LAX94LA135

NTSB accident investigation · Cessna 340A · Dunsmuir, CA · February 7, 1994

Accident · No injuriesLimited investigationFinal report
Date
February 7, 1994, 15:45 local (23:45 UTC)
Place
Dunsmuir, CA
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N1362CCessna 340A
Weather
Visual (VMC) · Day
Status
Completed · report November 14, 1994
Report
Approved by Office Director
FAA report
19940207003149A
Case key
28674

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 mechanics improper maintenance of the airplane's left brake system by failing to service its hydraulic reservoir. The lack of hydraulic fluid in the left brake reservoir which precipitated the left brake failure is a factor in this accident.

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.

Airframe/component/system failure/malfunctionLanding - roll
Landing gear,normal brake system - failure,totalFactor
Fluid,hydraulic - exhaustionFactor
Maintenance,service of aircraft/equipment - improperOther maintenance personnelCause
On ground/water collision with objectLanding - roll
Terrain condition - snowbankFactor
Ground loop/swerve - intentionalPilot in command

Analysis

During the landing roll, the left brake failed. The pilot was able to maintain directional control by intermittently using the right brake and the flight controls. When the airplane neared the end of the runway at 30 mph, the pilot intentionally ground looped the airplane by applying heavy right brake to prevent the airplane from exiting the runway. The airplane pivoted to the right and collided with a snow bank. Examination of the left brake system revealed that the left brake reservoir did not contain any fluid. A mechanic repaired the left brake 6 hours preceding the accident, but did not refill the reservoir.

Factual narrative

On February 7, 1994, at 1545 hours Pacific standard time, a Cessna 340A, N1362C, exited the right side of runway 32 and collided with a snow bank at Dunsmuir Airport, Dunsmuir, California. The pilot was conducting a visual flight rules business flight to Roseburg, Oregon. The airplane, registered to and operated by Paw Management, Inc., Idleyld Park, Oregon, sustained substantial damage. The certificated private pilot, the sole occupant, was not injured. Visual meteorological conditions prevailed. The flight originated at Red Bluff Municipal Airport, Red Bluff, California, at 1400 hours.

The pilot reported this accident by telephone to the National Transportation Safety Board on February 23, 1994. He said that he initially assessed the damage as minor; however, further inspection of the airplane by a mechanic revealed major structural damage to the right wing and right side of the fuselage.

When the pilot reported this accident, he said that during the landing roll the left brake failed. The right brake operated properly, but the airplane pivoted about 120 degrees to the right, exited the runway, and subsequently collided with a snow bank. He said that the left brake pads and "O" rings had been replaced by an airframe and powerplant mechanic at Red Bluff Airport within 6 flight hours preceding the accident.

The pilot submitted the required Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2, to the Safety Board, Southwest Regional Office. He said that bad weather prevented him from proceeding to Roseburg, Oregon. When the flight reached Dunsmuir, visual meteorological conditions prevailed and he elected to land.

He also reiterated his telephone statement in the report. He added, however, that he pumped the left brake pedal several times to get some braking action, but without success. The pilot maintained directional control by intermittently using the right brake and the flight controls.

When the airplane approached the end of the runway at 30 miles per hour, the pilot elected to use heavy right braking to stop the airplane before it exited the end of the runway. The airplane pivoted to the right, exited the right side of the runway, and collided with the snow bank.

Mr. Daniel Herlihy, Herlihy Enterprises, Dunsmuir, California, an airplane maintenance facility, called the Safety Board on June 14, 1994. He said that he repaired the airplane and during the repair he found the left brake reservoir empty. He also said that the reservoir and its associated lines to the left brake system did not leak. Other than filling the left brake reservoir, he did not effect any repairs on the airplane's brake system.

Aircraft

Registration
N1362C
Reported as
Cessna 340A
Category
Airplane
Serial number
340A0012
Airframe hours
2,981
Engine
Continental TSIO-520-N, 310 horsepower, reciprocating
Damage
Substantial damage
Flight
Business · Part 91
Operator
Paw Management
Registered owner
Paw Management
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 18, 1993 · 250 hours before
Departed
RBL · Red Bluff, CA
Destination
RGB · Roseburg, OR
Airport
1O6 · Dunsmuir, runway 32, 2,700 × 60 ft, asphalt

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
40
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Medical
Class 3, Expired
Seat
Left
Flight hours
501 total · 212 in this make and model · 457 as pilot in command · 70 in the last 90 days · 50 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
20 statute miles
Lowest ceiling
None
Temperature
37 °F

FAA reports on this event · 1

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

Other investigations on N1362C · 1

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