ASN Wikibase Occurrence # 34604
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| Date: | Saturday 2 September 1995 |
| Time: | 08:38 LT |
| Type: |  Cessna 421C |
| Owner/operator: | Adventure Airlines L.l.c. |
| Registration: | N6234G |
| MSN: | 421C0265 |
| Year of manufacture: | 1977 |
| Total airframe hrs: | 5461 hours |
| Engine model: | CONTINENTAL GTSIO-520-L |
| Fatalities: | Fatalities: 8 / Occupants: 8 |
| Aircraft damage: | Destroyed |
| Category: | Accident |
| Location: | Beaver Dam, AZ -
 United States of America
|
| Phase: | En route |
| Nature: | Executive |
| Departure airport: | Las Vegas, NV (KVGT) |
| W. Yellowstone, MT | |
| Investigating agency: | NTSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
After climbing to 18,400' msl, the pilot reported a turbocharger problem & reversed course. He said he 'may lose the left engine' & that he was unable to maintain altitude. He diverted to an alternate airport. During a right turn onto final approach, the airplane was observed to cross (overshoot) the extended centerline of the runway. It continued in a right turn back toward the centerline, and then entered a left turn to intercept the inbound course. The turn steepened, and then the airplane entered a spin & crashed 1/2 mile short of the runway. A warped flange & evidence of exhaust gas leakage were found on the Inconel exhaust system Wye collector, at the wastegate outlet of the left engine. Neither propeller was in a feather position. There was evidence that the left engine was providing low power during impact. A note on the pilot's clipboard indicated that the (left engine) fuel flow & cylinder head temperature went to zero, & the manifold pressure dropped to 10 inches. The note also indicated that the pilot switched the 'boost pump' to high, the fuel flow went to 260 psi, & manifold pressure increased to 18.5 inches. Calculations showed that the airplane's gross weight (GW) & center-of-gravity (CG) were 7,645 pounds & 158.32 inches. The maximum allowable GW & CG were 7,450 pounds & 158 inches. During impact, the flaps were fully extended. The 'Engine Inoperative Landing' procedure stated, 'Wing Flaps - DOWN when landing is assured.' Most of the pilot's flight time in the Cessna 421 was before 1985; no record was found of recurrent training in the airplane since 1984. Annual and turbocharger inspections were made at 78 and 120 flight hours, respectively, before the accident, but no logbook entries were made concerning maintenance or replacement parts for the exhaust system.
Probable Cause: Failure of the pilot to maintain adequate airspeed, while maneuvering on approach, which resulted in an inadvertent stall/spin and uncontrolled collision with terrain. Factors relating to the accident were: the pilot allowed the aircraft weight and balance limitations to be exceeded; the pilot's lack of recurrent training in the make and model of airplane; inadequate maintenance/inspection of the engine exhaust systems; a warped and leaking exhaust system flange on the left engine, which resulted in a loss of power in that engine; and the pilot's improper use of the flaps.
Accident investigation:
 |
|
Sources:
NTSB LAX95FA319
Location
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 24-Oct-2008 10:30 | ASN archive | Added |
| 09-Apr-2024 12:24 | ASN Update Bot | Updated [Time, Operator, Other fatalities, Phase, Departure airport, Destination airport, Source, Narrative, Category, Accident report] |
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