No fatalities

2007-05-23: Cessna 421A Golden Eagle I (N4082L) — Golden Eagle Air — Chesterfield-Spirit of St Louis, United States of America

Chesterfield-Spirit of St Louis, United States of AmericaTakeoff (climb)

On May 23, 2007, a Cessna 421A Golden Eagle I (registration N4082L) operated by Golden Eagle Air was involved in an aviation accident near Chesterfield-Spirit of St Louis, United States of America during takeoff. No fatalities were reported. Investigators recorded the probable cause as: Maintenance personnel failed to comply with an Airworthiness Directive which resulted in the total failure of the starter adapter gear teeth and the crankshaft gear teeth and the pilot failed to follow the published emergency procedures. This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A).

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781198149Data APIEditorial standards

After takeoff, the right engine lost power. Post-accident examination revealed fractured starter adapter and crankshaft gear teeth, with damper exceeding wear limits. Maintenance had not complied with airworthiness directives since engine installation, and the pilot did not follow emergency procedures.

Accident Details

Shortly after takeoff, the pilot experienced a loss of power on the right engine. Attempting to return to the airport, the pilot determined he could not reach the runway and elected to land on a dirt field. During the approach, the aircraft flew under power lines in the flight path, and the pilot attempted to flare before impact with the terrain.

Engine Examination

The airplane was equipped with Teledyne Continental GTSIO-520 engines. Post-accident examination of the right engine revealed that all teeth on the starter adapter gear and several teeth on the crankshaft gear were missing. Multiple gear teeth and metal filings were found in the oil sump. The torsional damper-to-shaft gear woodruff key was sheared. The torsional damper underwent bench testing to determine damping time; consecutive tests averaged 6.9 seconds, whereas a new damper has a damping time range of 1.5 to 3.125 seconds. Metallurgical examination showed that 15 starter gear teeth and 11 crankshaft gear teeth were fractured near their root, with no indications of preexisting cracking. At least two starter gear teeth and several crankshaft gear teeth displayed spalling and wear at the pitch line.

Service History

On June 13, 1994, Teledyne Continental issued 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. A revision, MSB94-4G, was issued on October 31, 2005. The service bulletin called for 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. 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 that the mandatory service bulletin was complied with when the right engine was overhauled and installed in March 2001. However, there was no indication in the maintenance records that either the mandatory service bulletin or the AD had been complied with since installation. The engine had a total time of 541.9 hours at the time of the accident.

Pilot Actions

The pilot did not follow the published emergency procedures.

Probable Cause

Maintenance personnel failed to comply with an Airworthiness Directive which resulted in the total failure of the starter adapter gear teeth and the crankshaft gear teeth and the pilot failed to follow the published emergency procedures. Contributing to the accident were the low altitude at which the loss of power occurred, the power lines, and the unsuitable terrain which prevented the pilot from adequately flaring the airplane and resulted in the subsequent hard landing.