LAX94LA137

NTSB accident investigation · Waco YMF-5 · Carlsbad, CA · February 24, 1994

Accident · Minor injuriesLimited investigationFinal report
Date
February 24, 1994, 09:15 local (17:15 UTC)
Place
Carlsbad, CA
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N50YMWaco YMF-5
Weather
Visual (VMC) · Day
Status
Completed · report December 7, 1994
Report
Approved by Office Director
FAA report
19940224002899A
Case key
28676

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 pilot's failure to follow the correct procedures when he released the parking brake. The inadvertently engaged parking brake and the outdated flight manual were factors in this accident.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.

Nose overLanding - roll
Landing gear,parking brake - engagedFactor
Procedures/directives - not followedPilot in commandCause
Acft/equip,inadequate designPilot in commandFactor

Analysis

The pilot was completing a local area maintenance test flight when it nosed over on landing. After performing a ground run-up in the maintenance area, the pilot failed to properly release the parking brake before departing on the accident flight. The owner did not update the airplane's flight manual. The updated version contained a caution note on releasing the parking brake procedure. This caution note was not a required placard. The maintenance manual parking brake releasing procedure differed from the airplane's flight manual.

Factual narrative

On February 24, 1994, about 0915 hours Pacific standard time, a Waco YMF-5, N50YM, nosed over during landing on runway 24 at the McClellan-Palomar Airport, Carlsbad, California. The pilot was conducting a visual flight rules (VFR) local area flight. The airplane, operated by Air Mikie International, Oceanside, California, sustained substantial damage. The certificated airline transport pilot, the sole occupant, received minor injuries. Visual meteorological conditions prevailed. The flight originated at McClellan-Palomar Airport at 0858 hours.

The pilot indicated in his accident report that he was conducting a maintenance test flight. A mechanic had just completed an annual inspection on the airplane.

Initially, the pilot did a ground static run-up with the parking brake set. After the ground run-up, he shut down the engine and inspected the airplane for fluid leaks. Everything checked normal. He then boarded the airplane, started the engine, and requested a taxi clearance from the ground controller.

After receiving the taxi clearance, the pilot applied power, but the airplane would not move. He then noticed that he had not released the parking brake. He said, in part:

"...I depressed the brake pedals to remove the parking brake. It did not work. I then tried pushing in the T-handle which sets the parking brake. This did not release it either. I called the mechanic over and told him the parking brake was not releasing. Finally, I tried pushing in the handle and depressing the brake pedals, simultaneously. The handle then clicked off into [the] normal position. [The] brake pressure was relieved on the pedals and the plane [airplane] felt free to move forward...."

During the taxi to the runway, the pilot applied the brakes and they operated normally. The pilot departed the airport without incident and flew to the practice area. The airplane functioned normally during the climb, level off, and routine maneuvers. The pilot then returned to the airport.

The pilot said that the landing conditions were excellent with clear skies and the winds were calm. He executed a "soft wheels landing." As the airplane transitioned to the tail low position, the airplane yawed to the left and its nose violently pitched down. The pilot was unable to control the airplane with the appropriate flight controls application.

A Federal Aviation Administration (FAA) airworthiness inspector conducted the on-scene examination. The inspector said that the pilot told him the facts, conditions, and circumstances as related in the accident report. The mechanic told him that the pilot had released the brakes by the time he arrived at the airplane during the initial parking brake problem.

The mechanic told the FAA inspector that he accomplished the annual inspection by using a checklist provided in the maintenance manual. He said that he inspected the parking brake system for operation, overall condition, and security as required by the checklist. With the lower fuselage panels removed, the mechanic observed normal operation of the parking brake valve with the brakes on and off.

The FAA inspector found the parking brake control valve midway between the full on and full off position. The brakes were locked. An unidentified person released the brakes from the cockpit. The FAA inspector and mechanic observed that the control arm on the valve rotated toward the off position, but did not go to the full off position; the brakes, however, released. The FAA inspector observed that the parking brake control cable was bent near the area where it attaches to the valve actuating arm. After the mechanic disconnected the cable from the valve, the valve rotated freely to both extremes.

The FAA inspector examined the airplane's maintenance records and found no evidence that the parking brake system had been previously worked on. The mechanic told the inspector that the maintenance manual contained no procedures for rigging the parking brake system.

The FAA inspector also found several pages missing from the airplane flight and maintenance manuals. The manufacturer's general manager provided the FAA inspector with copies of the missing pages. The maintenance manual procedures for releasing the parking brake differ from the airplane flight manual. The maintenance manual does not refer to applying brake pedal pressure before pushing in the brake T-handle. The airplane flight manual provides a "CAUTION" note with respect to releasing the parking brake. The note states:

Do not push parking brake control "t" handle off before applying brake pressure - doing so can bend the cable resulting in the control valve not being turned all the way off. Subsequent brake operation may result in unwanted parking brake application.

This caution is not a required instrument panel placard. The required placard only notes setting of the parking brake control.

The owner transported the airplane to the manufacturer's facility in Lansing, Michigan. The FAA inspector tagged the airplane to prevent any repairs on the airplane until examined by an FAA manufacturing inspector, from the Detroit, Michigan, Manufacturing Inspection Satellite Office (MISO).

The FAA manufacturing inspector examined the airplane and found no discrepancies. He noted that the bent cable was actually designed with a small bend where the wire passed through the clevis. He said the parking brake functioned the same as a factory new airplane.

The FAA manufacturing inspector reported that the company revised the Airplane Flight Manual on December 12, 1993. The revision places an increased emphasis on the parking brake operation. The accident airplane did not have the newer flight manual revision. He also said that of the 57 airplanes built by the manufacturer, 11 of them were involved in similar accidents.

Aircraft

Registration
N50YM
Reported as
Waco YMF-5
Category
Airplane
Serial number
F5C-053
Airframe hours
298
Engine
Jacobs R-755-B2V, 275 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Same As Registered Owner
Registered owner
Air Mikie International
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · February 23, 1994 · 1 hours before
Airport
CRQ · Mcclellan-Palomar, runway 24, 4,700 × 150 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
36
Certificates
Flight instructor, Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Rear
Flight hours
2,316 total · 170 in this make and model · 2,203 as pilot in command · 74 in the last 90 days · 30 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Lowest ceiling
None
Temperature
64 °F

FAA reports on this event · 1

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