ERA16LA213

NTSB accident investigation · Cessna 310 · Apopka, FL · June 10, 2016

Accident · No injuriesLimited investigationFinal report
Date
June 10, 2016, 16:10 local (20:10 UTC)
Place
Apopka, FL
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N8943ZCessna 310
Defining event
Landing-landing roll: Miscellaneous/other
Weather
Visual (VMC) · Day
Status
Completed · report October 17, 2017
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20160610010169A
Case key
93375

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

The intermittent failure of the left brake master cylinder, which resulted in asymmetric braking and the subsequent loss of directional control during the landing roll.

Findings · 3

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: master cylinder/brake valveAircraft › Aircraft systems · Damaged/degradedCessna 310G: 1 caseAll aircraft: 21 casesProbable cause
Performance/control parameters: directional controlAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleCessna 310G: 1 caseAll aircraft: 3,958 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 airline transport pilot reported that the accident flight was the airplane's first flight following completion of an annual inspection. He added that there were no issues with the brakes while taxiing to fuel the airplane or to depart. After performing two touch-and-go landings and a go-around, the pilot approached the runway intending to conduct a full-stop landing. He stated that the airplane touched down at the normal point/location and that he then retracted the flaps during the landing roll but waited to apply brakes until the airplane approached the end of the runway. Upon applying the brakes, the left brake did not work, but the right brake did, which resulted in the airplane drifting right. The pilot realized that the airplane was going to exit the right side of the runway, so he secured the engines and attempted to maintain control while applying right braking in an effort to slow the airplane. The airplane travelled off the right side of the runway and impacted upsloping terrain. Initial postaccident operational testing of the brakes revealed no discrepancies with the left brake. No brake system leaks were noted, and the fluid levels in both brake master cylinders were at correct levels. However, during subsequent operational testing of the left brake master cylinder, the left brake worked satisfactorily once but failed during subsequent testing.

Factual narrative

On June 10, 2016, about 1610 eastern daylight time, a Cessna 310G, N8943Z, collided with a berm while landing at Orlando Apopka Airport (X04), Apopka, Florida. The airline transport pilot was not injured, and the airplane was substantially damaged. The airplane was registered to SOFI, LLC, and was operated by a private individual under the provisions of 14 Code of Federal Regulations as a Part 91 local, post maintenance test flight. Visual meteorological conditions prevailed and no flight plan was filed for the flight that departed from X04 at 1515.The accident flight was the airplane's first flight after an annual inspection. Prior to that flight, it had not been operated in the previous 2 years. The pilot stated that after release from the inspection, he performed a preflight inspection and noticed several discrepancies, none of which were related to the aircraft's brake system. After the airplane was removed from the hangar, he started the engines and taxied to a place where he fueled the airplane, and during the taxi, he did not indicate any issues with the aircraft's brakes. Following fueling he taxied to runway 33, a 3.987-foot-long asphalt runway where he initiated takeoff and remained in the traffic pattern performing two touch-and-go landings to the same runway. After the second touch-and-go landing, he remained in the traffic pattern and intended to perform a full-stop landing; however, he had to initiate a go-around because another airplane was on the runway. He returned and reported the touchdown was normal and in the normal/typical location. After touchdown he retracted the flaps and allowed the airplane to slow aerodynamically to the end of the runway. As the airplane approached the end of the runway, the pilot applied the normal brakes; however, the left brake did not function. The airplane started drifting to the right, and as the airplane slowed to a slow taxi speed, the right deviation became more pronounced and he pumped the left brake and applied pressure but it seemed the left brake pedal went to the floor with no pressure or effect. When it became evidence that the airplane would depart the runway he secured the engines, and attempted to maintain control while applying the right brake in an effort to slow the airplane. The airplane went off the right side of the runway at the end and contacted upsloping terrain which caused spar damage to the left horizontal stabilizer. Operational testing of the pilot's side brakes by a Federal Aviation Administration (FAA) operations inspector following recovery revealed no discrepancies; however, operational testing of the brakes on the copilot's side revealed a discrepancy with the right brake. No brake system leaks were noted and the fluid levels in both brake master cylinders were at the correct level. The airplane was retained for further examination. Further examination of each brake master cylinder was performed by an FAA airworthiness inspector. Following removal from theairplane, the left brake worked once but on the second actuation, the actuating rod slowly leaked internally to the bottom. The right brake worked perfectly when removed. Both cylinders had an acceptable fluid level after removal. Disassembly of the brake master cylinders revealed all o-rings were in a reasonable condition with no visible cuts or tears. The left brake had a dark crusty compound and a small washer in the reservoir, while the right brake had the same compound including the washer, but was not as contaminated as the left. It was not possible to determine part numbers or serial numbers of either brake master cylinder as the data plates were damaged by hydraulic fluid. According to the facility that performed the inspection, they utilized a generic twin-engine checklist to perform the inspection. The owner/general manager of the facility where the inspection was performed stated there were no discrepancies related to the brakes during the engine run-ups prior to the inspection.

Aircraft

Registration
N8943Z
Reported as
Cessna 310 (G)
Category
Airplane
Serial number
310G-0043
Built
1962
Engines
Cont Motor IO-470-D, 260 horsepower, reciprocatingCont Motor IO-470-D, 260 horsepower, reciprocating
Damage
Substantial damage
Flight
Flight test · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 10, 2016 · 1 hours before
Departed
X04 · Apopka, FL
Destination
X04 · Apopka, FL
Airport
X04 · Orlando Apopka Airport, runway 33, 3,987 × 60 ft, asphalt
Equipment
Auto-pilot

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
59
Injuries
None
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Single-engine sea, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
November 28, 2015
Seat
Left
Restraint
Lap only
Flight hours
28,000 total · 500 in this make and model · 25,500 as pilot in command · 150 in the last 90 days · 0 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
50° at 10 knots
Visibility
10 statute miles
Temperature
93 °F, dew point 70 °F
Altimeter
30.04 inHg
Observed at
LEE, 14 nm away

Docket · 5

The files NTSB released with the investigation on August 21, 2017, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.6 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 N8943Z · 1

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