Individually Owned: 150,657
Corporate Owned: 137,281
Grand Rapids/Itasca Co-Gordon Airport
Aircraft Accident/Incident Report
Grand Rapids, Minnesota 55744
Monday, July 4, 2005 17:58 CDT
NTSB Narrative Summary Released at Completion of Accident
The airplane was destroyed on impact with terrain during a forced landing following an observed in-flight loss of engine power after takeoff. A witness observed the takeoff and stated that the airplane took off from the end of runway 34. About halfway down the runway the airplane emitted a sound like a rapid misfire, a pop, and then no more audible engine sounds. The airplane was about 300 to 400 feet above ground level at that point. He said that the airplane turned right then turned left to a bank where the wing was straight down. The airplane's wings then leveled, the airplane descended, and it impacted terrain. He stated that the time from the sounds to the impact was about two to three seconds. An on-scene examination revealed no airframe pre-impact anomalies. An engine examination revealed a cracked crankshaft propeller flange. The engine without the turbochargers and with the original crankshaft was test run up to 2,100 RPM. A propeller and governor inspection revealed no anomalies. Examination of the turbocharger system's exhaust bypass valve assembly revealed its butterfly valve was stuck (bound) in the extended closed position. The engine's cracked crankshaft was removed and a serviceable crankshaft was installed. The engine was test run again with a serviceable exhaust bypass valve assembly. The engine produced rated power. The original exhaust bypass valve assembly was reinstalled. The exhaust bypass valve assembly's wastegate bound again during an engine run and a loss of engine power was observed. Sectioning of the bypass valve assembly revealed a bent wastegate shaft. The valve assembly lever arm was bent and exhibited pre-impact toolmarks consistent with pliers loosening a bound wastegate shaft. The airplane's pilot operating handbook and Federal Aviation Administration (FAA) approved airplane flight manual (POH), in part, stated, "ENGINE POWER LOSS DURING TAKEOFF If sufficient runway remains for a normal landing, leave gear down and land straight ahead." The engine manufacturer's maintenance and operator's manual stated that the wastegate is required to be checked for operation and condition during 100 hour inspections. The manual did not specify a procedure for maintenance personnel on how to check the wastegate's operation and its acceptable condition. National Transportation Safety Board Recommendation A-94-081, issued to the FAA in 1994, stated, "Require the amendment of pilot operating handbooks and airplane flight manuals applicable to aircraft equipped with engine turbochargers by including in the 'Emergency Procedures' section information regarding turbocharger failure. The information should include procedures to minimize potential hazards relating to fire in flight and/or loss of engine power." The airplane's POH latest revision was dated October 14, 2002 and review of the emergency procedures section showed that the POH did not contain information, procedures, or amplified procedures on turbocharger failures. The airplane accumulated 8.7 hours of operation since the last annual inspection.
NTSB Probable Cause Narrative
An observed loss of engine power due to the bound/jammed turbocharger wastegate during takeoff, the pilot not maintaining airplane control, and the stall he inadvertently encountered. A factor was the maintenance personnel not replacing the turbocharger wastegate bypass valve assembly during the last annual inspection 8.7 hours of operation prior to the accident. An additional factor was the manufacturer's insufficiently defined inspection conditions for the bypass valve's proper operation.
Event Information
| Type of Event | Accident |
| Event Date | 7/4/2005 |
| Event Day of the Week | Monday |
| Time of Event | 1758 |
| Event Time Zone | Central Daylight Time |
| Event City | Grand Rapids |
| Event State | MINNESOTA |
| Event Country | -- |
| Zipcode of the event site | 55744 |
| Event Date Year | 2005 |
| Event Date Month | 7 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | 471240N |
| Event Location Longitude | 0933035W |
| Event Location Airport | GRAND RAPIDS/ITASCA CO-GORDON |
| Event Location Nearest Airport ID | GPZ |
| Indicates whether the acc/inc occurred off or on an airport | On Airport |
| Distance from airport in statute miles | 0.5 |
| Degrees magnetic from airport | -- |
| Airport Elevation | 1355 |
| Weather Briefing Completeness | -- |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 1755 Central Daylight Time |
| Direction of event from weather observation facility (degrees) | 0 |
| Weather Observation Facility ID | GPZ |
| Elevation of weather observation facility | 1355 |
| Distance of event from weather observation facility (units?) | 0 |
| Time Zone of the weather observation | CDT |
| Lighting Conditions | Day |
| Lowest Ceiling Height | -- |
| Lowest Non-Ceiling Height | 8000 |
| Sky/Lowest/Cloud Conditions | Few |
| Sky Condition for Lowest Ceiling | None |
| Visibility Runway Visual Range (Feet) | -- |
| Visibility Runway Visual Value (Statute Miles) | -- |
| Visibility (Statute Miles) | 10 |
| Air Temperature at event time (in degrees celsius) | 21 |
| Dew Point at event time (in degress fahrenheit) | 12 |
| Wind Direction (degrees magnetic) | 290 |
| Variable Wind Indicator | Wind direction could be determined |
| Wind Speed (knots) | 11 |
| Wind Velocity Indicator | -- |
| Wind Gust Indicator | Gusting |
| Wind Gust (knots) | 17 |
| Altimeter Setting at event time (in. Hg) | 29.94 |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | -- |
| METAR weather report | KGPZ 042255Z AUTO 29011G17KT 10SM FEW080 21/12 A29 |
| Event Highest Injury | Fatal |
| On Ground, Fatal Injuries | -- |
| On Ground, Minor Injuries | -- |
| On Ground, Serious Injuries | -- |
| Injury Total Fatal | 1 |
| Injury Total Minor | -- |
| Injury Total None | -- |
| Injury Total Serious | -- |
| Injury Total All | 1 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 20714 |
| NTSB Notification Source | FAA |
| NTSB Notification Date | Jul 4 2004 12:00AM |
| NTSB Notification Time | -- |
| Fiche Number and/or location -used to find docket information | DMS |
| Date of most recent change to record | Dec 28 2006 9:08AM |
| User who most recently changed record | NTSB\johb |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | Minneapolis, MN, FSDO |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N4386G |
| NTSB Number | CHI05FA162 |
| Missing Aircraft Indicator | -- |
| Federal Aviation Reg. Part | Part 91: General Aviation |
| Type of Flight Plan filed | None |
| Flight plan Was Activated? | -- |
| Damage | Destroyed |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | Piper |
| Aircraft Model | PA-46-310P |
| Aircraft Series Identifier | -- |
| Aircraft Serial Number | 46-8508037 |
| Certified Max Gross Weight | 4100 |
| Aircraft Category | Airplane |
| Aircraft Registration Class | -- |
| Aircraft is a homebuilt? | No |
| Flight Crew Seats | -- |
| Cabin Crew Seats | -- |
| Passenger Seats | -- |
| Total number of seats on the aircraft | 6 |
| Number of Engines | 1 |
| Fixed gear or retractable gear | Retractable |
| Aircraft, Type of Last Inspection | Annual |
| Date of Last Inspection | May 1 2005 12:00AM |
| Airframe hours since last inspection | 8.7 |
| Airframe Hours | 1856.4 |
| ELT Installed | Yes |
| ELT Activated | No |
| ELT Aided Location of Event Site | No |
| ELT Type | -- |
| Aircraft Owner Name | Stephen D. Jensen |
| Aircraft Owner Street Address | 7620 Auto Club Circle |
| Aircraft Owner City | Bloomington |
| Aircraft Owner State | MN |
| Aircraft Owner Country | USA |
| Aircraft Owner Zipcode | 55438 |
| Operator is an individual? | No |
| Operator Name | -- |
| Operator Same as Owner? | Yes |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | Yes |
| Operator Street Address | -- |
| Operator City | -- |
| Operator State | -- |
| Operator Country | -- |
| Operator Zip code | -- |
| Operator Code | -- |
| Owner has at least one certificate | None |
| Other Operator of large aircraft? | -- |
| Certified for Part 133 or 137 Operation | -- |
| 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 | No |
| Departure Point Same as Event | Yes |
| Departure Airport Code | GPZ |
| Departure City | Grand Rapids |
| Departure State | MN |
| Departure Country | USA |
| Departure Time | 1758 |
| Departure Time Zone | CDT |
| Destination Same as Local Flt | -- |
| Destination Airport Code | FCM |
| Destination City | MINNEAPOLIS |
| Destination State | MN |
| Destination Country | USA |
| Specific Phase of Flight | Emergency landing after takeoff |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Oct 6 2006 10:20AM |
| User who most recently changed record | SULP |
| Since inspection or accident | Time of Accident |
| Event Location Runway Number and Location | 34 |
| Runway Length | 5755 |
| Runway Width | 100 |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |