Premium research interface

The modern interface for aviation safety intelligence.

Search investigations, review source evidence, monitor watched reports, and trace long-term patterns from one calm, data-first workspace.

63k+
Reports indexed
1940-2026
Coverage
Recent
Last data refresh
Featured Report

Loading…

Loading featured report…

Loading…
Open Report

Safety trends by operating rule

Track fatal and non-fatal accident patterns across Part 91, Part 135, and Part 121 operations.

Loading trend charts…

Browse the aviation graph

Move quickly by aircraft, airport, operator, and time with indexes built for research, not wandering.

Last Data Update

By Decade

By Month

Aircraft Manufacturer

More manufacturers

Airports

More airports

Operators

More operators

About

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.

The goal is practical safety education: make it faster to find relevant investigations, compare similar events, review factual records, and understand the evidence behind probable-cause and preliminary reports.

The investigative work and source records belong to the National Transportation Safety Board and the published investigation record. This site is not affiliated with or endorsed by the NTSB.

FAQs

NTSB Report

July 5, 2004 · Cessna T210N · N5408A

Spanish Fork, UT

Overview

Report Status
Final with probable cause
Event Type
Accident
Date
July 5, 2004
Injury Outcomes
No injuries (4 uninjured)
Location
Spanish Fork, UT
Aircraft
Cessna T210N
Tail Number
N5408A
Injuries
None
Aircraft Damage
Substantial
NTSB Number
DEN04LA098

The pilot made an intentional wheels-up landing after first experiencing a low voltage light followed by a loss of engine power. The examination of the engine revealed the number 2 bearing and crankshaft had shifted forward with subsequent failure of the alternator drive shaft and other accessories, as well as damage to other components of the power drive train. Examination of the aircraft revealed the adhesive (Permatex) for the crankcase seam string was also applied on the crankcase halves surfaces, inside the seam face, and on the through bolts. According to the manufacturer, the adhesive should only be applied to hold the string in place. The excess sealant contributed to either the loss of torque or under-torquing of the through-bolts. The engine had 3692 hours tachometer time when it was overhauled in 1993 when the time between overhaul was extended to 1600 hours. In 2000, the engine had accumulated 1108 hours since the overhaul, when six new, "classic cast" cylinder assemblies, along with new pistons, rings, and piston pins, were installed. In order for this work to have been accomplished, the crankcase would have had to been separated. At the time of the accident, the engine had 5435 hours tachometer time at and 1743 hours since the overhaul.

NTSB Probable Cause

the improper reassembly of the engine following major overhaul (application of Permatex over entire crankcase surfaces). Contributing factors included the number 2 main bearing and crankshaft shifting forward, causing the alternator drive shaft and other accessory gears to fail, which disabled the camshaft.

Full Narrative

On July 5, 2004, approximately 1115 mountain daylight time, a Cessna T210N, N5408A, registered to and operated by PinesAir, Inc., of Pine Bluffs, Wyoming, and piloted by a private pilot, was substantially damaged when it collided with terrain during an off-airport forced landing about 8 miles west of Spanish Fork, Utah. The pilot and three passengers were not injured. Visual meteorological conditions prevailed, and no flight plan had been filed for the personal cross-country flight being conducted under Title 14 CFR Part 91. The flight originated at Provo, Utah, approximately 1100, and was en route to Kimball, Nebraska. According to the pilot, he departed runway 13, turned right onto the crosswind leg, departed the traffic pattern to the southwest, and climbed towards West Mountain. Shortly thereafter, the LOW VOLTAGE warning light illuminated. Cycling the avionics and master switches several times failed to extinguish the annunciator light. He decided to return to Provo. En route, the engine sounds "changed" and the engine began to lose power. Boost pump and magneto checks were made with negative results. Due to the loss of altitude, the pilot made an intentional wheels up landing in a field. The airplane slid 670 feet before coming to a halt. The airplane was later recovered and examined. The alternator pulley shaft was broken and the pulley and broken shaft lay atop the engine. Borescoping the cylinders revealed crescent-shaped indentations on all six piston heads. Drive train continuity was established, but the camshaft would not turn. The engine, a Continental TSIO-520-R (s/n 511784), was removed from the airframe and shipped to Teledyne Continental Motors (TCM) in Mobile, Alabama, where, on February 17, 2005, it was disassembled and examined. The magneto drive gear and axle were pushed up, and the right magneto coupling was fractured. The crankcase was also fractured in an upward direction at the axle seat. Pieces of gear teeth and magneto coupling were found in the oil sump. When bench tested, the left magneto fired consistently in the 500-3,000 rpm range; the right magneto would not fire. Disassembly revealed excessive distributor gear bushing wear. Reddish-brown filings, similar to bushing material, coated the inside of the magneto case. When the alternator drive assembly was removed, it was discovered that 9 of 15 gear teeth were stripped. Metallurgical examination by microscope revealed the shaft failed in torsional overload, followed by crushing and smearing of the gear teeth. The crankshaft and the number 2 main bearings had shifted forward approximately 1/8-inch. Fretting was noted on all the crankcase through-bolt holes. An adhesive residue covered the inside seam faces and through-bolt holes. The number 4 main bearing thrust washer was fractured with rotational scoring of the crankshaft. Both the crankshaft and camshaft had numerous fractured teeth that were crushed and ground. Crescent-shaped witness marks, consistent with intake and exhaust valve strikes, were noted on all six piston heads. The camshaft lobes and all lifters bore irregular impact signatures. The airplane maintenance records were examined. The engine was last overhauled on January 22, 1993, at a tachometer time of 3,692.0 hours. The logbook entry bore the following statement: "This engine has been overhauled to new factory fits and limits, and has been assembled in accordance with note 5 of TCM SB (Service Bulletin) M89-13, extending the TBO (time between overhaul) to 1,600 hours." On April 25, 2000, at a tachometer time of 4,700.0 hours (1,008.0 hours since major overhaul), 6 new "classic cast" cylinder assemblies were installed along with new pistons, rings, and piston pins. At the time of the accident, the tachometer read 5,435.0 hours. The engine had operated 1,743.0 hours since major overhaul (143.0 hours beyond recommended TBO), and 735.0 hours since the new cylinders and pistons were installed.

Flight

Event TypeAccident
Event Time11:15 MDT
Nearest Airport0nm
Flight Plan FiledNone
Flight Plan ActivatedNo
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftCessna T210N
Tail NumberN5408A
Aircraft CategoryAir
DamageSubstantial
Operating RulePart 91
Engines1
Engine TypeReciprocating
Engine DetailsContinental · TSIO-520-L · Reciprocating · 300
Seats6

People & Injuries

Injury SummaryNo injuries (4 uninjured)
Fatal0
Serious0
Minor0
Uninjured4
Total4
Crew 1Age 36 · Third Class · None

Conditions

ConditionsVMC
LightDaylight
Wind260° @ 6 kt
Visibility10 sm
CeilingNone
Temperature / Dew Point50
Altimeter30.12 inHg
Observation Time17:15
Weather SourceWFAC

Appendix: Source Data