# NTSB ERA13LA418: Fleet 7, N9433, Louisa, VA, September 7, 2013

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Limited investigation · Final report
- Date: September 7, 2013, 11:10 local (15:10 UTC)
- Place: Louisa, VA
- Coordinates: 38.009723, -77.970275 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=38.0097&lon=-77.9703&mi=10
- Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping)
- Defining event: [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230)
- Highest injury: No injuries
- Injuries: 2 uninjured
- Status: Completed, report August 14, 2014
- Report: Approved by Office Director
- NTSB office: Eastern Region Aviation
- Parties: FAA/FSDO
- NTSB case key (mKey): 88068
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA13LA418
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/88068/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=88068
- Page: https://openairdocs.org/ntsb/ERA13LA418

## Probable cause

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

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Landing gear system: brake](https://openairdocs.org/ntsb-findings/01023242): Aircraft › Aircraft systems · Incorrect service/maintenance (probable cause); cases with it: [Fleet 7, 1 case](https://openairdocs.org/ntsb-findings/01023242/cases.md?model=1461502), [All aircraft, 297 cases](https://openairdocs.org/ntsb-findings/01023242/cases.md)
- [Landing gear system: brake](https://openairdocs.org/ntsb-findings/01023242): Aircraft › Aircraft systems · Inadequate inspection (probable cause); cases with it: [Fleet 7, 1 case](https://openairdocs.org/ntsb-findings/01023242/cases.md?model=1461502), [All aircraft, 297 cases](https://openairdocs.org/ntsb-findings/01023242/cases.md)
- [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Fleet 7, 1 case](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=1461502), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md)
- [Inspection: scheduled/routine inspection](https://openairdocs.org/ntsb-findings/02061520): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Fleet 7, 1 case](https://openairdocs.org/ntsb-findings/02061520/cases.md?model=1461502), [All aircraft, 167 cases](https://openairdocs.org/ntsb-findings/02061520/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Fleet 7, 1 case](https://openairdocs.org/ntsb-events/230/sequence.md?model=1461502), [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: [Fleet 7, 1 case](https://openairdocs.org/ntsb-events/300/sequence.md?model=1461502), [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: [Fleet 7, 1 case](https://openairdocs.org/ntsb-events/096/sequence.md?model=1461502), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md)

## 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](https://openairdocs.org/aircraft/N9433), registered now, S/N 81 (OpenAirDocs)
- Reported make and model: FLEET 7 (NO SERIES)
- Registry model: [Fleet 7](https://openairdocs.org/model/fleet-7) (registry code 1461502) (OpenAirDocs)
- Registry engine: [Kinner B5 series](https://openairdocs.org/engine/kinner-b5-series) (registry code 37501, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 81
- Year built: 1929
- Airframe hours: 3740
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 53; injuries: none; 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

## 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 20130907017489A](https://openairdocs.org/incident/20130907017489A), Sep 7, 2013: Fleet 7, Lousia, VA, Substantial damage. Aircraft landed on runway 27 and veered off the left side of the runway onto the grass and flipped over. Pilot reported the aircraft touched down and left…

## Other investigations on N9433 (2)

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.

- [NTSB IAD75FIG20](https://openairdocs.org/ntsb/IAD75FIG20), May 11, 1975: Fleet 7 (N9433), Gaithersburg, MD, substantial damage
- [NTSB IAD74FIG02](https://openairdocs.org/ntsb/IAD74FIG02), Jul 14, 1973: Brewster FLEET7 (N9433), Gaithersburg, MD, substantial damage

## Docket (6 files)

The files NTSB released with the investigation on March 14, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=88068. 9.9 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 - Pilot (item 1, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402504&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20-%20Pilot-Redacted.PDF
- Aircraft Annual Inspection - Excerpt (item 2, .PDF, 154 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402505&FileExtension=.PDF&FileName=Aircraft%20Annual%20Inspection%20-%20Excerpt-Redacted.PDF
- Memorandum for Record - Louisa Weather (item 3, .PDF, 122 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402506&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20Louisa%20Weather-Master.PDF
- Photo 1: Tire Marks on Runway (Courtesy of the FAA) (item 4, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402508&FileExtension=.PDF&FileName=Photo%201%3A%20Tire%20Marks%20on%20Runway%20(Courtesy%20of%20the%20FAA)-Master.PDF
- Photo 2: Airplane at Rest (Courtesy of the FAA) (item 5, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402509&FileExtension=.PDF&FileName=Photo%202%3A%20Airplane%20at%20Rest%20(Courtesy%20of%20the%20FAA)-Master.PDF
- Photo 3: Airplane Post-Recovery Revealing Damage to Vertical and Rudder (Courtesy of the FAA) (item 6, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402510&FileExtension=.PDF&FileName=Photo%203%3A%20Airplane%20Post-Recovery%20Revealing%20Damage%20to%20Vertical%20and%20Rudder%20(Courtesy%20of%20the%20FAA)-Master.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.

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