ATL05TA055
2005-03-03 · Sparta, Tennessee, United States · Serious · 1 aircraft · Status: Completed
Aircraft involved
Probable cause & findings
Improper installation of the timing reference plug by other maintenance personnel, which resulted in oil starvation, and the loss of engine power.
Factual narrative
On March 3, 2005, about 1615 central standard time, a Cessna T-41B, N14449, registered to and operated by the State of Tennessee Division of Forestry, nosed over during emergency landing in Sparta, Tennessee. The public use flight was operated under the provisions of Title 14 CFR Part 91 with no flight plan filed. Visual meteorological conditions prevailed. The private pilot received serious injuries, and the airplane sustained substantial damage. The flight departed Nashville International Airport, Nashville, Tennessee, at 1544. The pilot stated the flight was cruising at 3,500 feet when the engine began to run rough. Moments later, engine oil sprayed on the windscreen and the cockpit filled with smoke. The pilot estimated he was five or six miles from the Upper Cumberland Regional Airport, Sparta, Tennessee, and he reported the emergency on the airport common traffic advisory frequency. The pilot continued flight towards the airport. The pilot ventilated the cabin by opening the passenger-side window, and attempted to maintain engine power but could see engine oil spurting out the oil service door in the cowling. Several hundred yards short of runway 4, the engine quit completely, and the propeller stopped. The pilot maneuvered the airplane to avoid trees and landed in a field. The pilot stated the field was soft with recent rains, and when the nose wheel touched down, it sank into the soft ground, and the airplane nosed over. Examination of the airplane revealed the empennage was nearly separated aft of the baggage compartment, the fuselage was buckled aft of the firewall, and damage was observed on the engine crankcase. Post-accident examination of the engine revealed the timing reference plug was missing from the crankcase. The timing reference plug threads in the crankcase were not stripped. The aircraft oil pressure gauge reference (45-degree fitting) located below and between the numbers two and four cylinder was loose at the union fitting in the crankcase. The crankshaft did not reveal any signs of movement or rotation, and the pistons, rings, and pins in all six cylinders revealed discoloration and mechanical damage. The crankshaft bearings revealed scoring, discoloration, and mechanical damage concentrated at the number two connecting rod journal. The crankcase was breached above the centerline of the number two-cylinder bay. The plug gasket seating area position on the crankcase revealed staining adjacent the crankcase breach. There was no safety wire in the area of the timing reference plug. Review of maintenance records revealed that the last 100 hour inspection was completed on December 16, 2004. During the 100-hour inspection both magnetos were installed and timed to the engine. The pilot stated the flight was cruising at 3,500 feet mean sea level when the engine began to run rough. Moments later, engine oil sprayed on the windscreen and the cockpit filled with smoke. Several hundred yards short of runway 4, the engine lost power completely, and the propeller stopped. The pilot maneuvered the airplane to avoid trees and landed in a field. The pilot stated when the nose wheel touched down, it sank into the soft ground, and the airplane nosed over. Examination of the airplane revealed the empennage was nearly separated aft of the baggage compartment, the fuselage was buckled aft of the firewall, and damage was observed on the engine crankcase. The post-accident examination of the engine revealed the timing reference plug was missing from the crankcase. The timing reference plug threads in the crankcase were not stripped. The crankshaft did not reveal any signs of movement or rotation, and the pistons, rings, and pins in all six cylinders revealed discoloration and mechanical damage. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_2005_ATL05TA055.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
Search this event elsewhere
External sources are reported, not agency: signal that something happened, not fact about what happened.
- TallyAero Live Wire Aviation press
- NTSB CAROL Agency ↗
- NTSB Docket Agency ↗
- Aviation Safety Network Aviation press ↗
- Kathryn's Report Aviation press ↗
- Aviation Herald Aviation press ↗
- AVweb Aviation press ↗
- Pilots of America Community ↗
- Reddit /r/flying Community ↗
- FlightAware Aviation press ↗
- AOPA accident database Aviation press ↗
- Google News News ↗
- DuckDuckGo News ↗
Related research
Matched on aircraft type or causal vocabulary (stall, maintenance). All research papers
- Embry-Riddle Scholarly Commons 2023 · Conference paper The Value of Strong Partnerships to Build a Successful Aviation Maintenance Career Pathway Program for Transitioning Military Service Members
The aerospace industry is competing with other industries for a qualified workforce, and many of those competing industries are investing heavily in creating workforce development pipelines.
- Embry-Riddle Scholarly Commons 2026 · Journal article (IJAAA) From Reactive to Predictive: A hybrid Trust-Mediated Adoption Framework for Data-Driven Maintenance in Distributed-Authority Aviation Environments
Modern aviation maintenance operates within increasingly data-intensive technological environments, yet the operational integration of predictive maintenance into routine decision-making remains incon…
- NASA NTRS 2026 · Conference Paper Computational Analysis of Steady State Aerodynamics of Transonic Truss-Braced Wing Configuration in Deep Stall
This study presents a computational investigation of steady state aerodynamics of the Subsonic Ultra-Green Aircraft Research (SUGAR) Transonic Truss-Braced Wing (TTBW) configuration over a wide range …
- Semantic Scholar 2026 · Article (Reliability Engineering & System Safety) Understanding human error in military aviation maintenance: The role of Performance shaping factors, cognitive workload and error orientation
- Semantic Scholar 2025 · Article (Applied Sciences) Decision-Making Framework for Aviation Safety in Predictive Maintenance Strategies
The implementation of predictive maintenance (PM) in aviation presents unique challenges due to strict safety requirements, complex operational environments, and regulatory constraints.
- Semantic Scholar 2024 · Article (Defence Science Journal) Modelling of Human Factors in Aviation Maintenance Using HFACS ME Human Factors Analysis and Classification System Maintenance Extension and Bayesian Network
Aircraft maintenance is a complex task involving a skilled human workforce, spare parts, and various other resources. Human factors are an inherent element of the human workforce.