# NTSB MIA05LA079: Rockwell Aero Commander 500, N8498C, San Juan, PR, March 12, 2005 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: March 12, 2005, 09:20 local (13:20 UTC) - Place: San Juan, PR - Coordinates: 18.456666, -66.10778 - Nearby events: https://openairdocs.org/map.md?lat=18.4567&lon=-66.1078&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 4 uninjured - Status: Completed, report October 27, 2005 - Report: Approved by Office Director - Parties: Caribbean Flight Standards District Office - NTSB case key (mKey): 61173 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA05LA079 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/61173/pdf - Page: https://openairdocs.org/ntsb/MIA05LA079 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, takeoff - initial climb - hydraulic system - undetermined - maintenance,inspection - not corrected, other maintenance personnel - operation with known deficiencies in equipment - inadvertent, pilot in command (cause) - Overrun, landing - roll - checklist - not followed, pilot in command (cause) - landing gear,normal brake system - inoperative - On ground/water collision with object, landing - 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](https://openairdocs.org/aircraft/N8498C), registered now, S/N 848, built 1960 (OpenAirDocs) - Reported make and model: Rockwell Aero Commander 500 - Registry model: [Aero Commander 500](https://openairdocs.org/model/aero-commander-500) (registry code 0141102) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 848 - Airframe hours: 4952 - Engines: Lycoming IO-540 250 horsepower reciprocating; Lycoming 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 54; injuries: none; 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 (OpenAirDocs). - [Accident 20050312006629A](https://openairdocs.org/incident/20050312006629A), Mar 12, 2005: Gulstm 500, San Juan, Puerto Rico, Substantial damage. (-23) Aero commander 500, N8498C collided with a ditch during landing roll at the fernando luis ribas dominicci airport, San Juan, PR. The pilot stated that… 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.