MIA05LA079

NTSB accident investigation · Rockwell Aero Commander 500 · San Juan, PR · March 12, 2005

Accident · No injuriesLimited investigationFinal report
Date
March 12, 2005, 09:20 local (13:20 UTC)
Place
San Juan, PR
Injuries
4 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N8498CRockwell Aero Commander 500
Weather
Visual (VMC) · Day
Status
Completed · report October 27, 2005
Report
Approved by Office Director
Parties
Caribbean Flight Standards District Office
FAA report
20050312006629A
Case key
61173

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 failure of the pilot to follow the emergency checklist and his inadvertent operation of the airplane with known discrepancies resulting in landing overrun and on-ground collision with a ditch during the landing roll.

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/malfunctionTakeoff - initial climb
Hydraulic system - undetermined
Maintenance,inspection - not correctedOther maintenance personnel
Operation with known deficiencies in equipment - inadvertentPilot in commandCause
OverrunLanding - roll
Checklist - not followedPilot in commandCause
Landing gear,normal brake system - inoperative
On ground/water collision with objectLanding - roll
Terrain condition - ditch

Analysis

Maintenance had been performed to the left main landing gear actuator and flexible hoses that connect to it earlier in the week. The mechanic who performed the work did not complete retraction tests of the landing gear and did not approve the airplane for return to service. The pilot stated that braking action was normal during taxiing, but after takeoff, at approximately 1,000 feet above ground level (AGL), the main gear would not retract and he noticed the hydraulic pressure gauge indicating 0 pressure. He selected gear down, observed three green lights, used the hydraulic emergency hand pump, and turned back to the airport. While operating the hydraulic emergency hand pump, he noticed "some pressure" up to 800 psi. While returning to the airport he moved the emergency hand pump selector valve to "brake only" to be able to stop the airplane but reported he did not get any pressure when using the emergency hydraulic pump. On final approach he slowed the airplane to approximately 85 miles per hour, touched down, and started pumping the hydraulic emergency hand pump for the brakes, with no success. Unable to stop the airplane, it collided with a ditch beyond the departure end of the runway. Following recovery of the airplane, the emergency hand pump selector valve was not found in the "brakes only" position. Operation of the hydraulic emergency hand pump with the selector set to "brakes only" revealed hydraulic pressure was produced. NTSB review of the airplane's Maintenance Manual reveals that the emergency hand pump selector valve, located between the pilot and co-pilot seats, provides a means of directing the flow of hand pumped pressure to either the brake system or the normal hydraulic system. With the selector valve in "brakes only" position, only the wheel brake system and nose steering cylinder received hand pump pressure which will not be indicated on the hydraulic pressure gauge.

Factual narrative

On March 12, 2005, about 0920 Atlantic standard time, an Aero Commander 500, N8498C, registered to a private individual, collided with a ditch during the landing roll at the Fernando Luis Ribas Dominicci Airport, San Juan, Puerto Rico. Visual meteorological conditions prevailed at the time and a visual flight rules (VFR) flight plan was filed for the 14 CFR Part 91 personal flight from Fernando Luis Ribas Dominicci Airport, to Benjamin Rivera Noriega Airport, Isla de Culebra, Puerto Rico. The airplane was substantially damaged and the airline transport-rated pilot and three passengers were not injured. The flight originated about 7 minutes earlier from the Fernando Luis Ribas Dominicci Airport.

The pilot stated that braking action was normal during taxiing, but after takeoff at approximately 1,000 feet above ground level, the main gear would not retract and he noticed the hydraulic pressure gauge indicating 0 pressure. He selected gear down, observed three green lights, used the hydraulic emergency hand operated pump, and turned back to the airport. While operating the hydraulic emergency hand pump, he noticed "some pressure" up to 800 psi. While en route to the departure airport, he advised the controller of the situation and moved the emergency hand pump selector valve to "brake only" to be able to stop the airplane after landing. He reportedly did not get any pressure while using the emergency hydraulic pump, and on final approach he slowed the airplane to approximately 85 miles-per-hour with the intention of landing at the very beginning of the runway. The airplane was landed, and he started pumping the emergency hydraulic pump for the brakes, with no success. Unable to stop the airplane, it collided with a ditch beyond the departure end of the runway.

The airplane was moved to a facility on the airport and a mechanic stated to the FAA inspector-in-charge (FAA-IIC) that when the airplane arrived at his facility, the emergency hand pump selector valve was not set to "brakes only." The mechanic further stated that when he selected "brakes only", and operated the emergency hand pump, he obtained hydraulic pressure.

According to the FAA-IIC, another mechanic performed maintenance to the airplane during the week of March 9, 2005. The work was performed to correct a hydraulic leak at the left main landing gear, and consisted of removal of the left main landing gear actuator to replace the fittings, and replacement of two flexible hydraulic hoses. The mechanic advised the FAA-IIC that the work was not completed and was pending a retraction test, and as such, he had not approved the airplane for return to service.

NTSB review of the airplane's Maintenance Manual reveals that the emergency hand pump selector valve, located between the pilot and co-pilot seats, provides a means of directing the flow of hand pumped pressure to either the brake system or the normal hydraulic system. With the selector valve in "brakes only" position, only the wheel brake system and nose steering cylinder received hand pump pressure, which will not be indicated on the hydraulic pressure gauge.

Aircraft

Registration
N8498C
Reported as
Rockwell Aero Commander 500
Category
Airplane
Serial number
848
Airframe hours
4,952
Engines
Lycoming IO-540, 250 horsepower, reciprocatingLycoming IO-540, 250 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 1, 2004
Departed
TJIG · San Juan
Destination
TJCP · Isla De Culebra, PR
Flight plan
VFR
Airport
TJIG · Fernando Luis Ribas Dominicci, runway 09, 5,317 × 100 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
54
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
January 1, 2005
Seat
Left
Flight hours
20,000 total · 17,000 as pilot in command · 210 in the last 90 days · 70 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
20° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
82 °F, dew point 70 °F
Altimeter
30.06 inHg
Observed at
TJSJ

FAA reports on this event · 1

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