# NTSB CEN21LA267: Great Lakes 2T-1A-1, N503GL, Roanoke, TX, June 14, 2021 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 4 · Limited · Final report - Date: June 14, 2021, 08:30 local (13:30 UTC) - Place: Roanoke, TX - Coordinates: 33.049845, -97.232237 - Nearby events: https://openairdocs.org/map.md?lat=33.0498&lon=-97.2322&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 4 - Basic report with no Prelim publish - NTSB office: Central Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 103263 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN21LA267 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103263/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103263 - Page: https://openairdocs.org/ntsb/CEN21LA267 ## Probable cause Inadequate maintenance of the brake system which resulted in the caliper binding closed and the subsequent loss of directional control during the landing roll. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Aircraft capability: braking capability](https://openairdocs.org/ntsb-findings/01061050): Aircraft › Aircraft oper/perf/capability · Malfunction (probable cause); cases with it: [Great Lakes 2T-1A-1, 1 case](https://openairdocs.org/ntsb-findings/01061050/cases.md?model=3910107), [All aircraft, 57 cases](https://openairdocs.org/ntsb-findings/01061050/cases.md) - [Landing gear system: brake](https://openairdocs.org/ntsb-findings/01023242): Aircraft › Aircraft systems · Incorrect service/maintenance (probable cause); cases with it: [Great Lakes 2T-1A-1, 1 case](https://openairdocs.org/ntsb-findings/01023242/cases.md?model=3910107), [All aircraft, 297 cases](https://openairdocs.org/ntsb-findings/01023242/cases.md) - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [Great Lakes 2T-1A-1, 1 case](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=3910107), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Great Lakes 2T-1A-1, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=3910107), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Landing-landing roll: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330) (defining event); cases with it: [Great Lakes 2T-1A-1, 1 case](https://openairdocs.org/ntsb-events/330/sequence.md?model=3910107), [All aircraft, 994 cases](https://openairdocs.org/ntsb-events/330/sequence.md) - [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230); cases with it: [Great Lakes 2T-1A-1, 1 case](https://openairdocs.org/ntsb-events/230/sequence.md?model=3910107), [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: [Great Lakes 2T-1A-1, 1 case](https://openairdocs.org/ntsb-events/300/sequence.md?model=3910107), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Great Lakes 2T-1A-1, 1 case](https://openairdocs.org/ntsb-events/096/sequence.md?model=3910107), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The pilot reported that when he applied “light even braking” during the landing roll, the airplane abruptly veered left. He added full right rudder and brake, but the airplane continued to the left and exited the runway surface. The airplane sunk into the soft dirt, nosed over, and came to rest inverted. The airplane sustained substantial damage to the upper wing and rudder. The pilot further reported that the brakes had been replaced during the last annual inspection which occurred about 1 hour before the accident. An on scene examination of the brake system revealed that the left wheel would not rotate. The brake caliper was disassembled; the caliper pins exhibited brake dust and brake fluid residue which is not consistent with new brakes. Therefore, it is likely the caliper was stuck closed during landing due to the brake dust and brake fluid reside on the caliper pins. ## Aircraft - Registration: [N503GL](https://openairdocs.org/aircraft/N503GL), registered now, S/N 0503 (OpenAirDocs) - Reported make and model: GREAT LAKES 2T-1A-1 - Registry model: [Great Lakes 2T-1A-1](https://openairdocs.org/model/great-lakes-2t-1a-1) (registry code 3910107) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 0503 - Year built: 1973 - Airframe hours: 1181 - Engines: Lycoming O-320-EZA 150 hp reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Aerobatic - Last inspection: Annual, April 6, 2021, 1 hours before - Airport: 52F, Northwest Regional Airport, runway 17, 3,500 × 40 ft, asphalt - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 59; injuries: minor; airline transport, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review January 23, 2021; seat: rear; restraint: 4-point; flight hours: 21,200 total, 75 in this make and model, 11,591 as pilot in command, 81 in the last 90 days, 67 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 60° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 84 °F, dew point 75 °F - Altimeter: 29.99 inHg - Icing: Clear - Observed at: AFW, 7 nm away - METAR: KAFW 141353Z 06005KT 10SM FEW180 SCT300 29/24 A2999 RMK AO2 SLP138 T02890239 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20210614014849A](https://openairdocs.org/incident/20210614014849A), Jun 14, 2021: Great Lakes 2T-1A-1, Roanoke, TX, Substantial damage. During a local flight, landing on rwy 17, with shifting winds, the left brake seemed to have more effect than the right brake. The aircraft departed the runway… ## Docket (4 files) The files NTSB released with the investigation on October 13, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103263. 3.3 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12400986&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - Mechanic statement (item 2, PDF, 1 page, 563 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12657976&FileExtension=pdf&FileName=mechanic%20statement-Rel.pdf - Record of conversation - federal aviation administration regarding on scene observations (item 3, PDF, 4 pages, 963 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12771471&FileExtension=pdf&FileName=ROC%20FAA%20EXAM-Rel.pdf - Maintenance log entry - most recent annual (item 4, PDF, 1 page, 207 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12772141&FileExtension=pdf&FileName=MX%20Log%20attempt%204-Rel.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.