Chesterfield - Cahokia

Shortly after takeoff the pilot experienced a loss of power on the right engine. He attempted to return to the airport to land, but determined that he was not going to reach the runway so he elected to land on a dirt field. He flew under power lines that were in his flight path and attempted to flare the airplane prior to it impacting the terrain. The airplane was equipped with Teledyne Continental GTSIO-520 engines. Post accident examination of the right engine revealed that all of the teeth on the starter adapter gear and several of the teeth on the crankshaft gear were missing. Several gear teeth and metal filings were located in the oil sump. The torsional damper to shaft gear woodruff key was sheared. The torsional damper was placed on a test bench to determine the damping time. The consecutive tests averaged a damping time of 6.9 seconds. The damping time of a new damper is min/max 1.5 to 3.125 seconds. Metallurgical examination revealed 15 starter gear teeth and 11 crankshaft gear teeth were fractured near their root. No indications of preexisting cracking were noted. At least two of the starter gear teeth and several of the crankshaft gear teeth displayed spalling and wear at the pitch line of the teeth. On June 13, 1994, Teledyne Continental issued a Mandatory Service Bulletin, MSB94-4, addressing the possible failure of the starter adapter gear and/or crankshaft gear on GTSIO-520 and GIO-550 engines. On October 31, 2005, Teledyne Continental issued revision, MSB94-4G. The service bulletin called for an inspection of the starter adapter viscous damper and shaft gear backlash every 100 hours of engine operation, and a visual inspection of the starter adapter shaft and crankshaft gear teeth for spalling, pitting, and wear, every 400 hours of engine operation. The Federal Aviation Administration (FAA) issued Airworthiness Directive (AD) 2005-20-04, effective November 1, 2005, requiring compliance with the Teledyne Continental Mandatory Service Bulletin. Maintenance records showed the mandatory service bulletin had been complied with when the right engine was overhauled and installed in March 2001. There was no indication in the maintenance records that either the mandatory service bulletin or the AD had been complied with since the engine was installed. The engine had a total time of 541.9 hours at the time of the accident. The pilot did not follow the published emergency procedures.

Flight / Schedule

Chesterfield - Cahokia

Registration

N4082L

MSN

421A-0082

Year of Manufacture

1968

Date

May 23, 2007 at 03:40 PM

Type

CRASH

Flight Type

Private

Flight Phase

Takeoff (climb)

Crash Site

Airport (less than 10 km from airport)

Crash Location

Chesterfield-Spirit of St Louis Missouri

Region

North America • United States of America

Crash Cause

Human factor

Narrative Report

On May 23, 2007 at 03:40 PM, Chesterfield - Cahokia experienced a crash involving Cessna 421A Golden Eagle I, operated by Golden Eagle Air, with the event recorded near Chesterfield-Spirit of St Louis Missouri.

The flight was categorized as private and the reported phase was takeoff (climb) at a airport (less than 10 km from airport) crash site.

1 people were known to be on board, 0 fatalities were recorded, 1 survivors were identified or estimated. This corresponds to an estimated fatality rate of 0.0%.

Crew on board: 1, crew fatalities: 0, passengers on board: 0, passenger fatalities: 0, other fatalities: 0.

The listed crash cause is human factor. Shortly after takeoff the pilot experienced a loss of power on the right engine. He attempted to return to the airport to land, but determined that he was not going to reach the runway so he elected to land on a dirt field. He flew under power lines that were in his flight path and attempted to flare the airplane prior to it impacting the terrain. The airplane was equipped with Teledyne Continental GTSIO-520 engines. Post accident examination of the right engine revealed that all of the teeth on the starter adapter gear and several of the teeth on the crankshaft gear were missing. Several gear teeth and metal filings were located in the oil sump. The torsional damper to shaft gear woodruff key was sheared. The torsional damper was placed on a test bench to determine the damping time. The consecutive tests averaged a damping time of 6.9 seconds. The damping time of a new damper is min/max 1.5 to 3.125 seconds. Metallurgical examination revealed 15 starter gear teeth and 11 crankshaft gear teeth were fractured near their root. No indications of preexisting cracking were noted. At least two of the starter gear teeth and several of the crankshaft gear teeth displayed spalling and wear at the pitch line of the teeth. On June 13, 1994, Teledyne Continental issued a Mandatory Service Bulletin, MSB94-4, addressing the possible failure of the starter adapter gear and/or crankshaft gear on GTSIO-520 and GIO-550 engines. On October 31, 2005, Teledyne Continental issued revision, MSB94-4G. The service bulletin called for an inspection of the starter adapter viscous damper and shaft gear backlash every 100 hours of engine operation, and a visual inspection of the starter adapter shaft and crankshaft gear teeth for spalling, pitting, and wear, every 400 hours of engine operation. The Federal Aviation Administration (FAA) issued Airworthiness Directive (AD) 2005-20-04, effective November 1, 2005, requiring compliance with the Teledyne Continental Mandatory Service Bulletin. Maintenance records showed the mandatory service bulletin had been complied with when the right engine was overhauled and installed in March 2001. There was no indication in the maintenance records that either the mandatory service bulletin or the AD had been complied with since the engine was installed. The engine had a total time of 541.9 hours at the time of the accident. The pilot did not follow the published emergency procedures.

Aircraft reference details include registration N4082L, MSN 421A-0082, year of manufacture 1968.

Fatalities

Total

0

Crew

0

Passengers

0

Other

0

Crash Summary

Shortly after takeoff the pilot experienced a loss of power on the right engine. He attempted to return to the airport to land, but determined that he was not going to reach the runway so he elected to land on a dirt field. He flew under power lines that were in his flight path and attempted to flare the airplane prior to it impacting the terrain. The airplane was equipped with Teledyne Continental GTSIO-520 engines. Post accident examination of the right engine revealed that all of the teeth on the starter adapter gear and several of the teeth on the crankshaft gear were missing. Several gear teeth and metal filings were located in the oil sump. The torsional damper to shaft gear woodruff key was sheared. The torsional damper was placed on a test bench to determine the damping time. The consecutive tests averaged a damping time of 6.9 seconds. The damping time of a new damper is min/max 1.5 to 3.125 seconds. Metallurgical examination revealed 15 starter gear teeth and 11 crankshaft gear teeth were fractured near their root. No indications of preexisting cracking were noted. At least two of the starter gear teeth and several of the crankshaft gear teeth displayed spalling and wear at the pitch line of the teeth. On June 13, 1994, Teledyne Continental issued a Mandatory Service Bulletin, MSB94-4, addressing the possible failure of the starter adapter gear and/or crankshaft gear on GTSIO-520 and GIO-550 engines. On October 31, 2005, Teledyne Continental issued revision, MSB94-4G. The service bulletin called for an inspection of the starter adapter viscous damper and shaft gear backlash every 100 hours of engine operation, and a visual inspection of the starter adapter shaft and crankshaft gear teeth for spalling, pitting, and wear, every 400 hours of engine operation. The Federal Aviation Administration (FAA) issued Airworthiness Directive (AD) 2005-20-04, effective November 1, 2005, requiring compliance with the Teledyne Continental Mandatory Service Bulletin. Maintenance records showed the mandatory service bulletin had been complied with when the right engine was overhauled and installed in March 2001. There was no indication in the maintenance records that either the mandatory service bulletin or the AD had been complied with since the engine was installed. The engine had a total time of 541.9 hours at the time of the accident. The pilot did not follow the published emergency procedures.

Cause: Human factor

Occupants & Outcome

Crew On Board

1

Passengers On Board

0

Estimated Survivors

1

Fatality Rate

0.0%

Known people on board: 1

Operational Details

Schedule / Flight

Chesterfield - Cahokia

Flight Type

Private

Flight Phase

Takeoff (climb)

Crash Site

Airport (less than 10 km from airport)

Region / Country

North America • United States of America

Aircraft Details

Registration

N4082L

MSN

421A-0082

Year of Manufacture

1968