LAX94LA050

NTSB accident investigation · Cessna 172RG · Santa Ana, CA · November 18, 1993

Accident · No injuriesLimited investigationFinal report
Date
November 18, 1993, 11:07 local (19:07 UTC)
Place
Santa Ana, CA
Injuries
4 uninjured
Phase of flight
Standing
Aircraft
N9620BCessna 172RGN97766Cessna 172P
Weather
Visual (VMC) · Day
Status
Completed · report September 13, 1994
Report
Approved by Office Director
Case key
28602

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

On this page

Probable cause

were the CFI's inadequate supervision of the flight and his delay in taking remedial action. The dual student's excessive taxi speed and the worn right brake lining were factors in this accident.

were the other airplane's CFI's inadequate supervision of the flight, and his delay in taking remedial action.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

On ground/water collision with objectStanding
Supervision - inadequatePilot of other aircraftCause
Remedial action - delayedPilot of other aircraftCause
On ground/water collision with objectTaxi - to takeoff
Landing gear,normal brake system - wornFactor
Supervision - inadequatePilot in command(cfi)Cause
Remedial action - delayedPilot in command(cfi)Cause
Taxispeed - excessiveDual studentFactor

Analysis

The airplane was taxiing for takeoff. When approaching a standing airplane holding short of the runway, the student pilot reduced the throttle and applied the brakes. The airplane began to turn to the left heading toward the standing airplane and the student applied right rudder, which controls the nose gear steering on the ground. When this action did not stop the airplane or arrest the turn, the student turned the ailerons. The student told the CFI that she was having a problem in stopping the airplane, but by this time the CFI was simultaneously applying the brakes and full right rudder, but without success. The airplane struck the standing airplane's left rear side. The examination of the brake system disclosed the right brake lining was worn beyond serviceable limits and both brake cylinders functioned normally.

The CFI and his student were holding at the runway approach end when another aircraft struck their aircraft on the left rear side.

Factual narrative

On November 18, 1993, at 1107 hours Pacific standard time, a Cessna 172RG, N9620B, was struck by a Cessna 172P, N97766, while on taxiway K while awaiting departure clearance at John Wayne Airport (SNA), Santa Ana, California. The pilots aboard both airplanes were beginning a local visual flight rules instructional flight. N9620B, operated by Lenair Aviation, SNA, sustained substantial damage; N97766, operated by American Flyers, SNA, sustained minor damage. Neither the certificated commercial pilot/flight instructor (CFI) nor the certificated private pilot/dual student aboard N9620B was injured. Neither the CFI nor the noncertificated student pilot aboard N97766 was injured. Visual meteorological conditions prevailed.

The Orange County Sheriff's Department, Airport Division, conducted the initial investigation immediately following the accident.

N9620B

Both pilots aboard N9620B told the investigating deputy that they were holding short (facing west) of runway 19L as instructed by the ground controller. Neither pilot saw the approaching Cessna 172 (N97766) while it was taxiing north on taxiway C.

N97766

The student pilot told the investigating deputy that the airplane began to veer toward N9620B. She tried to correct with the rudder (the rudder also controls the nose gear while on the ground), but got no response. She attempted to steer the airplane like a car using the ailerons, but without success. She then informed the instructor that they were going to hit the parked aircraft.

The CFI told the investigating deputy that he was instructing the student and noticed she was in trouble. He attempted to turn the airplane "...using slight rudder to the right...," but got no response. He then applied full right rudder and full braking and "...leaned the throttle [mixture] in the attempts to avoid the collision...."

The CFI submitted a Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2. He said in the report that as the airplane was approaching taxiway "K" the student retarded the throttle. He then instructed the student to apply the brakes while he was simultaneously applying the brakes.

As the airplane veered to the left toward the standing airplane (N9620B), the CFI applied right rudder and more right brake, but without success; the airplane did not stop or arrest the left turn. The CFI pulled the mixture control before the collision.

The CFI also reported that there were two other incidents where the right brake failed; one in Florida, and the other in New York. Both involved the Cessna 172 airplane.

The dual student submitted a written statement to the Federal Aviation Administration (FAA), Long Beach Flight Standards District Office. The student confirmed her previous statement to the Orange County deputy and added that she thought the airplane was taxiing too fast and she fully retarded the throttle. She didn't notice any difference in the airplane's speed and she informed her instructor. He instructed her to "...brake a little...", which she did.

The mechanic who repaired the airplane in Florida told National Transportation Safety Board investigators that the right brake failure was caused by a faulty "O" ring seal in the master cylinder. Safety Board investigators were unable to contact the mechanic who repaired the New York incident airplane.

A Cessna Aircraft Company representative was interviewed by telephone on June 7, 1994. He told Safety Board investigators that he has no knowledge of a brake failure without a known faulty mechanism involving the accident airplane make and model. Safety Board investigators examined the brake system of N97766 on December 3, 1993. Investigators visually examined the brake linings. The brake linings did not appear excessively worn. A functional test of both brakes appeared normal.

The investigators disassembled the brakes and both master cylinders. The investigators found that the right brake lining was worn to the height of the rivet heads, between 1/16 of an inch to 3/32 of an inch. The Cessna 172 maintenance manual requires replacement of the brake lining when it is worn to 3/32nd of an inch.

Investigators found no discrepancies in either brake master cylinder. Examination of N97766's airframe logbooks showed that the operator was maintaining the airplane according to an "Approved Aircraft Inspection Program " (AAIP). This program requires inspection events every 75 flight hours. The operator did the last inspection, the number two (2) event, 36.7 hours before the accident. The number two (2) event did not include inspection of the brakes. The airplane had accrued 111.7 hours since the number one (1) event, which included the brake inspection.

The mechanic who repaired the airplane told Safety Board investigators that he operated the right brake master cylinders for two hours after it was reassembled. The master cylinder operated normally throughout the functional test.

On November 18, 1993, at 1107 hours Pacific standard time, a Cessna 172RG, N9620B, was struck by a Cessna 172P, N97766, while on taxiway K while awaiting departure clearance at John Wayne Airport (SNA), Santa Ana, California. The pilots aboard both airplanes were beginning a local visual flight rules instructional flight. N9620B, operated by Lenair Aviation, SNA, sustained substantial damage; N97766, operated by American Flyers, SNA, sustained minor damage. Neither the certificated commercial pilot/flight instructor (CFI) nor the certificated private pilot/dual student aboard N9620B was injured. Neither the CFI nor the noncertificated student pilot aboard N97766 was injured. Visual meteorological conditions prevailed.

The Orange County Sheriff's Department, Airport Division, conducted the initial investigation immediately following the accident.

N9620B

Both pilots aboard N9620B told the investigating deputy that they were holding short (facing west) of runway 19L as instructed by the ground controller. Neither pilot saw the approaching Cessna 172 (N97766) while it was taxiing north on taxiway C.

N97766

The student pilot told the investigating deputy that the airplane began to veer toward N9620B. She tried to correct with the rudder (the rudder also controls the nose gear while on the ground), but got no response. She attempted to steer the airplane like a car using the ailerons, but without success. She then informed the instructor that they were going to hit the parked aircraft.

The CFI told the investigating deputy that he was instructing the student and noticed she was in trouble. He attempted to turn the airplane "...using slight rudder to the right...," but got no response. He then applied full right rudder and full braking and "...leaned the throttle [mixture] in the attempts to avoid the collision...."

The CFI submitted a Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2. He said in the report that as the airplane was approaching taxiway "K" the student retarded the throttle. He then instructed the student to apply the brakes while he was simultaneously applying the brakes.

As the airplane veered to the left toward the standing airplane (N9620B), the CFI applied right rudder and more right brake, but without success; the airplane did not stop or arrest the left turn. The CFI pulled the mixture control before the collision.

The CFI also reported that there were two other incidents where the right brake failed; one in Florida, and the other in New York. Both involved the Cessna 172 airplane.

The dual student submitted a written statement to the Federal Aviation Administration (FAA), Long Beach Flight Standards District Office. The student confirmed her previous statement to the Orange County deputy and added that she thought the airplane was taxiing too fast and she fully retarded the throttle. She didn't notice any difference in the airplane's speed and she informed her instructor. He instructed her to "...brake a little...", which she did.

The mechanic who repaired the airplane in Florida told National Transportation Safety Board investigators that the right brake failure was caused by a faulty "O" ring seal in the master cylinder. Safety Board investigators were unable to contact the mechanic who repaired the New York incident airplane.

A Cessna Aircraft Company representative was interviewed by telephone on June 7, 1994. He told Safety Board investigators that he has no knowledge of a brake failure without a known faulty mechanism involving the accident airplane make and model.

Safety Board investigators examined the brake system of N97766 on December 3, 1993. Investigators visually examined the brake linings. The brake linings did not appear excessively worn. A functional test of both brakes appeared normal.

The investigators disassembled the brakes and both master cylinders. The investigators found that the right brake lining was worn to the height of the rivet heads, between 1/16 of an inch to 3/32 of an inch. The Cessna 172 maintenance manual requires replacement of the brake lining when it is worn to 3/32nd of an inch.

Investigators found no discrepancies in either brake master cylinder. Examination of N97766's airframe logbooks showed that the operator was maintaining the airplane according to an "Approved Aircraft Inspection Program " (AAIP). This program requires inspection events every 75 flight hours. The operator did the last inspection, the number two (2) event, 36.7 hours before the accident. The number two (2) event did not include inspection of the brakes. The airplane had accrued 111.7 hours since the number one (1) event, which included the brake inspection.

The mechanic who repaired the airplane told Safety Board investigators that he operated the right brake master cylinders for two hours after it was reassembled. The master cylinder operated normally throughout the functional test.

Aircraft · 2

Registration
N9620B
Reported as
Cessna 172RG
Category
Airplane
Serial number
172RG0925
Airframe hours
5,385
Engine
Lycoming O-360-F1AG, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Registered owner
Lenair Aviation
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · August 1, 1993 · 75 hours before
Airport
SNA · John Wayne Airport

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.

Registration
N97766
Reported as
Cessna 172P
Category
Airplane
Serial number
17276228
Airframe hours
11,831
Engine
Lycoming O-320-D2J, 160 horsepower, reciprocating
Damage
Minor damage
Flight
Instructional · Part 91
Operator
American Flyers
Registered owner
A.T.E. Of California, Inc.
Airworthiness certificate
Standard, Normal; Standard, Utility
Last inspection
AAIP · November 8, 1993 · 50 hours before
Airport
SNA · John Wayne Airport

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot, aircraft N9620B
Age
49
Certificates
Airline transport, Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Right
Flight hours
3,000 total · 90 in this make and model · 2,850 as pilot in command · 200 in the last 90 days · 85 in the last 30 days · 2 in the last 24 hours
Role
Pilot, aircraft N97766
Age
28
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Right
Flight hours
1,430 total · 900 in this make and model · 1,371 as pilot in command · 153 in the last 90 days · 54 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
230° at 5 knots
Visibility
5 statute miles
Lowest ceiling
None
Temperature
70 °F, dew point 43 °F
Altimeter
30.00 inHg
Observed at
SNA

FAA reports on this event · 2

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N9620B · 1

Matched to the same aircraft by N-number and date.