# NTSB MIA91FA172: Cessna 411, N4940T, North Ft. Myers, FL, June 28, 1991

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Field investigation · Final report
- Date: June 27, 1991, 20:47 local (Jun 28, 1991, 00:47 UTC)
- Place: North Ft. Myers, FL
- Coordinates: 26.679613, -81.909179 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=26.6796&lon=-81.9092&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Highest injury: Serious injuries
- Injuries: 2 serious, 3 minor
- Status: Completed, report February 8, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 32755
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA91FA172
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/32755/pdf
- Page: https://openairdocs.org/ntsb/MIA91FA172

## Probable cause

THE PILOT IN COMMANDS FAILURE TO FOLLOW EMERGENCY PROCEDURES AND HIS FAILURE TO MAINTAIN AIRSPEED FOLLOWING LOSS OF POWER IN ONE ENGINE RESULTING IN AN INADVERTENT STALL AND THE INFLIGHT LOSS OF CONTROL WITH SUBSEQUENT INFLIGHT COLLISION WITH AN OBJECT AND THE TERRAIN DURING AN UNCONTROLLED DESCENT.

## Sequence of events

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

- Loss of engine power, takeoff - initial climb
  - 1 engine
  - exhaust system,wastegate - failure,total
  - exhaust system,wastegate - closed
  - engine assembly - pressure excessive
  - engine assembly,piston - eroded
  - emergency procedure - not followed, pilot in command (cause)
  - propeller feathering - not performed, pilot in command (cause)
- Loss of control - in flight, maneuvering - turn to reverse direction
  - airspeed - not maintained, pilot in command (cause)
  - stall - inadvertent, pilot in command (cause)
- In flight collision with object, descent - uncontrolled
  - object - residence
- In flight collision with terrain/water, descent - uncontrolled
  - terrain condition - residential area

## Analysis

PILOT STATED LEFT ENGINE LOST POWER FOLLOWED BY THE RIGHT ENGINE. HE INITIATED A LEFT TURN BACK TO THE AIRPORT BUT DID NOT SHUTDOWN ENGINES IN ACCORDANCE WITH EMERGENCY PROCEDURES. THE ACFT YAWED LEFT AND FELL OFF ON THE LEFT WING AS IF IT HAD STALLED. HE REGAINED PARTIAL CONTROL AND AIMED FOR A STREET. ACFT HIT ROOF OF HOUSE WHILE IN RIGHT BANK AND THEN CARTWHEELED ACROSS THE STREET. LEFT ENGINE WAS FOUND TO HAVE SEVERE DETONATION DAMAGE AND THE TURBOCHARGER WASTE GATE DOOR WAS MISSING ANTIVIBRATION SPRING. THE PIN CONNECTING THE DOOR AND ACTUATOR WAS FAILED. EVIDENCE INDICATED PIN HAD FAILED PRIOR TO ACCIDENT FLIGHT. SOOT INSIDE LEFT WASTEGATE INDICATED DOOR HAD BEEN FULLY CLOSED FOR SOMETIME. NO EVIDENCE TO INDICATE FAILURE OR MALFUNCTION OF THE RIGHT ENGINE WAS FOUND AND RIGHT PROPELLER SHOWED DAMAGE INDICATIVE OF ROTATION UNDER POWER AT GROUND IMPACT.

## Aircraft

- Registration: [N4940T](https://openairdocs.org/deregistered/N4940T-2014-10-14), registration cancelled 2014-10-14, S/N 411-0140, built 1965 (OpenAirDocs)
- Reported make and model: CESSNA 411
- Registry model: [Cessna 411](https://openairdocs.org/model/cessna-411) (registry code 2075902) (OpenAirDocs)
- Registry engine: [Continental GTSIO-520-C](https://openairdocs.org/engine/continental-gtsio-520-c) (registry code 17035, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 411-0140
- Airframe hours: 3358
- Engines: CONTINENTAL GTSIO-520-C 340 horsepower reciprocating
- Damage: Destroyed
- Fire: On-Ground
- Flight: Personal, Part 91
- Operator: Conrad Ramaker
- Registered owner: Mary Jane Hall
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, September 1, 1990, 52 hours before
- Airport: 94FL, Pine Shadows Airpark, runway 27, 3,200 × 100 ft, asphalt

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 35; private; airplane ratings: multi-engine land, single-engine land; medical: class 2, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 1,000 total, 52 in this make and model

## Weather

- Conditions: Visual (VMC), Dusk
- Visibility: 7 statute miles
- Lowest ceiling: 20,000 ft broken
- Temperature: 86 °F, dew point 75 °F
- Altimeter: 30.00 inHg
- Observed at: FMY, 9 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 19910627024309A](https://openairdocs.org/incident/19910627024309A), Jun 27, 1991: Cessna 411, Fort Myers, FL, Destroyed. Left engine quit on initial climb. Failed to secure. Rolled,hit house. Seized turbo waste gate caused overtemp.

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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