Failure to follow emergency procedures contributes to crash

Aircraft: Cessna 421. Injuries: 4 Fatal. Location: Sioux Falls, S.D. Aircraft damage: Destroyed.

What reportedly happened: Shortly after the airplane lifted off, the tower controller informed the pilot that a plume of smoke was visible behind the airplane.

Witnesses reported seeing flames at the inboard side of the left engine. The airplane began a left turn. When it reached a southerly heading, the nose dropped abruptly, and the airplane crashed and burned. Witnesses stated that they heard an increase in engine sound before impact.

The post-accident examination determined that the left engine fuel selector and fuel valve were in the OFF position, consistent with the pilot shutting down that engine after takeoff. However, the left engine propeller was not feathered. Extensive damage to the right engine propeller assembly was consistent with that engine producing power at the time of impact. The landing gear and wing flaps were extended at the time of impact.

The post-crash examinations of both engines did not reveal any anomalies consistent with a loss of engine power.

Emergency procedures outlined in the pilot’s operating handbook noted that when securing an engine, the propeller should be feathered. Performance data provided in the POH for single-engine operations were predicated on the propeller of the inoperative engine being feathered, and the wing flaps and landing gear retracted. Thus, the pilot did not follow the emergency procedures outlined in the POH for single-engine operation.

Probable cause: The pilot’s failure to maintain adequate airspeed after shutting down one engine, which resulted in an inadvertent aerodynamic stall and impact with terrain. Contributing to the accident was the pilot’s failure to follow the guidance contained in the pilot’s operating handbook, which advised feathering the propeller of the secured engine and retracting the flaps and landing gear.

NTSB Identification: CEN12FA100

This December 2011 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.


  1. Buford Suffridge says

    You misunderstood Tom. in this application I’m not advocating a more thorough flight exam beyond what we called in the Navy, “see lightening, hear thunder.” What I’m telling you is my friend’s physician heard something he didn’t like when he listened to his heart during his “see lightening, hear thunder” medical exam and sent him to a cardiologist; and he was and is thankful. But whatever, you answered my original question. I didn’t intend to get into a debate over whether or not the exam should be required. It is and it likely isn’t going to change any time soon so as long as I continue to fly I’m going to be required every two years to have one and I’m not getting my shorts in a wad over it. I’ll exert my energy on more important things such as defunding and repealing Obamcare.

  2. Buford Suffridge says

    Tom, I actually consider myself to be a Republican but have always voted as an Independent (up until the last election that is, when anyone with a “D” after their name did not have a chance for my vote and they never will again), although I’ve never voted for a Democrat for president. At the time I would have likely voted for Kennedy but didn’t turn 21 until two weeks following the 1961 election.

    I understand what you’re saying and I appreciate your position and opinion, but somehow I personally still can’t equate the danger to ones self or others as the result of a heart attack while driving a car with one while flying an airplane? I showed your comments to the fellow who had the coronary blockages detected during his flight physical and his comment was, he’d have been just as dead whether in his car, his plane or sitting at his dinner table so he was still thankful for the required flight physical that resulted in his condition being recognized. He also said he would hate to think that he might have taken someone else with him; whether car or plane even if the chance was 1% as you suggested. He added that he felt had he suffered a heart attack, which was inevitable considering his blockages, while driving it would have been much easier and safer for all concerned to pull to the side of the road than to try to land a plane; likely off field? He also jokingly said, he’d rather have wrecked his $10,000 truck or broken his $100 dinner table than crash landed his $250,000 airplane!!

    Merry Christmas to you!

    • Tom says

      I think we are almost there but I want to try once more to distinguish from a thorough “flight physical” (military or civilian) that could conceivably turn up heart disease from the primary gripe that most of us in general aviation are against and that is the 2 year FAA “examination” (by NO MEANS a flight “physical”) performed by an AME. The statistics have overwhelmingly shown that those that are recreational pilots and those light sport pilots that are flying on their drivers license “medical” are not dangerous to the public per se. It’s that simple Buford and that’s what Mooney and others on this blog are trying to emphasize. You see it is SOMETHING ELSE that causes accidents and the 3rd class medical certificate isn’t preventing ANY OF THEM. Moreover, you seem to be advocating even FURTHER OUT FROM REALITY FROM THE LEFT even more strict “flight physicals” that could uncover heart disease as a REQUIREMENT for general aviation pilots flying Cessna 172’s. That’s really what you seem to be saying and you are very simply standing out there by yourself from all of us small airplane drivers that want the Feds off our backs on this due to their untenable and most unsubstantiated position on a so called “safety to the public” concerns. Easy for them to do that because they have the uneducated public out there (and apparently you along with them) that are in dire fear of their lives that a small airplane is going to crash on top of them or their children on recess on a school playground and they don’t realize it but they are in more danger driving their kids to school than whether an airplane is going to fall on them. Where I differ from Mooney is that while he is correct that training would do more good than the 3rd class medical certificate, I take the “libertarian” view that we private pilot types in small airplanes that are already licensed (for life) pilots shouldn’t be REQUIRED by the Feds to take training and that the training should be the own individual’s responsibility based on his/her own needs and that we shouldn’t have to fit a cookie mold that the Feds provide but only to “protect” them in case someone in their own stupidity goes out there and crashes. This is about the ever over control by the government that is trying to garner votes if you really get down to the bottom line in the matter. Those on one side that believe in the government doing everything and those that don’t. Nice talking with you but it’s time to “turn in your badge” on this one.

      Merry Christmas

      P.S. Leap year improves my “risk argument” even more every 4 years

    • Tom says

      God bless you sir. As you spoke of me, I feel the same way that you seem to be an intelligent person and capable of reasoning in these matters. Think of it this way. Suppose you have a casual citizen automobile driver (to eliminate the commercial aspects from the discussion) and if you want to include a passenger that’s fine. He’s 42 years old, never had a physical examination (because it is a free country), driving up a 2 lane highway, dies of a massive heart attack, and runs head-on into another vehicle and deaths result. Now come along with me if you will and apply the logic that is being used by the FAA exacerbated by the medical profession who has a DEFINITE monetary interest in these matters and the insurance companies that have a DEFINITE monetary interest in these matters and most particularly a very “loose canon” liberal attitude of dem——ts in this country and you come up with the idea that it needs to be a Federal Law that EVERYBODY IN THE COUNTRY needs to have a yearly physical examination AS A CONDITION OF HAVING A DRIVER’s license. Now you know what I’m talking about here. Is it a “free” country or is it not a free country? You my friend will likely say that it SHOULD be the law and I do not believe that is correct in a free society for the same reason that the 3rd class physical should not be a Federal requirement for a private pilot’s license. This is about personal responsibility and not a dictatorship nanny state. Moreover, it is less likely that the pilot will cause a death from the air than the negligent driver on the highway. Have a nice day and think about vo….ing cons….tive next time.

  3. Buford Suffridge says

    Thanks for the explanation Tom although I don’t recall asking for, nor do I require your condescending comments. Not being clairvoyant I don’t know that it’s not about the $80 any more than you do? I’ve known pilots who wouldn’t top off their tanks before a flight because they knew their destination airport had fuel for five cents less a gallon. I also don’t know that it’s not about some pilots who can’t pass the flight physical? There is nothing that brings out quicker opposition to a rule than not being able to conform to it. However, all that being said, I personally know two people who recently had medical problems they were unaware of caught on flight physicals and they are very thankful for it. One of them had 90% blockage in the right coronary and anterior interventricular branch of the left coronary artery which not only could have caused his death but the death of any unfortunate passenger or persons on the ground had he crashed the plane as the result of an infarction. Should they have been having annual physicals on their own hook? Most certainly, but they didn’t. So you ask if I think the medical exam requirement is ridiculous. Most certainly not and I also religiously have an annual medical exam; not that this will necessarily catch every single malady but until something better comes along (not likely with Obamacare) it’s the best I know to do.

    During the Viet Nam War I was a dental officer at a Naval Air Station and aboard an aircraft carrier and Navy pilots were required to have flight physicals (which also included dental exams) on a regular basis, and for the most part these were young whippersnappers, so the Navy must have thought there was some value to them? One of my sons was a flight surgeon in the Air Force; same thing there. Thirty years following my own active duty my other two sons were Navy dental officers and the same requirement was still in place so the Air force and Navy must have some proof there is value to a regular flight physical?

    I was interested in what you had to say, and actually agreed with some of what you wrote, until I read your statement, “so what if someone is stupid and kills someone out there”, and your credibility went out the window. You write like a reasonably educated person and it’s unbelievable you’d make such a statement.

    I have to admit though that I do like your suggestion concerning monitoring the consumption of coffee and donuts. Not a bad idea. With fewer lard butts flying aircraft more fuel could be taken on board resulting in less fuel mismanagement accidents.

    • Tom says

      365 days X 24 hours in a day = 8760 hours in a year
      If a general aviation pilot flys 100 hours in a year thats 1 % of his time in the airplane and less time in the air if you subtract the taxi time. 100 minus 1 = 99% of the time he is doing something else so what do you think of the odds that he will be in the airplane when his heart stops? Pretty slim odds don’t you think when you try and defend the importance of a physical examination. Then there is the problem you have with “sudden incapacitation” versus those heart problems/attacks that didn’t result in sudden incapacitation. Also what are the odds that during the 1% of the pilot’s life that he is flying that he is suddenly incapacitated and that he crashes into something other than wide open spaces. All of this emphasis on medicals just doesn’t add up when you consider costs versus benefits. Of course you have those folks that could care less about the costs and will say “Oh if we can just save one life it’s worth it!” NO IT ISN”T worth it. The emperor has no clothes! It’s ridiculous. Do we need medicals to drive our cars?????????????? After all you might have a heart attack……………….Do you advocate the government requiring all of us to wear panic buttons around our necks when we get into the bath tub in case we fall and can’t get up? After all it could save one life………….. FREEDOM Buford. Go fly and enjoy yourself while you still can and while big brother is in his office trying to cook up some other requirement for you “for your own good and the good of the people”. The coffee and donuts was just an example of the ridiculous. I can’t believe it that you REALLY want to have the food police checking the pilot’s lunch box.

  4. Buford Suffridge says

    Someone please explain to me what having or not having a class 3 medical has to do with emergency procedures? If it’s the $80 the medical exam costs, then if an individual can’t afford the $80 AND “a couple of hours annually in real flight training” they likely should be playing checkers as a hobby rather than flying airplanes.

    I see this alluded to in practically every column concerning an aircraft accident and for the life of me can’t see what it has to do with the price of tea in China??

    • Tom says

      It’s not about the $80 Buford and you know it. I’d gladly through a couple of hundred dollars in my fire place if I could get the “Fed Meds” off my back. It has become ridiculous and you know it and it’s all about the FAA protecting themselves against “bad” publicity from the public if they even allow one bad accident to be attributable to someone’s health problem. This problem is one of basic ideology and has little to do with health. Those of us that are dealing with this situation don’t appreciate it one bit either and it’s all about over control by the government into our lives in many areas. Yes, and SO WHAT if someone is stupid and kills someone out there. I don’t want that to happen and you don’t either but if it happens it shouldn’t have been the FAA medical that was being used as leverage to try to stop it from happening. Don’t you see that? And as far as training is concerned I don’t want the government to tell me I have to have training either. I already resent the 2 year flight review. We are talking about “freedom” Buford and not “hand holding”. If a person is negligent then he should pay for that negligence himself and not all the rest of us for his negligence. Don’t you know if you are qualified and confident to fly your machine and whether you need to have training or not? It’s YOUR responsibility and not the “nanny states” job to have a rule on the matter. Maybe we should have FAA issued mandated sleep requirements that they monitor to be sure we aren’t too tired to fly that day. How about a restriction monitor to be sure we don’t have too much coffee or donuts? Are you even trying to understand what I’m saying?

  5. vaughn price says

    As usual Mooney hit the nail on the head. There is no substitute for flight proficiency, and because I have been fighting FAA to renew my medical, just a class 3, I am in shock, I have over 15000 hours general aviation, owned 2 large part 141 flight schools, and at age 83 I damn shore know whether to fly or not. CLASS THREE’S DONT CONTROL AN AIRPLANE, PILOTS DO !!!

  6. Mooney says

    RudyH has it right, practice moves us toward perfection. The First Class Medical didn’t help. Multi-engine can compound the troubles and we can bring a big discount factor to apply by having recurrency training. For non-commercial, lets give up the senseless medical which does nothing to reduce accidents and trade this off with a couple of hours annually in real flight training which will reduce accidents, save lives and reduce costs.

  7. RudyH says

    Aviators must commit to memory the engine-out emergency details…..practice same…..for when the time comes when their multi encounters engine-out…the steps must kick in …no doubts….

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