CEN18LA230

NTSB accident investigation · Cessna TR182 · Beloit, KS · June 18, 2018

Accident · No injuriesLimited investigationFinal report
Date
June 18, 2018, 12:30 local (17:30 UTC)
Place
Beloit, KS
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N756SWCessna TR182
Defining event
Approach-VFR pattern downwind: Sys/Comp malf/fail (non-power)
Weather
Visual (VMC) · Day
Status
Completed · report February 5, 2019
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA Flight Standards
FAA report
20180618008169A
Case key
97514

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The mechanic’s failure to properly torque one of the left brake caliper’s back plate attachment bolts while re-installing it during the annual inspection, which resulted in the left main landing gear not extending before landing.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Landing gear system: landing gear brakes systemAircraft › Aircraft systems · Incorrect service/maintenanceCessna TR182: 1 caseAll aircraft: 92 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelCessna TR182: 1 caseAll aircraft: 320 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The private pilot was practicing takeoffs and landings in the airport traffic pattern when the left main landing gear (MLG) failed to extend. He cycled the gear, but the left MLG still would not extend. He then attempted to manually extend the gear without success. The pilot subsequently executed an emergency landing on the turf runway. During recovery of the airplane, one of the left brake caliper's back plate bolts was found backed out. Scrape marks were present on the fuselage skin, consistent with contact from the extended back plate bolt. The MLG extension/retraction system and the emergency extension system both performed normally during postaccident examination. An annual inspection had been completed 6 days before the accident, and the airplane had accumulated a total of 3.2 hours since then. The mechanic that performed the inspection reported that the brake calipers were removed at that time and that the bolts had not been secured with safety wire after they were re-installed. Given the evidence, it is likely that the mechanic did not properly torque the left brake caliper back plate bolt after he re-installed it during the annual inspection, which allowed it to back out and led to the subsequent failure of the left MLG to extend. Although safety wire would have prevented the bolt from backing out, the airframe manufacturer's service manual was not consistent about whether to use safety wire. Regardless, the bolt would not have backed out if it had been tightened within the specified torque.

Factual narrative

On June 18, 2018, about 1230 central daylight time, a Cessna TR182 airplane, N756SW, was substantially damaged during an emergency landing on runway 22 (2,381 ft by 110 ft, turf) at the Moritz Memorial Airport (K61), Beloit, Kansas. The pilot was not injured. The airplane was registered to and operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. Day visual meteorological conditions prevailed. The flight was not operated on a flight plan. The local flight originated from K61 about 1140.The pilot reported that he was conducting takeoffs and landings in the traffic pattern when the left main landing gear failed to extend. He had not experienced any problems with the landing gear prior to that point during the flight. He remained in the traffic pattern and cycled the landing gear but the left main landing gear would not extend. He also attempted to use the manual gear extension without success. He decided to execute an emergency landing on the turf runway. The left horizontal stabilizer and elevator contacted the ground during the emergency landing resulting in substantial damage to the airplane. The airplane was recovered from the accident site by the owner/pilot and a local mechanic. The mechanic had recently completed an annual inspection on the airplane. During recovery, they noted that one of the brake caliper attachment bolts had backed out about 3 or 4 turns, which caused the bolt to protrude about 1/4-inch. It appeared that the protruding bolt had caught on the fuselage skin at the perimeter of the wheel well causing the left main landing gear to remain retracted. The left brake caliper and wheel assembly was removed to facilitate recovery. A postaccident examination conducted by a Federal Aviation Administration inspector did not reveal any anomalies with respect to the normal landing gear extension/retraction system, or with the emergency extension system. The inspector noted that about 1/2-inch of clearance existed between the wheel well opening and the brake caliper back plate bolts when the landing gear was retracted. The fuselage skin exhibited scrape marks in the vicinity of the back plate bolt when the landing gear was retracted. The inspector noted that the bolts on the right brake caliper back plate were not safety wired at the time of the examination. The airplane maintenance records noted that an annual inspection was completed on June 12, 2018; 6 days before the accident. A total of 3.2 hours had accumulated since the inspection. The entry indicated testing of the landing gear extension/retraction and emergency extension systems were completed. The mechanic informed the inspector that the brake calipers were removed during the annual inspection and that the bolts had not been secured with safety wire after they were re-installed. The Cessna TR182 service manual noted, in figure 5.10, that the brake caliper back plate bolts should be torqued to 100 – 110 in-lbs and safety wired. In section5-169, Brake Installation, the service manual stated that the back plate bolts should be torqued to 110 – 120 in-lbs. The use of safety wire was not mentioned in section 5-169.

Aircraft

Registration
N756SW
Reported as
Cessna TR182 (NO SERIES)
Category
Airplane
Serial number
R18201148
Built
1979
Airframe hours
3,661.6
Engine
Lycoming O-540-L3C5D, 235 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 12, 2018 · 3 hours before
Departed
K61 · Beloit, KS
Destination
K61 · Beloit, KS
Airport
K61 · Moritz Memorial, runway 22, 2,381 × 110 ft, grass/turf
Equipment
Electronic primary flight display, Electronic flight bag or handheld device, Auto-pilot, ADS-B, Stall warning system

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
64
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
BasicMed, With waivers/limitations
Last flight review
October 28, 2017
Seat
Left
Restraint
3-point
Flight hours
716 total · 399 in this make and model · 716 as pilot in command · 14 in the last 90 days · 4 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
200° at 18 knots, gusting 23
Visibility
10 statute miles
Lowest ceiling
None
Temperature
91 °F, dew point 70 °F
Altimeter
29.94 inHg
Observed at
CNK, 23 nm away

Docket · 4

The files NTSB released with the investigation on July 12, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.7 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.