ERA13LA418

NTSB accident investigation · Fleet 7 · Louisa, VA · September 7, 2013

Accident · No injuriesLimited investigationFinal report
Date
September 7, 2013, 11:10 local (15:10 UTC)
Place
Louisa, VA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N9433Fleet 7
Defining event
Landing-landing roll: Loss of control on ground
Weather
Visual (VMC) · Day
Status
Completed · report August 14, 2014
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20130907017489A
Case key
88068

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

Maintenance personnel’s improper service, adjustment, and inspection of the brakes, which resulted in a runway excursion and subsequent noseover.

Findings · 4

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: brakeAircraft › Aircraft systems · Incorrect service/maintenanceFleet 7: 1 caseAll aircraft: 297 casesProbable cause
Landing gear system: brakeAircraft › Aircraft systems · Inadequate inspectionFleet 7: 1 caseAll aircraft: 297 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelFleet 7: 1 caseAll aircraft: 320 casesProbable cause
Inspection: scheduled/routine inspectionPersonnel issues › Task performance · Maintenance personnelFleet 7: 1 caseAll aircraft: 167 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 reported that, following a normal left-crosswind landing, the airplane veered left. Further right rudder application resulted in the airplane continuing to veer left until it exited the edge of the runway and nosed over. Postaccident examination of the airplane revealed that the brake cable was not properly adjusted and that, as a result, the application of the right rudder pedal engaged the left brake. The airplane's last annual inspection occurred about 2 months before the accident, and, during this inspection, maintenance personnel were required to check the brakes for proper adjustment. It is likely that if maintenance personnel had adequately conducted the annual inspection they could have recognized the incorrectly adjusted brakes. No other anomalies or mechanical malfunctions were found that would have precluded normal operation.

Factual narrative

On September 7, 2013, about 1110 eastern daylight time, a Fleet 7, N9433, was substantially damaged following a runway excursion after landing at Louisa County Airport/Freeman Field (LKU), Louisa, Virginia. The airline transport pilot and passenger were not injured. The flight was conducted under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91 as a personal flight. Visual meteorological conditions prevailed and no flight plan had been filed for the flight which originated from Warrenton-Fauquier Airport (HMY), Warrenton, Virginia. The pilot reported that following a normal crosswind landing on runway 27, the airplane began to veer to the left. Following an application of right rudder, the airplane continued to the left and departed the left side of the runway. The airplane continued into the grass, nosed over, and came to rest inverted. An inspector with the Federal Aviation Administration responded to the accident site and examined the airplane. The examination revealed substantial damage to the vertical stabilizer. Further examination of the rudder revealed that during the full application of the right rudder the left brake would apply. Photographs provided by the FAA inspector revealed rubber tire marks on the runway, veering to the left, looking towards the direction of travel, and ceasing at the edge of the runway. The rubber tire marks coincided with the tire tracks in the grass which led to the accident airplane. According to airplane maintenance records, the most recent annual inspection was completed on June 29, 2013 at a recorded tachometer time of 3739.7 hours. According to the FAA inspector, the tachometer at the time of the accident indicated about 3742 hours. According to CFR Part 43 Appendix D "Scope and Detail of Items (as Applicable to the Particular Aircraft) to be Included in Annual and 100-Hour Inspections," states in part "Each person performing an annual or 100-hour inspection shall inspect (where applicable) the following components of the landing gear group: (9) Brakes – for improper adjustment." At the time of the accident, the airplane had been flown about 2 hours since this inspection. The wind at the time of the accident was 200 degrees at 6 knots.

Aircraft

Registration
N9433
Reported as
Fleet 7 (NO SERIES)
Category
Airplane
Serial number
81
Built
1929
Airframe hours
3,740
Engine
Kinner R55, 160 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 29, 2013
Departed
3VA3 · Bealton, VA
Destination
LKU · Louisa, VA
Airport
LKU · Louisa County/Freeman Field, runway 27, 4,300 × 100 ft, asphalt

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
53
Injuries
None
Certificates
Flight engineer, Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
January 16, 2013
Seat
Rear
Flight hours
17,035 total · 500 in this make and model · 5,785 as pilot in command · 264 in the last 90 days · 88 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
200° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
73 °F, dew point 63 °F
Altimeter
30.11 inHg
Observed at
KLKU

Docket · 6

The files NTSB released with the investigation on March 14, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 9.9 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.

Other investigations on N9433 · 2

Matched to the same aircraft by N-number and date.