LAX91LA129

NTSB accident investigation · Cessna 421B · Tucson, AZ · March 12, 1991

Accident · Serious injuriesLimited investigationFinal report
Date
March 11, 1991, 18:58 local (Mar 12, 1991, 01:58 UTC)
Place
Tucson, AZ
Injuries
3 serious, 3 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N924MDCessna 421B
Weather
Visual (VMC) · Dusk
Status
Completed · report March 24, 1993
Report
Approved by Office Director
FAA report
19910311005209A
Case key
27137

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 fatigue failure of the right engine turbo exhaust clamp, and, the failure of the flying pilot to complete the single engine emergency procedures in a timely manner. A factor in the accident was the failure of the pilot in command to adequately supervise the conduct of the flight.

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
Exhaust system,clamp - fatigueCause
Exhaust system,clamp - failure,totalCause
In flight collision with objectDescent
Object - wire,transmission
Descent - inadvertent
Emergency procedure - delayedCopilot/second pilotCause
Propeller feathering - delayedCopilot/second pilotCause
Remedial action - delayedPilot in commandCause
Supervision - inadequatePilot in commandFactor
In flight collision with terrain/waterManeuvering - turn to landing area (emergency)

Analysis

The plt (PIC) was a part 135 check airman & was occupying the rgt seat. A 2nd company plt was in the l seat to get some time in the Cessna 421. The 2nd plt made the takeoff & the acft was 10 to 15 sec into the initial climb, when a loss of pwr was detected in the rgt eng. A 3rd plt (sitting in the back) called out that he saw fire coming fm the rgt eng nacelle. The PIC stated that the 2nd plt 'apprehensively attempt(ed) the emergency procedures & gave the airplane to me as (the) airspeed rapidly declined.' The PIC said some pwr lines were drctly ahd & he elected to go under the wires toward a vacant fld. The acft collided with the pwr lines, then impacted the gnd in the fld. An on site exam of the acft revealed the rgt eng turbocharger exhaust clamp had failed, allowing exhaust gasses to flow thru louvers in the rgt nacelle. No evidence of an actual fire was fnd. A metallurgical exam of the rgt eng turbo exhaust clamp revealed it had failed fm fatigue.

Aircraft

Registration
N924MD
Reported as
Cessna 421B
Category
Airplane
Serial number
421B0427
Engine
Continental GTSIO-520-H, 375 horsepower, reciprocating
Damage
Substantial damage
Flight
Positioning · Part 91
Operator
Deer Valley Aviation, Inc
Registered owner
Golden Eagle Aviation, Inc
Destination
SDL · Scottsdale, AZ
Flight plan
Company VFR

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
37
Certificates
Airline transport, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Flight hours
4,800 total · 400 in this make and model · 4,200 as pilot in command · 180 in the last 90 days · 50 in the last 30 days · 6 in the last 24 hours

Weather

Conditions
Visual (VMC) · Dusk
Wind
310° at 15 knots
Visibility
30 statute miles
Lowest ceiling
None
Temperature
-0 °F, dew point -0 °F
Observed at
TUS, 1 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.