FTW90FA013

NTSB accident investigation · Cessna 414 · San Antonio, TX · October 19, 1989

Accident · Serious injuriesField investigationFinal report
Date
October 19, 1989, 10:17 local (15:17 UTC)
Place
San Antonio, TX
Injuries
3 serious, 3 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N5820HCessna 414
Weather
Visual (VMC) · Day
Status
Completed · report September 9, 1992
Report
Approved by Office Director
FAA report
19891019044189A
Case key
22997

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The failure of the right propeller unfeathering accumulator hose due to improper installation and chaffing, and the pilot's operation of the airplane beyond its engine out performance capability. Factors were inadequate company maintenance, and the pilot's continued operation with known mechanical malfunctions, and improper emergency procedures.

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/malfTakeoff - initial climb
1 engine
Propeller system/accessories,hydraulic pitch ctl - leakCause
Maintenance,installation - improperOther maintenance personnelCause
Hydraulic system,line - chafedCause
Maintenance,inspection - inadequateCompany maintenance personnelFactor
Forced landingDescent - emergency
Aircraft weight and balance - exceededPilot in commandCause
Exhaust system - cracked
Operation with known deficiencies in equipment - continuedPilot in commandFactor
Emergency procedure - not followedPilot in commandFactor
Object - wire,static
Object - tree(s)
On ground/water encounter with terrain/waterLanding - flare/touchdown

Analysis

During the takeoff roll, the plt was advised by tower that he was trailing smoke. He disregarded the rpt as he had seen smoke before and thought it was a normal condition. He continued the takeoff. Shortly thereafter, the acft experienced a thrust loss of the rt eng. An attempt was made to return to the arpt, but it was unsuccessful. There was evidence of single eng performance degradation due to a 9.4% over gross condition and the plt's failure to raise the gear and feather the rt prop. The plt executed a forced landing into a vacant lot. Investigation revealed that the thrust loss was a result of the failure, due to chaffing, of the rt unfeathering accumulator hose which had been misrouted during eng installation. The original smoke observed by the plt was due to cracks in the rt exhaust sys which originated from previous weld repairs during eng installation. Neither condition had been identified by operator maintenance personnel.

Aircraft

Registration
N5820H
Reported as
Cessna 414
Category
Airplane
Serial number
414-0642
Airframe hours
2,296
Engine
Continental TSIO-520-J2, 310 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Operator
Eglin Aero Club
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · August 18, 1989
Departed
SKF · San Antonio, TX
Destination
VPS · Eglin Afb, FL
Flight plan
IFR
Airport
SKF · Kelly Afb

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
59
Certificates
Airline transport, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
14,332 total · 115 in this make and model · 14,132 as pilot in command · 24 in the last 90 days · 16 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
350° at 2 knots
Visibility
7 statute miles
Lowest ceiling
None
Temperature
50 °F, dew point 25 °F
Altimeter
30.00 inHg
Observed at
SKF

FAA reports on this event · 1

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