# NTSB LAX94LA135: Cessna 340A, N1362C, Dunsmuir, CA, February 7, 1994 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: February 7, 1994, 15:45 local (23:45 UTC) - Place: Dunsmuir, CA - Coordinates: 41.190013, -122.259025 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.1900&lon=-122.2590&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 14, 1994 - Report: Approved by Office Director - NTSB case key (mKey): 28674 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX94LA135 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28674/pdf - Page: https://openairdocs.org/ntsb/LAX94LA135 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, landing - roll - landing gear,normal brake system - failure,total (contributing factor) - fluid,hydraulic - exhaustion (contributing factor) - maintenance,service of aircraft/equipment - improper, other maintenance personnel (cause) - On ground/water collision with object, landing - roll - terrain condition - snowbank (contributing factor) - ground loop/swerve - intentional, pilot 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](https://openairdocs.org/aircraft/N1362C), registered now, S/N 340A0012 (OpenAirDocs) - Reported make and model: CESSNA 340A - Registry model: [Cessna 340A](https://openairdocs.org/model/cessna-340a) (registry code 2076405) (OpenAirDocs) - Category: Airplane - Serial number: 340A0012 - Airframe hours: 2981 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 40; 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 (OpenAirDocs). - [Accident 19940207003149A](https://openairdocs.org/incident/19940207003149A), Feb 7, 1994: Cessna 340A, Dunsmuir, CA, Substantial damage. Left brake failed on landing. Used hard right to stop on runway. Veered off into snowbank. Brake cylinder empty. (.19) on February 7, 1994, at 1500 hours… ## Other investigations on N1362C (1) 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 LAX92LA138](https://openairdocs.org/ntsb/LAX92LA138), Mar 12, 1992: Cessna 340A (N1362C), Long Beach, CA, substantial damage. Probable cause: THE FATIGUE FAILURE OF THE LEFT MAIN LANDING GEAR DOWN LOCK BELL CRANK PIVOT BOLT. 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.