MIA06LA052

NTSB accident investigation · Cessna 501 · Fort Pierce, FL · February 12, 2006

Accident · No injuriesLimited investigationFinal report
Date
February 11, 2006, 21:15 local (Feb 12, 2006, 02:15 UTC)
Place
Fort Pierce, FL
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N501DRCessna 501
Weather
Visual (VMC) · Night
Status
Completed · report January 31, 2008
Report
Approved by Office Director
Parties
FAA-Orlando FSDO
FAA report
20060211002989A
Case key
63252

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

mechanical binding of the normal brake system, rendering directional control impossible. Contributing factors were the improper overhaul, inadequate quality control procedures by the overhaul facility, and the rough terrain.

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.

Loss of control - on ground/waterLanding - roll
Landing gear,normal brake system - binding(mechanical)Cause
Directional control - not possiblePilot in commandCause
Maintenance,overhaul - improperSupplier/distributor of partsFactor
Inadequate quality controlSupplier/distributor of partsFactor
On ground/water encounter with terrain/waterLanding - roll
Terrain condition - rough/uneven

Analysis

During the landing roll, the pilot was unable to maintain directional control and the airplane swerved side-to side before going off the right side of the runway. The pilot said overhauled brake assemblies had been installed before the accident. He complained that the brakes felt "spongy" and the pedals went "almost to the floor, requiring two or three additional pumps for a hard pedal." He was told that this was "normal" since the airplane was not equipped with power brakes or anti-skid. The brakes were removed and sent to the overhaul facility. They found that both brake assemblies each had one return mechanism binding. The return mechanism had a self adjusting friction bushing meant to slip along the return pin at a predetermined spring pressure. As pressure was applied to the brake, the pressure plate extended toward the number one rotor, pulling the return pins through the swage and tube assemblies and compressing the return springs. Although the swage should move through the tube, one swage on each brake was not moving freely. The brake travel went further than normal because "normal travel" was never set.

Factual narrative

On February 11, 2006, approximately 2115 eastern standard time, a Cessna 501, N501DR, registered to Eagle Aviation LLC, and piloted by a private pilot, was substantially damaged when directional control was lost during landing at St. Lucie County International Airport, Fort Pierce, Florida. Visual meteorological conditions prevailed at the time of the accident. The personal flight was being conducted under the provisions of Title 14 CFR Part 91, and an Instrument flight rules (IFR) flight plan had been filed and activated. The pilot and passenger on board the airplane were not injured. The cross-country flight was originated from Columbia Metropolitan Airport, Columbia, South Carolina, approximately 1930 and was en route to Fort Pierce.

According to the pilot's accident report, the flight proceeded to Fort Pierce without incident, and he executed an instrument landing system (ILS) approach to runway 09. He said he flew the approach at an airspeed of Vref plus 15 to 20 knots with full flaps extended, then slowed to approximately 95 knots. The airplane touched down within 300 to 500 feet of the runway threshold. During the landing roll, he could not maintain directional control of the airplane which was going side to side. He attempted to correct the side-to-side motion with rudder control input. The airplane departed the right side of the runway and came to rest on grass approximately 500 feet from the south edge of the runway.

According to an FAA inspector who went to the scene, rubber residue found on the runway was indicative that the airplane was yawing to the right. The tire marks were associated with the nose and right main landing gear tires. The right main tire had a flat spot, and the nose gear fork was fractured.

The pilot submitted an addendum statement in which he said four months before the accident, an Oklahoma City, Oklahoma, maintenance facility installed overhauled brake assemblies on the left and right main landing gears, and bled the brakes. After the work was completed, the pilot told them that the brake pedals felt "spongy" and went "almost to the floor, requiring two or three additional pumps for a hard pedal." Maintenance personnel bled the brakes a second time, but there was no change. They told the pilot that this was "normal" since the airplane was not equipped with power brakes or anti-skid. Maintenance personnel in Wilmington, Delaware, the pilot's home base, and Fort Pierce, Florida, after repairs were made, also bled the brakes and reiterated that the sponginess was "normal."

After the accident and after repairs had been made to the airplane, the pilot assisted a Wilmington A&P mechanic in bleeding the brakes. Again, there was no change in pedal "feel." Examination of the brake assemblies, however, revealed the amount of pedal travel appeared to be greater than normal. The brakes were removed and sent to the overhaul company. In the maintenance logbook, they wrote: "Both brake assemblies had one return mechanism binding. The return mechanism has a self adjusting friction bushing. This bushing is meant to slip along the return pin as a predetermined spring pressure. As pressure is applied to the brake, the pressure plate is extended toward the number one rotor pulling the return pins through the swage and tube assemblies and compressing the return springs. The swage should move through the tube throughout the life of the brake. However, one swage on each brake was not freely moving along the pin and tube. Therefore the brake travel was further than it should have been due to the normal travel never having been set. We have completely resealed these housings and replaced all of the return mechanisms with fully functioning ones. We have repeatedly tested the units and applied operating pressure to the housing to ensure that normal brake travel has been achieved and set, and that the friction (or swage and tube) assemblies are free of binding and functioning properly."

Aircraft

Registration
N501DR
Reported as
Cessna 501
Category
Airplane
Serial number
501-141
Airframe hours
6,356
Engines
Pratt & Whitney JT15D-1A, 2,200 lbs thrust, turbo fanPratt & Whitney JT15D-1A, 2,200 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Personal · Part 91
Operator
David Roeberg
Registered owner
Eagle Aviation, LLC
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · October 1, 2005
Departed
KCAE · Columbia, SC
Destination
KFPR · Fort Pierce, FL
Flight plan
IFR
Airport
FPR · St. Lucie County International, runway 9, 6,492 × 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
68
Injuries
None
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
November 1, 2005
Seat
Left
Flight hours
3,200 total · 475 in this make and model · 3,200 as pilot in command · 25 in the last 90 days · 12 in the last 30 days · 6 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night
Wind
290° at 6 knots
Visibility
10 statute miles
Lowest ceiling
3,800 ft overcast
Temperature
66 °F, dew point 57 °F
Altimeter
29.95 inHg
Observed at
KFPR

FAA reports on this event · 1

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