# NTSB FTW90FA013: Cessna 414, N5820H, San Antonio, TX, October 19, 1989

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Field investigation · Final report
- Date: October 19, 1989, 10:17 local (15:17 UTC)
- Place: San Antonio, TX
- Location: 29.4241° N, 98.4936° W: Placed by OpenAirDocs: center of San Antonio, TX, within about 13 miles (OpenAirDocs)
- Nearby events: https://openairdocs.org/map.md?lat=29.4241&lon=-98.4936&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Highest injury: Serious injuries
- Injuries: 3 serious, 3 minor
- Status: Completed, report September 9, 1992
- Report: Approved by Office Director
- NTSB case key (mKey): 22997
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW90FA013
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/22997/pdf
- Page: https://openairdocs.org/ntsb/FTW90FA013

## 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

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

- Loss of engine power(partial) - mech failure/malf, takeoff - initial climb
  - 1 engine
  - propeller system/accessories,hydraulic pitch ctl - leak (cause)
  - maintenance,installation - improper, other maintenance personnel (cause)
  - hydraulic system,line - chafed (cause)
  - maintenance,inspection - inadequate, company maintenance personnel (contributing factor)
- Forced landing, descent - emergency
  - aircraft weight and balance - exceeded, pilot in command (cause)
  - exhaust system - cracked
  - operation with known deficiencies in equipment - continued, pilot in command (contributing factor)
  - emergency procedure - not followed, pilot in command (contributing factor)
  - object - wire,static
  - object - tree(s)
- On ground/water encounter with terrain/water, landing - 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](https://openairdocs.org/deregistered/N5820H-1989-12-19), registration cancelled 1989-12-19, S/N 4140642 (OpenAirDocs)
- Reported make and model: CESSNA 414
- Registry model: [Cessna 414](https://openairdocs.org/model/cessna-414) (registry code 2075908) (OpenAirDocs)
- Category: Airplane
- Serial number: 414-0642
- Airframe hours: 2296
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 59; 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 (OpenAirDocs).

- [Accident 19891019044189A](https://openairdocs.org/incident/19891019044189A), Oct 19, 1989: Cessna 414, San Antonio, TX, Substantial damage. ATC advised trailing smoke. Pilot acknowledged at lift off. Engine malfunctioned. Forced landing.

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.

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