# NTSB GAA17CA415: Cessna 195, N4432C, Leavenworth, KS, July 17, 2017 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: July 17, 2017, 11:20 local (16:20 UTC) - Place: Leavenworth, KS - Coordinates: 39.3675, -94.914443 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.3675&lon=-94.9144&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report December 15, 2017 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 95601 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA17CA415 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/95601/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=95601 - Page: https://openairdocs.org/ntsb/GAA17CA415 ## Probable cause The pilot’s inadvertent toe brake application during the landing roll, which resulted in a runway excursion and a ground loop. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [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 195B, 13 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=2073112), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/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 195B, 3 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=2073112), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Landing gear system: brake](https://openairdocs.org/ntsb-findings/01023242): Aircraft › Aircraft systems · Unintentional use/operation (probable cause); cases with it: [Cessna 195B, 1 case](https://openairdocs.org/ntsb-findings/01023242/cases.md?model=2073112), [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: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Cessna 195B, 12 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=2073112), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Cessna 195B, 6 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=2073112), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 195B, 4 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2073112), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot of the tailwheel airplane reported that he made a normal approach to an asphalt runway. During the landing roll, the tail started to move to the left, and he corrected with left rudder application, but he recalled that "I may have unintentionally put pressure on the left toe brake." The airplane veered to the left and exited the left side of the runway. The airplane entered a drainage culvert and ground looped to the left. The right main landing gear (MLG) collapsed, and the right wing tip struck the ground. The airplane sustained substantial damage to the right MLG attachment point. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. ## Factual narrative The pilot of the tailwheel airplane reported that he made a normal approach to an asphalt runway. During the landing roll, the tail started to move to the left and he corrected with left rudder application, but he recalled that, "I may have unintentionally put pressure on the left toe brake." The airplane veered to the left and exited the left side of the runway. The airplane entered a drainage culvert and ground looped to the left. The right main landing gear collapsed, and the right wing tip struck the ground. The airplane sustained substantial damage to the right main landing gear attachment point. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. ## Aircraft - Registration: [N4432C](https://openairdocs.org/aircraft/N4432C), registered now, S/N 16017, built 1952 (OpenAirDocs) - Reported make and model: CESSNA 195 (B) - Registry model: [Cessna 195B](https://openairdocs.org/model/cessna-195b) (registry code 2073112) (OpenAirDocs) - Registry engine: [Jacobs R755B series](https://openairdocs.org/engine/jacobs-r755b-series) (registry code 35007, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 16017 - Year built: 1952 - Airframe hours: 3554 - Engines: JACOBS R755B SERIES 275 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 1, 2017 - Departed: GLD, Goodland, KS - Destination: FLV, Leavenworth, KS - Airport: FLV, Sherman Aaf, runway 16, 5,318 × 102 ft, asphalt - Equipment: Auto-pilot, Electronic flight bag or handheld device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 69; injuries: none; private, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: helicopter, airplane; medical: class 3, without waivers/limitations; last flight review July 15, 2016; seat: left; restraint: 3-point; flight hours: 4,000 total, 38 in this make and model, 40 in the last 90 days, 38 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 200° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 84 °F, dew point 72 °F - Altimeter: 30.02 inHg - Observed at: KMCI, 10 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 20170717015449A](https://openairdocs.org/incident/20170717015449A), Jul 17, 2017: Cessna 195B, Leavenworth, KS, Substantial damage. The aircraft departed goodland, KS (gld) with Leavenworth, KS (flv) as the final destination. During landing on runway 16, the tail wheel touched down and the… ## Docket (2 files) The files NTSB released with the investigation on November 27, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=95601. 3.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458373&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Photo (Courtesy of FAA) (item 2, .PDF, 1 photo, 106 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458374&FileExtension=.PDF&FileName=Photo%20(Courtesy%20of%20FAA)-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.