GAA16CA042

NTSB accident investigation · Cessna 421 · Amarillo, TX · October 14, 2015

Accident · No injuriesData collectionFinal report
Date
October 14, 2015, 13:45 local (18:45 UTC)
Place
Amarillo, TX
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Taxi
Aircraft
N19CHCessna 421
Defining event
Taxi-to runway: Ground collision
Weather
Visual (VMC) · Day
Status
Completed · report December 5, 2016
Report
Approved by Office Director
NTSB office
General Aviation Accidents
Parties
Federal Aviation Administration
FAA report
20151014018329A
Case key
92290

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 loss of directional control during taxi to the runway as a result of insufficient brake fluid level in the right brake master cylinder, resulting in a taxiway excursion and collision with a drainage culvert.

Findings · 7

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: brakeAircraft › Aircraft systems · InoperativeCessna 421B: 1 caseAll aircraft: 297 casesProbable cause
Performance/control parameters: directional controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna 421B: 3 casesAll aircraft: 3,958 casesProbable cause
FluidsAircraft › Fluids/misc hardware · Fluid levelCessna 421B: 1 caseAll aircraft: 11 casesProbable cause
Landing gear system: brakeAircraft › Aircraft systems · Not serviced/maintainedCessna 421B: 1 caseAll aircraft: 297 cases
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelCessna 421B: 2 casesAll aircraft: 320 cases
Use of equip/info: aircraft controlPersonnel issues › Task performance · Instructor/check pilotCessna 421B: 11 casesAll aircraft: 9,295 cases
Object/animal/substanceEnvironmental issues › Physical environment · Contributed to outcomeCessna 421B: 1 caseAll aircraft: 224 cases

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

According to the flight instructor, during the taxi to the runway, the pilot receiving instruction stated that he did not have authority in the right brake. The flight instructor reported that he too applied pressure to the right brake to no avail. He reported that the airplane exited the runway to the left, impacted a drainage culvert and the left main landing gear collapsed. The airplane sustained substantial damage to the left wing spar. The airplane brake system was examined by the operator's Director of Maintenance, who determined that the right brake master cylinder was low on fluid causing the brakes to be weak. The last maintenance performed on the brakes occurred on 7/8/2015 at which time both brake discs were replaced and all the brake pads were replaced. The total time on the airplane since the last maintenance on the brakes was 33.6 hours.

Factual narrative

According to the flight instructor, during the taxi to the runway, the pilot receiving instruction stated that he did not have authority in the right brake. The flight instructor reported that he too applied pressure to the right brake to no avail. He reported that the airplane exited the runway to the left, impacted a drainage culvert and the left main landing gear collapsed. The airplane sustained substantial damage to the left wing spar. The airplane brake system was examined by the operator's Director of Maintenance, who determined that the right brake master cylinder was low on fluid causing the brakes to be weak. The last maintenance performed on the brakes occurred on 7/8/2015 at which time both brake discs were replaced and all the brake pads were replaced. The total time on the airplane since the last maintenance on the brakes was 33.6 hours.

Aircraft

Registration
N19CH
Reported as
Cessna 421 (B)
Category
Airplane
Serial number
421B0462
Built
1973
Airframe hours
4,525.1
Engines
Cont Motor GTSIO-520-H, 375 horsepower, reciprocatingCont Motor GTSIO-520-C, 340 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Denny Ohara, doing business as First Flight
Registered owner
Ohara Aviation Management Services Lc
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · April 15, 2015
Departed
H81 · Amarillo, TX
Destination
H81 · Amarillo, TX
Airport
H81 · River Falls, runway 17, 6,015 × 60 ft, asphalt
Equipment
Stall warning system, Onboard weather, 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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
68
Injuries
None
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
June 26, 2015
Seat
Right
Restraint
3-point
Flight hours
32,000 total · 4,000 in this make and model · 32,000 as pilot in command · 24 in the last 90 days · 12 in the last 30 days
Role
Pilot
Age
26
Injuries
None
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2
Last flight review
December 31, 2014
Seat
Left
Restraint
3-point
Flight hours
1,620 total · 38 in this make and model · 1,500 as pilot in command · 146 in the last 90 days · 73 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 13 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
88 °F, dew point 45 °F
Altimeter
30.12 inHg
Observed at
KAMA, 1 nm away

Docket · 3

The files NTSB released with the investigation on October 27, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.5 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.