Aircraft Accident/Incident Report

Evansville, Indiana 47708
Tuesady, May 28, 1991 16:30 CDT

NTSB Narrative Summary Released at Completion of Accident

THE SINGLE ENGINE AIRPLANE DEPARTED ON ITS FIRST FLIGHT AFTER MAINTENANCE INVOLVING REPLACEMENT OF A CYLINDER. PASSING 200 FEET ON CLIMBOUT, THE PILOT IN COMMAND OBSERVED ENGINE RPM AND POWER DECREASING. UNABLE TO RETURN TO THE FIELD, THE PILOT EXECUTED AN OFF AIRPORT FORCED LANDING. ENGINE EXAMINATION AFTER THE ACCIDENT REVEALED A USED CYLINDER WITH A STANDARD SIZE BORE HAD BEEN INSTALLED AS A REPLACEMENT. THE REMAINING CYLINDERS AND ALL PISTONS WERE 0.010 INCH OVERSIZE.

NTSB Probable Cause Narrative

THE FAILURE BY MAINTENANCE PERSONNEL TO IDENTIFY THE PROPER REPLACEMENT CYLINDER.

Event Information

Type of Event Accident
Event Date 5/28/1991
Event Day of the Week Tuesday
Time of Event 1630
Event Time Zone Central Daylight Time
Event City EVANSVILLE
Event State INDIANA
Event Country --
Zipcode of the event site 47708
Event Date Year 1991
Event Date Month 5
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude
Event Location Longitude
Event Location Airport
Event Location Nearest Airport ID
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles 0
Degrees magnetic from airport 0
Airport Elevation --
Weather Briefing Completeness Unknown
Investigator's weather source Weather Observation Facility
Time of the weather observation 1653 Central Daylight Time
Direction of event from weather observation facility (degrees) 60
Weather Observation Facility ID EVV
Elevation of weather observation facility 418
Distance of event from weather observation facility (units?) 6
Time Zone of the weather observation CDT
Lighting Conditions Day
Lowest Ceiling Height 25000
Lowest Non-Ceiling Height 4300
Sky/Lowest/Cloud Conditions Scattered
Sky Condition for Lowest Ceiling Broken
Visibility Runway Visual Range (Feet) 0
Visibility Runway Visual Value (Statute Miles) 0
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 31
Dew Point at event time (in degress fahrenheit) 24
Wind Direction (degrees magnetic) 170
Variable Wind Indicator Unknown
Wind Speed (knots) 7
Wind Velocity Indicator Unknown
Wind Gust Indicator Unknown
Wind Gust (knots) 0
Altimeter Setting at event time (in. Hg) 30
Density Altitude (feet) 0
Intensity of Precipitation Unknown
METAR weather report --
Event Highest Injury Serious
On Ground, Fatal Injuries 0
On Ground, Minor Injuries 0
On Ground, Serious Injuries 0
Injury Total Fatal --
Injury Total Minor --
Injury Total None --
Injury Total Serious 2
Injury Total All 2
Investigating Agency NTSB
NTSB Docket Number (internal use) 1374
NTSB Notification Source --
NTSB Notification Date --
NTSB Notification Time 0
Fiche Number and/or location -used to find docket information 44076
Date of most recent change to record Dec 12 2000 9:58AM
User who most recently changed record dbo
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N5675L
NTSB Number CHI91LA173
Missing Aircraft Indicator N
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed None
Flight plan Was Activated? --
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name GULFSTREAM AMERICAN
Aircraft Model AA1A
Aircraft Series Identifier AA1A
Aircraft Serial Number 0075
Certified Max Gross Weight 1500
Aircraft Category Airplane
Aircraft Registration Class U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 2
Number of Engines 1
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection Annual
Date of Last Inspection May 28 1991 12:00AM
Airframe hours since last inspection --
Airframe Hours --
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site Unknown
ELT Type --
Aircraft Owner Name FIRESIDE GALLERY, INC.
Aircraft Owner Street Address 1017 S. WEINBACH
Aircraft Owner City EVANSVILLE
Aircraft Owner State IN
Aircraft Owner Country
Aircraft Owner Zipcode 47714
Operator is an individual? --
Operator Name FIRESIDE GALLERY, INC.
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address 1017 S. WEINBACH
Operator City EVANSVILLE
Operator State IN
Operator Country
Operator Zip code 47714
Operator Code
Owner has at least one certificate None
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation Unknown
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Personal
Second Pilot on Board Yes
Departure Point Same as Event Yes
Departure Airport Code
Departure City
Departure State
Departure Country
Departure Time 1625
Departure Time Zone CDT
Destination Same as Local Flt dest & departure same, accident can occur anywhere
Destination Airport Code
Destination City
Destination State
Destination Country
Specific Phase of Flight Takeoff
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jan 2 2001 10:30AM
User who most recently changed record dbo
Since inspection or accident --
Event Location Runway Number and Location 0
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --