# NTSB GAA18CA455: Cessna 140, N1902V, Healdsburg, CA, July 26, 2018 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: July 26, 2018, 11:00 local (18:00 UTC) - Place: Healdsburg, CA - Coordinates: 38.652778, -122.898612 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.6528&lon=-122.8986&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report June 5, 2019 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 97954 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA18CA455 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/97954/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=97954 - Page: https://openairdocs.org/ntsb/GAA18CA455 ## Probable cause The pilot's improper brake application during the landing roll, 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 140, 56 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2071602), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Landing gear system: brake](https://openairdocs.org/ntsb-findings/01023242): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Cessna 140, 11 cases](https://openairdocs.org/ntsb-findings/01023242/cases.md?model=2071602), [All aircraft, 297 cases](https://openairdocs.org/ntsb-findings/01023242/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 140, 8 cases](https://openairdocs.org/ntsb-findings/01062045/cases.md?model=2071602), [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-landing roll: Abnormal runway contact](https://openairdocs.org/ntsb-events/090); cases with it: [Cessna 140, 3 cases](https://openairdocs.org/ntsb-events/090/sequence.md?model=2071602), [All aircraft, 1,506 cases](https://openairdocs.org/ntsb-events/090/sequence.md) - [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096) (defining event); cases with it: [Cessna 140, 49 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=2071602), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## 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](https://openairdocs.org/deregistered/N1902V-2020-07-10), registration cancelled 2020-07-10, S/N 14093, built 1947 (OpenAirDocs) - Reported make and model: Cessna 140 (Undesignat) - Registry model: [Cessna 140](https://openairdocs.org/model/cessna-140) (registry code 2071602) (OpenAirDocs) - Registry engine: [Continental C85 series](https://openairdocs.org/engine/continental-c85-series) (registry code 17008, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 14093 - Year built: 1947 - Airframe hours: 4333.5 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 70; injuries: none; 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 ## 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 20180726018079A](https://openairdocs.org/incident/20180726018079A), Jul 26, 2018: Cessna 140, Healdsburg, CA, Substantial damage. A Cessna 140 N1902V took off from santa rosa, CA. Airport and pilot was flying to Healdsburg Airport. Pilot was landing on runway 13, pilot lost control of… ## Docket (3 files) The files NTSB released with the investigation on March 22, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=97954. 4.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471306&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Memorandum for Record - FAA (item 2, .PDF, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471307&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20FAA-Master.PDF - Photo (item 3, .PDF, 1 photo, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471308&FileExtension=.PDF&FileName=Photo-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.