NTSB Factual Report

HISTORY OF FLIGHT

On December 2, 2004, at 1324 eastern standard time, a Cessna 421B, N421SD, registered to Georgia Cumberland Conference of Seventh Day Adventist, operating as a 14 CFR Part 91 business flight, collided with trees and the ground while attempting a forced landing in the vicinity of Apison, Tennessee. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed. The flight plan was not activated. The airplane was destroyed and there was a post-crash fire. The commercial pilot, and four passengers were fatally injured. The airline transport pilot-rated passenger (ATP) reported serious injuries. The flight originated from Collegedale Municipal Airport, Collegedale, Tennessee, on December 2, 2004, at 1318.

The ATP passenger seated in the right front cockpit seat stated the pilot departed from runway 03 without completing an engine run-up. The airplane was between 200 to 300 feet on initial takeoff climb when the right engine lost power and the airplane yawed to the right. The pilot lowered the nose of the airplane to gain airspeed, pulled the right power lever rearward and nothing happened. The pilot did not feather the right propeller and started moving switches in the vicinity of the boost pump switches. At one point the ATP passenger stated, he did not think the left engine was producing full power. He scanned the instruments with his eyes looking at the manifold pressure gauges. "One needle was at zero and the other was at 25-inches. The manifold pressure should have been 39-inches of manifold pressure. I assumed the zero reading on the manifold pressure was the right engine.” The ATP passenger observed trees to their front and thought the pilot was trying to make a forced landing in an open field to their left. The ATP passenger thought the airplane would skim the top of the trees and they would be able to complete the forced landing to the open field. He then realized the airplane was going to collide with the trees. Just before the airplane hit the trees, the pilot feathered the right engine. The ATP passenger observed the right propeller going into the feather position, and the propeller came to a complete stop. As soon as the airplane came to a stop he observed he pilot slumped over in his seat, and then observed the airplane was on fire. He immediately exited the airplane, and departed the crash site seeking assistance.

A witness stated he was walking in his front yard when he heard an airplane approaching. " The engine sounded like it was surging." The airplane approached his home from the south going north, and was located above the tee line. The witness observed the airplane make a left bank estimated at 20-degres degrees. The airplane disappeared from view behind the trees and smoldering smoke pursued. The witness called the emergency 911 operators, and notified them of the accident. He then observed an individual coming from the direction of the crash site and saw a ball of fire when the airplane exploded.

Another witness who lives near the airport stated he and his wife were in their home when they heard an airplane approaching. He assumed that the airplane had departed from Collegedale Municipal Airport. The airplane sounded like a twin-engine airplane and it sounded as if the airplane was flying low. He went outside and observed the airplane flying towards him. The left engine was turning but he could not see propeller blades as if it was idling, and the engine sounded like a Harley engine. The right engine was not running. It appeared the pilot was trying to start the right engine. The propeller would turn and stop. It did this about two times. The airplane was about 100 feet high and was descending fast. The airplane was observed to start a left turn towards an open field in the vicinity of Pine Hill Road and McDonald Road. The witness stated he knew the airplane was in trouble and he told his wife that the airplane was going to crash. The airplane disappeared from view and he heard it hit the ground and subsequently observed smoke rising in the general area of Pine Hill Road and McDonald Road. He called the airport to report the accident and his neighbor called the 911 emergency operators.

PERSONNEL INFORMATION

Review of information on file with the FAA Airman's Certification Division, Oklahoma City, Oklahoma, revealed the commercial pilot was issued a commercial pilot certificate on August 30, 1994, with ratings for airplane single engine land, airplane multiengine land, and instrument airplane. In addition, the pilot held a flight instructor certificate issued on May 30, 2003, with ratings for airplane single engine land, and instrument airplane. The pilot also held an advanced ground instructor instrument certificate issued on June 19, 1992. In addition, the pilot held a mechanic airframe and power plant certificate issued on June 30, 1989. The pilot held a first class medical certificate issued on April 6, 2004, with no limitations. The pilot's last biennial flight review was completed on September 1, 2004.

Review of information on file with the FAA Airman's Certification Division, Oklahoma City, Oklahoma, revealed the airline transport pilot rated passenger was issued an airline transport pilot certificate on August 23, 2002. In addition, the pilot holds a commercial pilot certificate with ratings for airplane single engine land and rotorcraft helicopter issued on August 23, 2002. The pilot holds a ground instructor certificate for advanced instruments issued on June 2, 1993. In addition, the pilot holds a flight instructor certificate with ratings for airplane single engine land, rotorcraft helicopter, and instrument airplane issued on March 10, 2004. The pilot holds a first class medical with no restrictions issued on July 1, 2004, and the pilot's last biennial flight review was not determined.

AIRCRAFT INFORMATION

A review of the airframe maintenance records revealed the last annual inspection was performed on September 22, 2004, at Hobbs meter 6741.4 hours. According to the maintenance manger for Georgia Cumberland Conference of Seventh Day Adventist, the airplane had flown 67.2 hours since the annual inspection. The left engine had 832 hours at the time of the accident. The right engine had 1,084 hours at the time of the accident. The total airframe hours at the time of the accident was 6,808 hours. The Hobbs meter at the crash site was not recovered. The airplane was last refueled with 79.9 gallons of 100 low lead fuel on December 2, 2004, at Chattanooga, Tennessee. The main fuel tanks were topped off to 50 gallons per side, and the auxiliary fuel tanks contained 30 gallons of fuel per side.

Review of the engine logbook revealed Teledyne Continental Motors had completed Critical Service Bulletin (CSB) SB 94-4, STARTER ADAPTER SHAFTGEAR AND CRANKSHAFT GEAR INSPECTION on the right engine and installed new gears on April 16, 2000. Teledyne Continental Motors completed CSB 94-4B on the left engine on April 24, 2001. The operator's maintenance personnel had not recorded as completed the CSB94-4D or the Cessna Multi-Engine Service Bulletin MEB94-7 during the100-hour inspection or annual inspection. The Critical Service Bulletin states in a WARNING, "Compliance with this bulletin is required to prevent possible failure of the starter adapter shaft gear and or crankshaft gear which can result in metal contamination and or engine failure." According to records on file with the Georgia-Cumberland Conference of Seventh-Day Adventist, the Conference entered into a contract agreement with an individual for his services to serve as Aviation Manager providing maintenance and service on N421SD and 4 days of pilot time each month. The Aviation Manager stated Chattanooga Aero Service and Star Avionics worked on the airplane allot, to include oil changes. Chattanooga Aero Service stated they had not performed any annual inspections on N421SD. In addition, the Aviation Manager stated, the annual inspections followed the Cessna Aircraft Company Ground Handling Servicing and Inspection procedures listed on page 2-21A. The airframe and power plant mechanic who performed the annual inspection on N421SD on September 22, 2004, stated the Aviation Manager for N421SD did not want the Service Information Letters, Cessna Service Bulletins, and Supplier Service Bulletins complied with since they were not mandatory requirements.

The pilot filed 3 Direct User Access System (DUATS) instrument flight rules (IFR) flight plans on December 2, 2004. The first flight was from Chattanooga, Tennessee, to Calhoun, Georgia, proposing off at 07:00, with 20 minutes en route, and 3 hours of fuel on board. The second IFR flight plan was proposed off Calhoun, Georgia, at 07:45 to Collegedale, Tennessee, with 17 minutes en route, and 2 hours 45 minutes of fuel on board. The third flight plan was from Collegedale, Tennessee, to Knoxville, Tennessee, proposing off at 12:30, with 27 minutes en route and 4 hours of fuel on board. No weather briefing was obtained from the DUATS system.

METEOROLOGICAL INFORMATION

The Chattanooga, Tennessee 1335 surface weather observation was wind light and variable at 3-knots, visibility 10 miles, few clouds at 11,000, temperature 52-degrees Fahrenheit, dew point temperature 32-degrees Fahrenheit, altimeter 30.10.

WRECKAGE AND IMPACT INFORMATION

The wreckage of the airplane was located in a wooded area 2.3 nautical miles north of Collegedale Municipal Airport, and adjacent to 5418 Mc Donald Road, and 10820 Pine Hill Road in Apison, Tennessee.

Examination of the crash site revealed the airplane collided with trees on a heading of 020-degrees magnetic separating the outboard 3 feet of the left wing, left main fuel tip tank, nose cone, and left and right baggage door. The airplane came to rest inverted on a heading of 200-degrees magnetic. Browning of vegetation was present and "v" cuts were present on tree branches located along the crash debris line. The crash debris line extended 230 feet.

The airplane was fire damaged from the nose baggage area extending aft to the tail cone. The nose wheel separated from the nose section. The elevator and rudder flight control cables were intact from the control column aft to the third bulkhead. The left side aileron control cables separated 5 feet inboard of the outboard aileron bell crank adjacent to the left engine nacelle. The right side aileron control cables were cut in the vicinity of the third bulkhead. The left and right fuel selector handles were not located. The left fuel selector valve was in the auxiliary position. The right selector valve was in the off position.

The right wing was fire damaged and separated from the fuselage 3½ feet outboard of the right engine nacelle. The right engine separated from the engine nacelle and was located against the left engine and propeller assembly. The right propeller separated from the propeller crankshaft flange. The outboard 7 feet of the right wing was fire damaged, separated, and located next to the empennage. The inboard and outboard flap remained attached to the aft spar and were extended 9-inches at the trailing edge. The right aileron separated from its hinge points. The right aileron control cables were separated 3 feet outboard of the engine nacelle and extended inboard to the engine nacelle. The auxiliary fuel tank and main fuel tank were ruptured and fire damaged. The outline of the auxiliary fuel tank was visible with discolored fire damaged paint. The right engine nacelle fuel tank was not installed. The right main landing gear was in the retracted position.

The right propeller was forwarded to the manufacturer for examination. Examination of the right propeller spinner revealed no rotational crushing. All three-propeller blades remained attached to the propeller hub. The propeller blades were in the feathered positioned. One propeller blade was bent aft 15-degrees opposite the direction of rotation. Another propeller blade was bent forward towards the tip with wood embedded in-between the propeller hub and the spinner. The remaining propeller blade was bent forward with lengthwise scarring present on the aft side of the propeller blade. The propeller governor was damaged, disassembled, and no anomalies were noted.

The aft fuselage received fire damage. The vertical stabilizer was compressed downward and to the left 8-inches above the rudder trim actuator. The rudder was bent to the left and attached to the vertical stabilizer by the middle and lower hinge points. The balance weight remained attached to the rudder and was not deflected.

The right horizontal stabilizer separated 1½ feet outboard of the tail cone in an upward and rearward direction. Accordion crushing was present on the leading edge extending outboard to the horizontal stabilizer tip. Soot was present on the upper and lower surface of the horizontal stabilizer. The right elevator separated from its hinge points and was located in front of the right engine nacelle. The elevator trim tab remained attached to the elevator and separated from the trim tab actuator. The elevator trim tab was extended 2-inches. The elevator balance weight remained attached to the right elevator.

The left horizontal stabilizer was attached to the tail cone and received fire damage. The left elevator was attached to the inboard, outboard, and center hinges. The trailing edge of the horizontal stabilizer was crushed inward and forward with tree bark embedded in-between the stabilizer skin.

The left wing separated at the fuselage and was fire damaged. The engine and propeller assembly remained attached to the airframe. The left wing outboard of the nacelle was consumed by fire. The inboard flap was extended 9-inches at the trailing edge. The left aileron separated from its hinges and 3 feet of the aileron was fire damaged. The left aileron cables remained attached to the aileron bell crank in the outboard section of the left wing. The cables extended inboard to the engine nacelle and separated. The auxiliary fuel tank and main fuel tank were ruptured and fire damaged. The left engine nacelle fuel tank was ruptured. The left main landing gear was in the retracted position.

The left propeller was forwarded to the manufacturer for examination. The left propeller assembly remained attached to the propeller crankshaft flange and the spinner was crushed inward. All propeller blades were loose in the propeller hub. One propeller blade tip was bent forward 7-inches inboard of the propeller tip. Another propeller blade was bent aft 11-inches outboard of the propeller hub, and the propeller blade was embedded in the ground. The remaining propeller blade was bent aft 40-degrees, 8-inches outboard of the propeller hub. No scoring or leading edge damage was present on all three-propeller blades. The McCauley propeller teardown Inspection Report stated: "The left propeller was being operated under conditions of low power at impact." The left propeller governor was damaged, disassembled, and no anomalies were noted."

The right engine was transported to the engine manufacturer for further examination. The top and bottom sparkplugs on the right engine were removed and the electrodes were "worn out-severe" on cylinders 1, 3, 5, 4, and 6, when compared to the Champion Aviation Check-A-Plug Chart. The top No. 5 cylinder sparkplug was oil soaked. The top and bottom spark plugs on cylinder No. 2 were "worn out-normal. " The No. 2 cylinder bottom sparkplug contained tan moisture laden oil. The sparkplug electrodes were dark in color. The top ignition leads Nos. 1, 3, 5, and bottom leads 2, 4, and 6 were damaged. The remaining leads were intact. The fuel pump was intact and removed from the engine. The drive coupling was intact and rotated freely when turned by hand. A trace of fuel was present in the fuel pump. The fuel pump was tested on a fuel test bench and flowed within Teledyne Continental flow pressure specifications. The fuel manifold valve and fuel nozzles were tested on a fuel test bench and flowed within Teledyne Continental flow pressure specifications. The fuel flow transducer was fire damaged. The throttle body and control assembly were damaged and separated from the engine and remained in the

NTSB Probable Cause

The pilot's improper identification of a partial loss of engine power on initial takeoff climb resulting in a collision with trees and the ground. A factor was a partial failure of the left engine starter adapter due to overload.