Palm Beach County Park Airport
Aircraft Accident/Incident Report

Lake Worth, Florida 33461
Saturday, December 8, 2012 13:34 EST

NTSB Narrative Summary Released at Completion of Accident

The twin-engine airplane was released to the pilot (who was also the airplane owner) after an annual inspection and repainting of the airplane had been completed. Before the accident flight, which was the second flight after maintenance, the pilot performed an engine run-up for several minutes before taxiing to the end of the departure runway for takeoff. According to witnesses, the airplane lifted off about halfway down the runway and initially climbed at a normal rate. Several witnesses then observed the airplane suddenly yaw to the left for 1 or 2 seconds, and the airplane's nose continued to pitch up before the airplane rolled left and descended vertically, nose-down, until it disappeared from view. One witness, a flight instructor, said, "The airplane just kept pitching up, and then it looked like a VMC [the airplane’s minimum controllable airspeed with only one engine operating] roll." Examination of the left engine revealed signatures consistent with contact between the piston domes and the valves. The crankcase halves were separated and the No. 1 cylinder main bearing was rotated, and damaged and distorted severely, with bearing fragments located in the oil sump. Bearing material was also extruded from its steel backing. The No. 3 cylinder main bearing showed accelerated wear and wiping of the bearing material. Damage and signatures consistent with excessive heat due to oil starvation were observed on the No. 1 and No. 3 cylinder main bearing journals as well as the No. 1 and No. 2 cylinder connecting rod journals. The camshaft gear was also damaged, with five gear teeth sheared from the gear. A review of engine maintenance records revealed that no maintenance had been performed on the engine that would have required breaking of crankcase thru-bolt torques (such as cylinder removal) since its most recent overhaul, which was completed more than 3 years and 314 flight hours before the accident flight. The reason for the engine failure could not be determined because of the impact and postaccident fire damage. Examination of the wreckage revealed that the landing gear was in the down and locked position, the left engine propeller blades were in the feathered position, and the left fuel selector valve was in the off position. Examination of the manufacturer's Pilot Operating Handbook revealed that if properly configured, with the landing gear retracted, the airplane would have been capable of a 500 foot-per-minute rate of climb with only one operating engine on the day of the accident. As found, the airplane was not configured in accordance with the after-takeoff checklist or the engine failure after takeoff checklist.

NTSB Probable Cause Narrative

The pilot's failure to follow established engine-out procedures and to maintain a proper airspeed after the total loss of engine power on one of the airplane’s two engines during the initial climb. Contributing to the accident was the total loss of engine power due to a loss of torque on the crankcase bolts for reasons that could not be determined because of impact- and fire-related damage to the engine.

Event Information

Type of Event Accident
Event Date 12/8/2012
Event Day of the Week Saturday
Time of Event 1334
Event Time Zone Eastern Standard Time
Event City Lake Worth
Event State FLORIDA
Event Country --
Zipcode of the event site 33461
Event Date Year 2012
Event Date Month 12
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 263605N
Event Location Longitude 0800432W
Event Location Airport Palm Beach County Park Airport
Event Location Nearest Airport ID LNA
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles 1
Degrees magnetic from airport --
Airport Elevation 14
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1332 Eastern Standard Time
Direction of event from weather observation facility (degrees) 352
Weather Observation Facility ID PBI
Elevation of weather observation facility 20
Distance of event from weather observation facility (units?) 5
Time Zone of the weather observation EST
Lighting Conditions Day
Lowest Ceiling Height 3500
Lowest Non-Ceiling Height 2600
Sky/Lowest/Cloud Conditions Scattered
Sky Condition for Lowest Ceiling Broken
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 27
Dew Point at event time (in degress fahrenheit) 20
Wind Direction (degrees magnetic) 110
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 11
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 29.97
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report KPBI 081853Z 11011KT 10SM SCT026 BKN035TCU BKN140
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) 32033
NTSB Notification Source FAA Southern C-ROC
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Nov 20 2013 8:58AM
User who most recently changed record kenj
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N297DB
NTSB Number ERA13FA082
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed None
Flight plan Was Activated? No
Damage Substantial
Aircraft Fire Ground
Aircraft Explosion None
Aircraft Manufacturer's Full Name CESSNA
Aircraft Model 421C
Aircraft Series Identifier --
Aircraft Serial Number 421C0826
Certified Max Gross Weight 7450
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats 2
Cabin Crew Seats --
Passenger Seats 6
Total number of seats on the aircraft 8
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Annual
Date of Last Inspection Dec 3 2012 12:00AM
Airframe hours since last inspection 2
Airframe Hours 7040
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site Unknown
ELT Type Unknown
Aircraft Owner Name Subway Development of Southeast Florida, Inc.
Aircraft Owner Street Address --
Aircraft Owner City Miami Lakes
Aircraft Owner State FL
Aircraft Owner Country USA
Aircraft Owner Zipcode 33014
Operator is an individual? No
Operator Name Subway Development of Southeast Florida, Inc.
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address --
Operator City Miami Lakes
Operator State FL
Operator Country USA
Operator Zip code 33014
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 No
Departure Airport Code LNA
Departure City Palm Beach
Departure State FL
Departure Country USA
Departure Time 1332
Departure Time Zone EST
Destination Same as Local Flt --
Destination Airport Code TMB
Destination City Miami
Destination State FL
Destination Country USA
Specific Phase of Flight --
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Nov 20 2013 8:59AM
User who most recently changed record kenj
Since inspection or accident Time of Accident
Event Location Runway Number and Location 03
Runway Length 3256
Runway Width 75
Sight Seeing flight No
Air Medical Flight No
Medical Flight --