henderson, TX, Substantial damage. (-23) Aircraft had been undergoing test flight. While initiating turn during taxi procedure nose landing gear collapsed-actual defect landing gear trunion… 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.