# NTSB CEN23LA103: Cessna 425, N425Z, Bismarck, ND, February 6, 2023 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: February 6, 2023, 15:45 local (21:45 UTC) - Place: Bismarck, ND - Coordinates: 46.772734, -100.74573 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=46.7727&lon=-100.7457&mi=10 - Phase of flight: [Taxi](https://openairdocs.org/ntsb-phases/250) (OpenAirDocs' grouping) - Defining event: [Taxi: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: Minor injuries - Injuries: 2 minor, 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA, Flight Standards District Office - NTSB case key (mKey): 106701 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN23LA103 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106701/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=106701 - Page: https://openairdocs.org/ntsb/CEN23LA103 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Action: incorrect action selection](https://openairdocs.org/ntsb-findings/02041010): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 425, 1 case](https://openairdocs.org/ntsb-findings/02041010/cases.md?model=2076018), [All aircraft, 397 cases](https://openairdocs.org/ntsb-findings/02041010/cases.md) - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna 425, 1 case](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=2076018), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md) - [Landing gear system: landing gear brakes system](https://openairdocs.org/ntsb-findings/01023240): Aircraft › Aircraft systems · Incorrect service/maintenance (probable cause); cases with it: [Cessna 425, 1 case](https://openairdocs.org/ntsb-findings/01023240/cases.md?model=2076018), [All aircraft, 92 cases](https://openairdocs.org/ntsb-findings/01023240/cases.md) - [Object/animal/substance: residence/building](https://openairdocs.org/ntsb-findings/03022022): Environmental issues › Physical environment · Effect on equipment; cases with it: [Cessna 425, 1 case](https://openairdocs.org/ntsb-findings/03022022/cases.md?model=2076018), [All aircraft, 58 cases](https://openairdocs.org/ntsb-findings/03022022/cases.md) - [Fluids](https://openairdocs.org/ntsb-findings/01071000): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Cessna 425, 1 case](https://openairdocs.org/ntsb-findings/01071000/cases.md?model=2076018), [All aircraft, 11 cases](https://openairdocs.org/ntsb-findings/01071000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Taxi: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330); cases with it: [Cessna 425, 1 case](https://openairdocs.org/ntsb-events/330/sequence.md?model=2076018), [All aircraft, 994 cases](https://openairdocs.org/ntsb-events/330/sequence.md) - [Taxi: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Cessna 425, 2 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=2076018), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Taxi: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 425, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=2076018), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N425Z-2024-04-30), registration cancelled 2024-04-30, S/N 425-0186, built 1983 (OpenAirDocs) - Reported make and model: CESSNA 425 - Registry model: [Cessna 425](https://openairdocs.org/model/cessna-425) (registry code 2076018) (OpenAirDocs) - Registry engine: [Pratt & Whitney Canada PT6A-60A](https://openairdocs.org/engine/pratt-whitney-canada-pt6a-60a) (registry code 52043, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 425-0186 - Year built: 1983 - Airframe hours: 2728 - Engines: Pratt & Whitney PT6-112 450 horsepower turbo prop; Pratt & 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 63; injuries: none; 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 ## 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 20230206001139A](https://openairdocs.org/incident/20230206001139A), Feb 6, 2023: Cessna 425, Bismarck, ND, Substantial damage. Pilot was taxiing aircraft to parking in front of FBO. Braking was insufficient to stop aircraft. Aircraft continued forward motion as pilot mismanaged… ## Docket (6 files) The files NTSB released with the investigation on May 2, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=106701. 4.7 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16494764&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - Passenger statement (item 2, PDF, 3 pages, 635 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16495704&FileExtension=pdf&FileName=Passenger%20statement_Redacted-Rel.pdf - Correspondence with FAA inspector (item 3, PDF, 1 page, 132 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16495351&FileExtension=pdf&FileName=Correspondence%20with%20FAA%20Inspector-Rel.pdf - Maintenance logs - excerpt (item 4, PDF, 1 page, 702 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16494754&FileExtension=pdf&FileName=Maintenance%20Logs%20-%20Excerpt_Redacted-Rel.pdf - Photo of damage airplane (item 5, PDF, 1 page, 215 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16495361&FileExtension=pdf&FileName=Photo%20of%20Damaged%20Airplane-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 6, PDF, 1 page, 889 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16495261&FileExtension=pdf&FileName=Wreckage%20release_Redacted-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.