# NTSB ERA15CA329: Cessna 195, N1516D, Lancaster, NY, August 26, 2015 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: August 26, 2015, 15:30 local (19:30 UTC) - Place: Lancaster, NY - Coordinates: 42.921943, -78.611946 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.9219&lon=-78.6119&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report January 15, 2016 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 91874 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA15CA329 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91874/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91874 - Page: https://openairdocs.org/ntsb/ERA15CA329 ## Probable cause The pilot's excessive application of brake pressure, which resulted in the airplane nosing over. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 195A, 13 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2073110), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Landing gear system: brake](https://openairdocs.org/ntsb-findings/01023242): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Cessna 195A, 2 cases](https://openairdocs.org/ntsb-findings/01023242/cases.md?model=2073110), [All aircraft, 297 cases](https://openairdocs.org/ntsb-findings/01023242/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: Abrupt maneuver](https://openairdocs.org/ntsb-events/270); cases with it: [Cessna 195A, 1 case](https://openairdocs.org/ntsb-events/270/sequence.md?model=2073110), [All aircraft, 346 cases](https://openairdocs.org/ntsb-events/270/sequence.md) - [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096) (defining event); cases with it: [Cessna 195A, 4 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=2073110), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis According to the pilot, he had just completed a circuit in the airport traffic pattern. During the flare, the airplane began to "settle" when the wind speed decreased. He then applied engine power in order to arrest the descent. The airplane veered left and landed with the nose of the airplane pointing to the left side of the runway. During the landing roll, the pilot was concerned with exiting the paved portion of the runway and applied brake pressure. Subsequently, the airplane nosed over and came to rest inverted on the paved portion of the runway, which resulted in substantial damage to the rudder and vertical stabilizer. The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation. ## Factual narrative According to the pilot, he had just completed a circuit in the airport traffic pattern. During the flare, the airplane began to "settle" when the wind speed decreased. He then applied engine power in order to arrest the descent. The airplane veered left and landed with the nose of the airplane pointing to the left side of the runway. During the landing roll, the pilot was concerned with exiting the paved portion of the runway and applied brake pressure. Subsequently, the airplane nosed over and came to rest inverted on the paved portion of the runway, which resulted in substantial damage to the rudder and vertical stabilizer. The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation. ## Aircraft - Registration: [N1516D](https://openairdocs.org/deregistered/N1516D-2018-05-30), registration cancelled 2018-05-30, S/N 7738, built 1951 (OpenAirDocs) - Reported make and model: CESSNA 195 (A) - Registry model: [Cessna 195A](https://openairdocs.org/model/cessna-195a) (registry code 2073110) (OpenAirDocs) - Registry engine: [Jacobs R-755B2](https://openairdocs.org/engine/jacobs-r-755b2) (registry code 35023, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 7738 - Year built: 1951 - Airframe hours: 2707 - Engines: JACOBS R-755B2 275 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 23, 2015 - Departed: BQR, Lancaster, NY - Destination: BQR, Lancaster, NY - Airport: BQR, Buffalo-Lancaster Rgnl, runway 26, 3,200 × 75 ft, asphalt - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 52; injuries: none; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1; last flight review June 1, 2013; seat: left; restraint: 4-point; flight hours: 1,200 total, 50 in this make and model, 1,200 as pilot in command - Flight instructor; injuries: none; flight instructor, commercial; seat: right; restraint: 4-point ## Weather - Conditions: Visual (VMC), Day - Wind: 260° at 12 knots, gusting 18 - Visibility: 10 statute miles - Lowest ceiling: 5,500 ft broken - Observed at: BUF, 6 nm away ## 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 20150826014569A](https://openairdocs.org/incident/20150826014569A), Aug 26, 2015: Cessna 195A, Lancaster, NY, Substantial damage. On August 26, 2015, a CE-195 aircraft, N1516D, was substantially damaged upon landing at the Buffalo-Lancaster airport (bqr). The flight was being conducted as… ## Docket (3 files) The files NTSB released with the investigation on January 5, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91874. 5.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435306&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Weather Reports and Records (item 2, .PDF, 114 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435307&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Photographs (item 3, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435308&FileExtension=.PDF&FileName=Photographs-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. --- 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.