# NTSB MIA04LA097: Gulfstream American AA5B, N4516V, Crystal River, FL, June 14, 2004 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: June 14, 2004, 09:45 local (13:45 UTC) - Place: Crystal River, FL - Coordinates: 28.867221, -82.571113 - Nearby events: https://openairdocs.org/map.md?lat=28.8672&lon=-82.5711&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 4 uninjured - Status: Completed, report March 30, 2005 - Report: Approved by Office Director - Parties: FAA FSDO - NTSB case key (mKey): 59467 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA04LA097 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/59467/pdf - Page: https://openairdocs.org/ntsb/MIA04LA097 ## Probable cause The failure of the number three cylinder exhaust valve which resulted in the partial loss of engine power. The pilot's misjudgment of speed and distance resulted in an overrun of the runway. ## 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, cruise - engine assembly,valve,exhaust - failure (contributing factor) - Forced landing, descent - emergency - Overrun, landing - roll - distance/speed - misjudged, pilot in command (contributing factor) - In flight collision with object, go-around (vfr) - object - tree(s) (cause) ## Analysis The pilot stated that he was en route to Athens, Georgia, and the airplane was in level cruise flight at 8,000 feet, when all of a sudden the engine started running roughly. He stated that he was unable to maintain altitude, so he declared an emergency with FAA Jacksonville Air Route Traffic Control Center, and was given vectors for Crystal River Airport, Crystal River, Florida. He stated that he flew the subsequent approach to a forced landing with too much speed, and was unable to stop the airplane on the runway. As he was nearing the end of the runway, he stated that he thought he had enough power to execute a go-around, but as he was attempting to do so, he was able to avoid the fence, but collided with some trees. Post crash examination of the airplane's engine showed no compression was noted in the No. 3 cylinder. Further examination revealed that the No. 3 cylinder exhaust valve head was missing and that the cylinder head and top of the piston had incurred mechanical damage. The center electrode of No. 3's upper spark plug showed evidence of physical contact, and was found pushed against the side electrodes. Two pieces of metal appearing to be pieces of the valve head were found in the exhaust system. According to information obtained from the pilot, the engine had accumulated a total of 1,547 total flight hours since overhaul, and 56 flight hours since its last annual inspection, which had been conducted in October 2003. ## Factual narrative On June 14, 2004, about 0945 eastern daylight time, a Gulfstream American AA5B, N4516V, registered to and operated by a private individual, as a Title 14 CFR part 91 personal flight, collided with trees while attempting a go-around at Crystal River, Florida. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed. The private-rated pilot and three passengers were not injured, and the airplane incurred substantial damage. The flight originated in Sarasota, Florida, the same day, about 0900. The pilot stated that he was en route to Athens, Georgia, and the airplane was in level cruise flight at 8,000 feet, when all of a sudden the engine started running roughly. He stated that he was unable to maintain altitude, so he declared an emergency with FAA Jacksonville Air Route Traffic Control Center, and was given vectors for Crystal River Airport, Crystal River, Florida. He stated that he flew the subsequent approach to a forced landing with too much speed, and was unable to stop the airplane on the runway. As he was nearing the end of the runway, he stated that he thought he had enough power to execute a go-around, but as he was attempting to do so, he was able to avoid the fence, but collided with some trees. On June 23, 2004, the accident airplane's engine was examined and no compression was noted in the No. 3 cylinder. Further examination revealed that the No. 3 cylinder exhaust valve head was missing and that the cylinder head and top of the piston had incurred mechanical damage. The center electrode of No. 3's upper spark plug showed evidence of physical contact, and was found pushed against the side electrodes. Two pieces of metal appearing to be pieces of the valve head were found in the exhaust system. According to information obtained from the pilot, the engine had accumulated a total of 1,547 total flight hours since overhaul, and 56 flight hours since its last annual inspection, which had been conducted in October 2003. ## Aircraft - Registration: [N4516V](https://openairdocs.org/deregistered/N4516V-2007-04-10), registration cancelled 2007-04-10, S/N AA5B1022, built 1978 (OpenAirDocs) - Reported make and model: Gulfstream American AA5B - Registry model: [Gulfstream American AA-5B](https://openairdocs.org/model/gulfstream-american-aa-5b) (registry code 3970106) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: AA5B-1022 - Airframe hours: 1547 - Engines: Lycoming O-360-A4K 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Arthur L Kaiser - Airworthiness certificate: Standard, Utility; Standard, Normal - Last inspection: Annual, October 1, 2003, 56 hours before - Departed: SRQ, Satasota-Braden, FL - Destination: AHN, Athens, GA - Flight plan: IFR - Airport: CGC, Crystal River, runway 09, 4,700 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 41; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; last flight review June 5, 2004; seat: left; flight hours: 314 total, 58 in this make and model, 297 as pilot in command, 46 in the last 90 days, 15 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 110° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 79 °F, dew point 72 °F - Altimeter: 30.05 inHg - Observed at: OCF ## 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 20040614017629A](https://openairdocs.org/incident/20040614017629A), Jun 14, 2004: Amrgen AA5B, Crystal River, FL, Substantial damage. (-23) On June 14, 2004, about 0945 eastern daylight time, a Gulfstream American AA5B, N4516V, registered to and operated by a private individual, as a title 14… ## Other investigations on N4516V (1) 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. - [NTSB NYC80DHD16](https://openairdocs.org/ntsb/NYC80DHD16), Jun 2, 1980: Grum-Amer AA-5B (N4516V), Bristol, PA, substantial damage 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.