CEN23LA103

NTSB accident investigation · Cessna 425 · Bismarck, ND · February 6, 2023

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
February 6, 2023, 15:45 local (21:45 UTC)
Place
Bismarck, ND
Injuries
2 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Taxi
Aircraft
N425ZCessna 425
Defining event
Taxi: Loss of control on ground
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
FAA, Flight Standards District Office
FAA report
20230206001139A
Case key
106701

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

A loss of braking due to inadequate servicing of brake fluid by the pilot/mechanic, which resulted in a loss of airplane control on the ground.

Findings · 5

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.

Action: incorrect action selectionPersonnel issues › Action/decision · PilotCessna 425: 1 caseAll aircraft: 397 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelCessna 425: 1 caseAll aircraft: 320 casesProbable cause
Landing gear system: landing gear brakes systemAircraft › Aircraft systems · Incorrect service/maintenanceCessna 425: 1 caseAll aircraft: 92 casesProbable cause
Object/animal/substance: residence/buildingEnvironmental issues › Physical environment · Effect on equipmentCessna 425: 1 caseAll aircraft: 58 cases
FluidsAircraft › Fluids/misc hardware · Fluid levelCessna 425: 1 caseAll aircraft: 11 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 pilot taxied to the ramp after an uneventful flight. After moving the throttles toward the ground idle position while in front of the marshaller, the airplane turned left, and the pilot observed that the right brake was inoperative. He attempted to stop the airplane by placing both propeller levers to the feather position and subsequently moved both throttles toward the reverse (beta) position. The airplane continued forward and struck a hangar, which resulted in substantial damaged to the left wing. Postaccident examination of the braking system revealed the brake master cylinders were nearly empty of brake fluid, with no leaks observed. The pilot, who was also a mechanic, recorded completion of a phase inspection about nine months before the accident. The inspection included servicing the brake master cylinders, but the pilot reported he did not check the fluid levels of the master cylinders.

Factual narrative

On February 6, 2023, about 1545 central standard time, a Cessna 425, N425Z, was substantially damaged when it was involved in an accident at Bismarck Municipal Airport (BIS), Bismarck, North Dakota. The pilot was not injured and the two passengers sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported an uneventful flight and landing at BIS. After taxiing to the ramp, the pilot proceeded to stop the airplane in front of a marshaller. After moving the throttles toward the ground idle position, the pilot observed the airplane turn left and reported that the right brake was inoperative. The pilot reported moving both propeller levers to the feather position and subsequently moved both throttles toward the reverse (beta) position. The airplane continued forward and struck a hangar, which substantially damaged the left wing. Postaccident examination of the braking system revealed the brake master cylinders were nearly empty of brake fluid, with no leaks observed. A review of maintenance logs revealed that the pilot, who was also a mechanic, recorded completion of the Phase 3 inspection of the Cessna 425 maintenance manual on May 21, 2022. The Phase 3 inspection includes servicing the brake master cylinders. The pilot/mechanic reported that during this inspection he checked the brake pads and checked for leaks around the brakes and the master cylinders. He depressed the brake pedals to find there was resistance; however, he reported that he did not check the fluid levels of the master cylinders during the inspection.

Aircraft

Registration
N425Z
Reported as
Cessna 425
Category
Airplane
Serial number
425-0186
Built
1983
Airframe hours
2,728
Engines
Pratt & Whitney PT6-112, 450 horsepower, turbo propPratt & Whitney PT6-112, 450 horsepower, turbo prop
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Pegasus Royalty Group LLC
Registered owner
Pegasus Royalty Group LLC
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · May 25, 2022
Departed
CHD · Chandler, AZ
Destination
BIS · Bismark, ND
Flight plan
IFR
Airport
KBIS · Bismarck Municipal Airport, runway 31, 8,794 × 150 ft, concrete
Equipment
Auto-pilot, ADS-B, Stall warning system, Electronic primary flight display, Electronic multifunction display

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
63
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine sea, Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
June 10, 2022
Seat
Left
Restraint
3-point
Flight hours
6,740 total · 272 in this make and model · 6,357 as pilot in command · 56 in the last 90 days · 14 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
310° at 18 knots, gusting 30
Visibility
10 statute miles
Lowest ceiling
8,000 ft overcast
Temperature
37 °F, dew point 28 °F
Altimeter
29.67 inHg
Observed at
KBIS, 1 nm away
METAR
KBIS 062152Z AUTO 31018G30KT 10SM OVC080 03/M02 A2967 RMK AO2 PK WND 31034/2114

Docket · 6

The files NTSB released with the investigation on May 2, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.7 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.