# NTSB FTW04LA049: Cessna 195B, N6850D, Amarillo, TX, December 20, 2003 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: December 20, 2003, 16:00 local (22:00 UTC) - Place: Amarillo, TX - Coordinates: 35.064998, -101.879165 - Nearby events: https://openairdocs.org/map.md?lat=35.0650&lon=-101.8792&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report March 30, 2004 - Report: Approved by Office Director - Parties: Lubbock FSDO - NTSB case key (mKey): 58536 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW04LA049 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58536/pdf - Page: https://openairdocs.org/ntsb/FTW04LA049 ## Probable cause The leakage of the left brake master cylinder cap, which resulted in the loss of hydraulic fluid and the failure of the left brake. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - on ground/water, landing - roll - brakes(normal) - unavailable, pilot in command - hydraulic system - leak (cause) - maintenance - not performed - ground loop/swerve - encountered, pilot in command ## Analysis The 1,073-hour pilot reported that during his preflight inspection prior to the accident flight, he observed a red fluid seeping from the belly of the aircraft. The pilot stated this was "becoming a common occurrence, requiring him to fill the brake reservoir frequently." The pilot checked the brakes prior to starting the engine and had no problems holding the airplane still with brakes during the engine run up. Unsatisfied with the landing on runway 20 (a 5,500-foot long and 124-foot wide turf runway), the pilot decided to make a touch-n-go landing without the use of the brakes. During the second landing, "all was well until the ground roll, at an approximate speed of 50 miles per hour." The aircraft started to veer to the right, and the pilot applied left brake. As the speed reduced, the aircraft began to ground loop, shearing off the left landing gear at the fuselage. Examination of the aircraft brake system by the pilot revealed hydraulic fluid was leaking the reservoir cap on the left brake master cylinder (Cessna Aircraft Illustrated Parts Catalog Part Number 0411302-21) in the area where the mounting lug (Part Number 0411302-8) bolts onto the reservoir cap. ## Factual narrative On December 20, 2003, approximately 1600 central standard time, a Cessna 195B tailwheel equipped single-engine airplane, N6850D, was substantially damaged when it ground looped during landing roll at the Buffalo Airport (1E7), near Amarillo, Texas. The private pilot, sole occupant of the airplane, sustained serious injuries. The airplane was registered to and operated by the pilot. Visual meteorological conditions prevailed, and a flight plan was not filed for the 14 Code of Federal Regulations Part 91 personal flight. The round robin flight departed 1E7 destined for the Tucumcari Municipal Airport, near Tucumcari, New Mexico, at approximately 1400 and returned to 1E7. The 1,073-hour pilot reported in the Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1/2) that during his preflight inspection prior to the accident flight, he observed a "red fluid seeping from the belly of the aircraft." He stated this was "becoming a common occurrence, requiring him to fill the brake reservoir frequently." He checked the brakes prior to starting the engine and noted no problems holding the airplane still with the brakes during the engine run up. Unsatisfied with the landing to runway 20 (a 5,500-foot long and 124-foot wide turf runway), the pilot decided to execute a touch-n-go landing without the use of brakes. During the second landing, "all was well until the ground roll, at an approximate speed of 50 miles per hour." The aircraft started to veer to the right, and he applied left brake. As the airspeed reduced, the aircraft began to ground loop, shearing off the left landing gear at the fuselage. The aircraft came to an "abrupt halt" in an upright position. The pilot stated in the NTSB Form 6120.1/2 under the Recommendation (How This Accident Could Have Been Prevented) section: "By proper preflight of brakes prior to flight. Attention to the tell-tale signs of red fluid leaking down the aircraft belly." Examination of the airplane by the Federal Aviation Administration (FAA) inspector, who responded to the accident site revealed, the outboard three feet of the left wing was bent upward approximately 45 degrees. The fuselage was wrinkled approximately four feet aft of the cabin area, and the left main landing gear was separated from the fuselage. Examination of the aircraft brake system by the pilot revealed hydraulic fluid was leaking the reservoir cap on the left brake master cylinder (Cessna Aircraft Illustrated Parts Catalog Part Number 0411302-21) in the area where the mounting lug (Part Number 0411302-8) bolts onto the reservoir cap. ## Aircraft - Registration: N6850D (not matched to a registry record) - Reported make and model: Cessna 195B - Category: Airplane - Serial number: 16026 - Airframe hours: 2420 - Engines: Jacobs R755-82 275 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, April 8, 2003, 19 hours before - Departed: 1E7, Amarillo, TX - Destination: 1E7, Amarillo, TX - Airport: 1E7, Buffalo Airport, runway 20, 5,500 × 124 ft, grass/turf ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 79; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; last flight review June 17, 2003; seat: left; flight hours: 1,073 total, 667 in this make and model, 1,033 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 210° at 13 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 66 °F, dew point 21 °F - Altimeter: 29.94 inHg - Observed at: AMA, 13 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 20031220032959A](https://openairdocs.org/incident/20031220032959A), Dec 20, 2003: Cessna 195B, Amarillo, TX, Substantial damage. (-23) On December 20, 2003, at approximately 1600 hours CST, while attempting to land on runway 20 at Buffalo Airport (1E7), a Cessna 195B aircraft, N6850D… 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.