GAA18CA455

NTSB accident investigation · Cessna 140 · Healdsburg, CA · July 26, 2018

Accident · No injuriesData collectionFinal report
Date
July 26, 2018, 11:00 local (18:00 UTC)
Place
Healdsburg, CA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N1902VCessna 140
Defining event
Landing-landing roll: Nose over/nose down
Weather
Visual (VMC) · Day
Status
Completed · report June 5, 2019
Report
Approved by Office Director
NTSB office
General Aviation Accidents
Parties
FAA
FAA report
20180726018079A
Case key
97954

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's improper brake application during the landing roll, which resulted in a nose-over.

Findings · 3

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.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotCessna 140: 56 casesAll aircraft: 9,295 casesProbable cause
Landing gear system: brakeAircraft › Aircraft systems · Incorrect use/operationCessna 140: 11 casesAll aircraft: 297 casesProbable cause
Performance/control parameters: surface speed/brakingAircraft › Aircraft oper/perf/capability · Incorrect use/operationCessna 140: 8 casesAll aircraft: 238 casesProbable cause

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 pilot in the tailwheel-equipped airplane, he had performed two previous touch-and-go takeoffs and landings. During the third landing roll, the tailwheel settled on the runway, and then the airplane nosed over. He reported that he was “not certain whether I accidentally stepped on the brakes or the brakes seized." The airplane sustained substantial damage to the vertical stabilizer and the rudder. A Federal Aviation Administration inspector’s postaccident examination of the brake system revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation.

Factual narrative

According to the pilot in the tailwheel-equipped airplane, he had performed two previous touch-and-go takeoffs and landings. During the third landing roll, the tailwheel settled on the runway and then the airplane nosed over. He reported that, "I am not certain whether I accidentally stepped on the brakes or the brakes seized." The airplane sustained substantial damage to the vertical stabilizer and the rudder. A post-accident airplane examination performed by a Federal Aviation Administration Inspector revealed that no issues with the brake system was found.

Aircraft

Registration
N1902V
Reported as
Cessna 140 (Undesignat)
Category
Airplane
Serial number
14093
Built
1947
Airframe hours
4,333.5
Engine
Continental C85, 104 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Departed
HES · Healdsburg, CA
Destination
HES · Healdsburg, CA
Airport
HES · Healdsburg Muni, runway 13, 2,652 × 60 ft, asphalt
Equipment
Stall warning system, Auto-pilot, Handheld GPS, Electronic flight bag or handheld device

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
70
Injuries
None
Certificate
Private
Airplane ratings
Single-engine sea, Multi-engine sea, Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
April 10, 2017
Seat
Left
Restraint
Lap only
Flight hours
4,800 total · 4 in this make and model · 4,800 as pilot in command · 5 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Visibility
9 statute miles
Lowest ceiling
None
Temperature
70 °F, dew point 54 °F
Altimeter
29.98 inHg
Observed at
KSTS, 10 nm away

Docket · 3

The files NTSB released with the investigation on March 22, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.7 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.