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Aviation safety reports, made easier to study

NTSB Reports is an independent research and search tool for public aviation accident and incident records. It brings NTSB aviation reports, structured fields, docket files, extracted figures, photos, videos, and update history into one searchable interface.

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June 28, 1991 · Cessna 411 · N4940T

North Ft. Myers, FL

Overview

Report Status
Probable Cause
Event Type
Accident
Date
June 28, 1991
Injury Outcomes
5 injuries (2 serious injuries, 3 minor injuries)
Location
North Ft. Myers, FL
Aircraft
Cessna 411
Tail Number
N4940T
Operator
Conrad Ramaker
Injuries
Serious
Aircraft Damage
Destroyed
NTSB Number
MIA91FA172

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.

NTSB 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.

Full Narrative

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.

Flight

Event TypeAccident
Event Time20:47 EDT
Nearest AirportPine Shadows Airpark (1nm W)
Runway27
Runway Length3200 ft
Runway Width100 ft
Flight Plan FiledNone
Aircraft FireGrd
Aircraft ExplosionNo

Aircraft

AircraftCessna 411
Tail NumberN4940T
Aircraft CategoryAir
DamageDestroyed
OperatorConrad Ramaker
Operating RulePart 91
Engines2
Engine TypeReciprocating
Engine DetailsContinental · GTSIO-520-C · Reciprocating · 340
Seats8

People & Injuries

Injury Summary5 injuries (2 serious injuries, 3 minor injuries)
Fatal0
Serious2
Minor3
Uninjured0
Total5
Crew 1Age 35 · Second Class

Conditions

ConditionsVMC
LightDusk
WindCalm
Visibility7 sm
CeilingBroken clouds 20000 ft
Altimeter30.00 inHg
Observation Time00:50
Weather SourceWFAC

Appendix: Source Data