# NTSB ERA19LA268: Beech K35, N5300E, St. Augustine, FL, September 11, 2019 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: September 11, 2019, 17:30 local (21:30 UTC) - Place: St. Augustine, FL - Coordinates: 29.959167, -81.339721 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.9592&lon=-81.3397&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 100240 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19LA268 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100240/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100240 - Page: https://openairdocs.org/ntsb/ERA19LA268 ## Probable cause An unintended brake application of the right main landing gear brake system during the landing rollout due to excessive play between the brake caliper anchor bolts and their bushings. ## 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 · Fatigue/wear/corrosion (probable cause); cases with it: [Beech K35, 1 case](https://openairdocs.org/ntsb-findings/01023242/cases.md?model=1151524), [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: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330) (defining event); cases with it: [Beech K35, 1 case](https://openairdocs.org/ntsb-events/330/sequence.md?model=1151524), [All aircraft, 994 cases](https://openairdocs.org/ntsb-events/330/sequence.md) - [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Beech K35, 4 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=1151524), [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: [Beech K35, 1 case](https://openairdocs.org/ntsb-events/096/sequence.md?model=1151524), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The pilot was conducting a personal flight when, about halfway through the landing rollout and before the pilot could apply the brakes, the airplane suddenly veered to the right. The pilot attempted to correct the veer with left pedal and brake but was unsuccessful. The airplane departed the runway into the grass, struck a berm, flipped over, and came to rest inverted. The airplane sustained substantial damage to the forward fuselage, horizontal stabilizers, and left ruddervator. Postaccident examination of the airplane revealed that the right main landing gear tire had a flat spot in its tread that was worn to the reinforcement chords. The tire left a black skid mark on the runway that led from the right edge to the grass, consistent with a locked right wheel. The wheel rotated smoothly during recovery of the airplane; therefore, damage or malfunction of the wheel’s bearings was unlikely. The airplane did not have the optional copilot-side brake pedals installed. Examination of the brake system revealed that the brakes functioned normally; however, the right caliper was found to have some play between the two anchor bolts and their bushings in the torque plate. Excessive caliper play can result in too much clearance between the brake pads and the brake disc. The excessive clearance can cause the brake pads to shift out of place and jam against the brake disc, which could result in an unintended brake application. Disassembly and further examination of the primary brake system components revealed no other anomalies that would have precluded normal operation. Therefore, the right brake was likely applied unintentionally due to the play between the caliper anchor bolts and their bushings. The play likely developed due to wear on the anchor bolts, the bushings, or both. ## Factual narrative On September 11, 2019, about 1730 eastern daylight time, a Beech K35, N5300E, was involved in an accident at Northeast Florida Regional Airport (SGJ), St. Augustine, Florida. The commercial pilot and pilot-rated passenger sustained minor injuries, and the airplane was substantially damaged. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. According to the pilot, about halfway through the landing rollout on runway 13, the airplane suddenly veered to the right with the engine power at idle. She attempted to correct the turn with left pedal and brake but was unsuccessful. She confirmed with the pilot-rated passenger that the power was at idle. The airplane departed the runway into the grass, struck a berm, flipped over, and came to rest inverted. The pilot further stated that the veer to the right occurred before she could apply the brakes or retract the flaps from the 10° position. The airplane did not have the optional copilot-side brake pedals installed. The airplane’s most recent brake maintenance was performed on January 24, 2019, the same day as the airplane’s most recent annual inspection (when the airframe had accrued a total time of 6,462 flight hours). During that maintenance, the right brake caliper was replaced. The airplane had flown about 60 hours since that time. A Federal Aviation Administration inspector examined the wreckage and the accident site. The examination revealed substantial damage to the fuselage forward of the windscreen, both horizontal stabilizers, and the left ruddervator. A black skid mark was found on the runway that led from the right edge of the runway to the grass. Both wheel brakes and ruddervators and the nosewheel steering functioned normally when the rudder pedals were pressed. The parking brake was found disengaged. Visual inspection of the brake components revealed no mechanical or thermal damage to the brake discs, calipers, or pad material. No hydraulic leaks were visible on any of the fittings or components. Both main landing gear wheels rolled smoothly when the airplane was moved during recovery. The right main landing gear tire had a flat spot worn through the reinforcement cords in the tire tread. Review of a video clip that the pilot provided revealed that the right brake caliper had some play between the two anchor bolts (often called “pins”) and the bushings in the torque plate (the flange to which the caliper is attached). The caliper shifted about the bolts when moved by hand in a twisting motion. The right brake master cylinder was removed and disassembled. The o-rings were intact with no signs of leakage. The return spring was intact. The cylinder exhibited no scoring or signatures of abnormal wear. The poppet valve operated normally. The parking brake actuator valve was sent to the NTSB’s Materials Laboratory for examination. The valve operated normally when compressed air was applied to the inlet port. The valve was then dissembled. Theo-ring was intact, and the spring-loaded ball, ball seat, and plunger were undamaged. The plunger moved freely when the actuator arm was moved back and forth. ## Aircraft - Registration: [N5300E](https://openairdocs.org/deregistered/N5300E-2022-09-09), registration cancelled 2022-09-09, S/N D-5765, built 1958 (OpenAirDocs) - Reported make and model: Beech K35 (NO SERIES) - Registry model: [Beech K35](https://openairdocs.org/model/beech-k35) (registry code 1151524) (OpenAirDocs) - Registry engine: [Continental I0-470 series](https://openairdocs.org/engine/continental-i0-470-series) (registry code 17027, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: D-5765 - Year built: 1958 - Airframe hours: 6507 - Engines: Continental IO-470-C 250 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: St Augustine Beech Llc - Registered owner: St Augustine Beech Llc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, January 24, 2019, 60 hours before - Departed: TIX, Titusville, FL - Destination: Same as departure - Airport: SGJ, Northeast Florida Rgnl, runway 13, 7,997 × 150 ft, asphalt - Equipment: Onboard weather, Auto-pilot, ADS-B, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 68; injuries: minor; commercial, flight instructor; airplane ratings: single-engine sea, single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review January 1, 2019; seat: left; restraint: 3-point; flight hours: 11,500 total, 300 in this make and model, 11,000 as pilot in command, 60 in the last 90 days, 25 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 40° at 13 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 84 °F, dew point 75 °F - Altimeter: 30.11 inHg - Observed at: SGJ ## 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 20190911023429A](https://openairdocs.org/incident/20190911023429A), Sep 11, 2019: Beech K35, St. Augustine, FL, Substantial damage. During landing rollout the right brake locked forcing the aircraft to the right into the grass off of runway 13. The aircraft hit a dirt berm and flipped onto… ## Other investigations on N5300E (1) 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 FTW69D0551](https://openairdocs.org/ntsb/FTW69D0551), Apr 18, 1969: Beech K35 (N5300E), San Marcos, TX, substantial damage ## Docket (6 files) The files NTSB released with the investigation on April 26, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100240. 33.6 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=12718781&FileExtension=pdf&FileName=01-01%20NTSB%20Form%206120_print_Redacted-Rel.pdf - Excerpts from maintenance records (item 2, PDF, 14 pages, 20.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12717872&FileExtension=pdf&FileName=03-01%20Exceprts%20From%20Maintenance%20Records_Redacted-Rel.pdf - Investigative photographs (item 3, PDF, 5 pages, 5 photos, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12718889&FileExtension=pdf&FileName=06-01-%20photo%20array_ERA19LA268-Rel.pdf - Video clip - brake caliper (item 4, MOV, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12718001&FileExtension=mov&FileName=06-01b%20video_caliper-Rel.mov - Memorandum for record - wreckage examination (item 5, PDF, 8 pages, 7 photos, 4.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12718791&FileExtension=pdf&FileName=06-02%20%20MFR%20-%20Wreckage%20Examination%20Information%20from%20FAA%20Inspector_ERA19LA268-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 6, PDF, 2 pages, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13757812&FileExtension=pdf&FileName=09-01%20wreckage%20release_Redacted_B-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.