# NTSB CEN13LA379: Piper PA-25-235, N4812Y, Salisbury, MO, June 28, 2013 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: June 28, 2013, 14:00 local (19:00 UTC) - Place: Salisbury, MO - Coordinates: 38.941387, -92.676109 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.9414&lon=-92.6761&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report February 10, 2014 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA/FSDO - NTSB case key (mKey): 87337 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN13LA379 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/87337/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=87337 - Page: https://openairdocs.org/ntsb/CEN13LA379 ## Probable cause The airplane's reduced braking efficiency and the pilot's subsequent delayed decision to go around, which resulted in a loss of directional control. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-25-235, 18 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102504), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Action: delayed action](https://openairdocs.org/ntsb-findings/02041025): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-25-235, 4 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md?model=7102504), [All aircraft, 894 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md) - [Flight control system: rudder control system](https://openairdocs.org/ntsb-findings/01022720): Aircraft › Aircraft systems · Not specified; cases with it: [Piper PA-25-235, 1 case](https://openairdocs.org/ntsb-findings/01022720/cases.md?model=7102504), [All aircraft, 93 cases](https://openairdocs.org/ntsb-findings/01022720/cases.md) - [Landing gear system: brake](https://openairdocs.org/ntsb-findings/01023242): Aircraft › Aircraft systems · Not specified (probable cause); cases with it: [Piper PA-25-235, 3 cases](https://openairdocs.org/ntsb-findings/01023242/cases.md?model=7102504), [All aircraft, 297 cases](https://openairdocs.org/ntsb-findings/01023242/cases.md) - [Wind: crosswind](https://openairdocs.org/ntsb-findings/03034040): Environmental issues › Conditions/weather/phenomena · Ability to respond/compensate (probable cause); cases with it: [Piper PA-25-235, 1 case](https://openairdocs.org/ntsb-findings/03034040/cases.md?model=7102504), [All aircraft, 1,008 cases](https://openairdocs.org/ntsb-findings/03034040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Piper PA-25-235, 4 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=7102504), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Piper PA-25-235, 3 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=7102504), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) ## Analysis The pilot landed the tailwheel-equipped airplane with a left crosswind on a dirt road. As the airplane slowed down, he applied the right rudder and brake. The pilot said the right brake was soft, and he tried to pump it several times before he decided to go around. After applying power, the pilot was unable to maintain directional control, and the airplane veered off of the road and into a ditch. A postaccident examination of the airplane revealed that, when the right rudder pedal was in the neutral position and the brake was applied, it held pressure. However, when full right rudder and brake were applied, the brake contacted the hopper, which limited the brake's full travel. It could not be determined if the amount of pressure applied to the brake in this condition was enough to provide adequate braking power. However, even with the limitations of the brake with the rudder pedal fully extended, the pilot had made several uneventful landings before the accident and reported no problems with the brakes. He said that the accident could have been prevented if he had decided to go around sooner. ## Factual narrative On June 28, 2013, at 1400 central daylight time, N4812Y, a Piper PA25-235, sustained substantial damage when it lost control while attempting to land on a dirt road near Salisbury, Missouri. The commercial pilot was not injured. The airplane was registered to and operated by the pilot. Visual meteorological conditions prevailed and no flight plan was filed for the local aerial application flight conducted under 14 Code of Federal Regulations Part 137. The pilot said he landed the tail wheel-equipped airplane on a dirt road with a left crosswind. As the airplane slowed down, he applied right rudder and brake. The pilot said the right brake was soft and he tried to pump it several times before he elected to go around. He also said the rudder pedal was hitting up against the hopper. The pilot was unable to maintain directional control and the airplane veered off of the road and into a ditch, which resulted in substantial damage to the airframe. Examination of the airplane revealed that when the right rudder pedal was in the neutral position and the brake was applied, it held pressure. However, when full right rudder pedal was applied and the brake was pressed, it came in contact with the hopper and limited full travel of the brake. It was not determined if this partial extension of the brake would have had sufficient braking action to slow the airplane. It was also unlear as to why the pedal was hitting the hopper. However, even with the limitations of the brake with the rudder pedal fully extended, the pilot said that he had made several uneventful landings prior to the accident and reported no problems with the brakes. He said the accident could have been prevented if he decided to go around sooner. ## Aircraft - Registration: [N4812Y](https://openairdocs.org/aircraft/N4812Y), registered now, S/N 25-4594 (OpenAirDocs) - Reported make and model: PIPER PA-25-235 - Registry model: [Piper PA-25-235](https://openairdocs.org/model/piper-pa-25-235) (registry code 7102504) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 25-4594 - Airframe hours: 7105 - Engines: LYCOMING 0-540 SERIES 250 horsepower reciprocating - Damage: Substantial damage - Flight: Aerial application, Part 137 - Operator: Slaughter Bradley R - Registered owner: Slaughter Bradley R - Airworthiness certificate: Special, Restricted (Special) - Last inspection: Annual, April 8, 2013 - Departed: Salisbury, MO - Destination: Salisbury, MO ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 47; injuries: none; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review March 11, 2013; seat: center; flight hours: 3,000 total, 900 in this make and model, 2,800 as pilot in command, 120 in the last 90 days, 50 in the last 30 days, 8 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 190° at 10 knots, gusting 18 - Temperature: 90 °F, dew point 70 °F - Altimeter: 29.81 inHg - Observed at: VER, 14 nm away ## Other investigations on N4812Y (1) From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. - [NTSB MKC71DTG28](https://openairdocs.org/ntsb/MKC71DTG28), Jun 1, 1971: Piper PA-25 (N4812Y), Devils Lake, ND, substantial damage ## Docket (2 files) The files NTSB released with the investigation on December 4, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=87337. 1.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40397060&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - FAA Inspector's Statement (item 2, .PDF, 250 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40397630&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Statement-Redacted.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.