# NTSB GAA16CA422: Cessna 195, N4026A, Hillsborough, OR, August 6, 2016 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: August 6, 2016, 08:20 local (15:20 UTC) - Place: Hillsborough, OR - Coordinates: 45.428333, -122.942222 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=45.4283&lon=-122.9422&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-flare/touchdown: Loss of visual reference](https://openairdocs.org/ntsb-events/402) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report January 18, 2017 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 93793 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA16CA422 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93793/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93793 - Page: https://openairdocs.org/ntsb/GAA16CA422 ## Probable cause The pilot's failure to attain a proper touchdown point and loss of directional control and her subsequent excessive brake application, which resulted in a nose-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, 9,308 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 195A, 11 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=2073110), [All aircraft, 3,969 cases](https://openairdocs.org/ntsb-findings/01062020/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) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 195A, 1 case](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=2073110), [All aircraft, 1,397 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Performance/control parameters: descent/approach/glide path](https://openairdocs.org/ntsb-findings/01062040): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 195A, 1 case](https://openairdocs.org/ntsb-findings/01062040/cases.md?model=2073110), [All aircraft, 810 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md) - [Performance/control parameters: surface speed/braking](https://openairdocs.org/ntsb-findings/01062045): Aircraft › Aircraft oper/perf/capability · Incorrect use/operation (probable cause); cases with it: [Cessna 195A, 1 case](https://openairdocs.org/ntsb-findings/01062045/cases.md?model=2073110), [All aircraft, 238 cases](https://openairdocs.org/ntsb-findings/01062045/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-flare/touchdown: Loss of visual reference](https://openairdocs.org/ntsb-events/402) (defining event); cases with it: [Cessna 195A, 1 case](https://openairdocs.org/ntsb-events/402/sequence.md?model=2073110), [All aircraft, 242 cases](https://openairdocs.org/ntsb-events/402/sequence.md) - [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230); cases with it: [Cessna 195A, 12 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=2073110), [All aircraft, 4,590 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Cessna 195A, 4 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=2073110), [All aircraft, 2,289 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The pilot of the tailwheel-equipped airplane reported that during the landing flare she could not see forward beyond the engine cowl, and due to the side-by-side seat configuration of the airplane she lost sight of right side of runway. She recalled that the airplane touched down slightly left of the center line and continued to roll further left. She reported that she applied full right rudder and applied the brakes in order prevent a runway excursion to the left, but the airplane nosed over and partially exited the left side of the runway. The airplane sustained substantial damage to the left wing, the vertical and horizontal stabilizer, and the rudder. The pilot reported that there were no mechanical malfunctions or anomalies with any portion of the airplane during the flight that would have prevented normal flight operation. ## Factual narrative The pilot of the tailwheel-equipped airplane reported that during the landing flare she could not see forward beyond the engine cowl, and due to the side-by-side seat configuration of the airplane she lost sight of right side of runway. She recalled that the airplane touched down slightly left of the center line and continued to roll further left. She reported that she applied full right rudder and applied the brakes in order prevent a runway excursion to the left, but the airplane nosed over and partially exited the left side of the runway. The airplane sustained substantial damage to the left wing, the vertical and horizontal stabilizer, and the rudder. The pilot reported that there were no mechanical malfunctions or anomalies with any portion of the airplane during the flight that would have prevented normal flight operation. ## Aircraft - Registration: [N4026A](https://openairdocs.org/deregistered/N4026A-2019-03-09), registration cancelled 2019-03-09, S/N 7830, built 1952 (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 R755B series](https://openairdocs.org/engine/jacobs-r755b-series) (registry code 35007, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 7830 - Year built: 1952 - Airframe hours: 4325.43 - Engines: JACOBS R755B SERIES 275 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 28, 2015 - Departed: SLE, Salem, OR - Destination: 7S3, Hillsborough, OR - Airport: 7S3, Stark'S Twin Oaks Airpark, runway 02, 2,465 × 48 ft, asphalt - Equipment: Electronic flight bag or handheld device, Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review January 27, 2016; seat: left; restraint: 4-point; flight hours: 755 total, 308 in this make and model, 633 as pilot in command, 52 in the last 90 days, 45 in the last 30 days, 5 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 55 °F, dew point 48 °F - Altimeter: 30.02 inHg - Observed at: KHIO, 7 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 20160806014039A](https://openairdocs.org/incident/20160806014039A), Aug 6, 2016: Cessna 195A, Hillsboro, OR, Substantial damage. The pilot in command allowed the Cessna 195 airplane to drift left of centerline during approach and touchdown to runway 02 at starks Twin Oaks airpark. During… ## Other investigations on N4026A (2) 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 WPR13CA232](https://openairdocs.org/ntsb/WPR13CA232), May 16, 2013: Cessna 195A (N4026A), San Carlos, CA, substantial damage. Probable cause: The pilot’s failure to maintain directional control during the landing roll. - [NTSB LAX88LA073](https://openairdocs.org/ntsb/LAX88LA073), Dec 21, 1987: Cessna 195A (N4026A), Burbank, CA, minor damage ## Docket (3 files) The files NTSB released with the investigation on November 18, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93793. 1.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 267 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459004&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Witness Statement (item 2, .PDF, 133 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446628&FileExtension=.PDF&FileName=Witness%20Statement-Master.PDF - Photos (item 3, .PDF, 762 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446629&FileExtension=.PDF&FileName=Photos-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.