# NTSB LAX93LA205: Cessna 195B, N2171C, Placerville, CA, May 9, 1993 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: May 9, 1993, 10:20 local (17:20 UTC) - Place: Placerville, CA - Coordinates: 38.73019, -120.799064 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.7302&lon=-120.7991&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report November 15, 1993 - Report: Approved by Office Director - NTSB case key (mKey): 28375 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX93LA205 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28375/pdf - Page: https://openairdocs.org/ntsb/LAX93LA205 ## Probable cause THE UNRELIABILITY OF THE NORMAL BRAKE SYSTEM AND THE LEAKING MASTER CYLINDER ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - on ground/water, landing - roll - landing gear,normal brake system - unreliable (cause) - fluid,hydraulic - leak (cause) - On ground/water collision with object, landing - roll - object - tree(s) ## Analysis THE AIRPLANE EXITED THE RUNWAY AND SUBSEQUENTLY STRUCK A TREE DURING THE LANDING ROLL AT AN UNCONTROLLED AIRPORT. EXAMINATION OF THE WRECKAGE DISCLOSED THAT THE LEFT BRAKE WAS INTACT AND OPERATED NORMALLY. THE RIGHT BRAKE LINE SEVERED DURING THE IMPACT SEQUENCE, BUT THE BRAKE HOUSING APPEARED NORMAL. THERE WAS NO EVIDENCE OF ANY EXTERNAL HYDRAULIC FLUID LEAKS EMANATING FROM THE RIGHT WHEEL MASTER CYLINDER. THE A & P MECHANIC WHO EXAMINED THE AIRPLANE SAID HE SUSPECTED THAT THE RIGHT WHEEL MASTER CYLINDER WAS LEAKING DUE TO A WORN LOCK O-RING SEAL ## Factual narrative On May 9, 1993, at about 1020 hours Pacific daylight time, a Cessna 195, N2171C, ran off the runway during the landing roll and collided with a tree at Swansboro Airport, Placerville, California. The pilot was completing a local area visual flight rules personal flight. The airplane, owned and operated by the pilot, sustained substantial damage. The certificated airline transport pilot, the sole occupant, was not injured. Visual meteorological conditions prevailed. The flight originated at Swansboro Airport at about 0812 hours. The pilot stated in the pilot/operator report that he entered the Swansboro Airport traffic pattern to land on runway 090. He said that the initial rollout was normal, and then "a slight turn to the right was corrected for...then rudder and finally brake was applied to stop the movement to the left...it was then apparent full rudder, brake and up elevator was not working." The aircraft left the runway as he applied full braking. The left wing struck a pine tree which spun the aircraft into more brush, trees, and a dirt bank which runs parallel to the runway. The pilot said he suspected a weak right brake because of the leaking wheel cylinder and the fluid found on the brake after the accident. In the written pilot/operator report, the pilot said the right side main landing gear collapsed and that the gear box area was "badly damaged." The airplane was examined by an aircraft mechanic with airplane and powerplant ratings under the guidance of the Federal Aviation Administration on June 15, 1993. The mechanic told Safety Board investigators in a telephone conversation on June 17, 1993, that after examining the airplane, the left brake appeared to be operational. The brake pucks were in good condition and the brake housing was free and moved back and forth. He reported that the left brake appeared "good and hard" when he pushed on the brake pedal. The mechanic reported that the right brake housing "looked good." The right brake line was broken from impact damage. The mechanic did not find any fluid leaking from the wheel cylinder. The mechanic told Safety Board investigators that he "suspected the lock O ring seal had gone bad in the master cylinder." The mechanic was unable to disassemble the master cylinder. ## Aircraft - Registration: [N2171C](https://openairdocs.org/deregistered/N2171C-2018-03-01), registration cancelled 2018-03-01, S/N 16156, built 1954 (OpenAirDocs) - Reported make and model: CESSNA 195B - 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: 16156 - Airframe hours: 6700 - Engines: JACOBS R-755A2 300 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Kenneth Or Thelma Kinne - Registered owner: Kenneth Or Thelma Kinne - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 9, 1992, 8 hours before - Departed: 061, CAMERON PARK, CA - Airport: Swansboro Airport, runway 9, 3,100 × 60 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 63; airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: left; flight hours: 22,000 total, 6 in this make and model, 15,000 as pilot in command, 30 in the last 90 days, 12 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 230° at 1 knots - Visibility: 60 statute miles - Lowest ceiling: none - Temperature: 70 °F, dew point 45 °F - Altimeter: 29.00 inHg - Observed at: MHR, 35 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 19930509013349A](https://openairdocs.org/incident/19930509013349A), May 9, 1993: Cessna 195B, Placerville, CA, Substantial damage. Pilot reported no right brake landing. Ran off. Struck a tree. Beleive o ring went bad in master cylinder. ## Other investigations on N2171C (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 WPR10CA101](https://openairdocs.org/ntsb/WPR10CA101), Jan 7, 2010: Cessna 195B (N2171C), Palm Springs, CA, substantial damage. Probable cause: The pilot's improper use of brakes during landing. - [NTSB DEN7LFTE11](https://openairdocs.org/ntsb/DEN7LFTE11), Aug 6, 1975: Cessna 195 (N2171C), Denver, CO, substantial damage 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.