NYC01LA216

NTSB accident investigation · Cessna 182R · Elizabethtown, KY · August 23, 2001

Accident · No injuriesLimited investigationFinal report
Date
August 23, 2001, 16:45 local (20:45 UTC)
Place
Elizabethtown, KY
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N5419ECessna 182R
Weather
Visual (VMC) · Day
Status
Completed · report November 28, 2001
Report
Approved by Office Director
Parties
Federal Aviation Administration
FAA report
20010823023939A
Case key
53104

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 improper decision to fly the airplane with a known deficiency, and his inflight decision to land with a quartering tailwind. A factor was the wing maintenance officer's concurrence to fly the airplane with the known deficiency.

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.

OverrunLanding - roll
Operation with known deficiencies in equipment - intentionalPilot in commandCause
Improper decisionCompany/operator managementFactor
In-flight planning/decision - improperPilot in commandCause
Nose overLanding - roll

Analysis

The Civil Air Patrol (CAP) pilot elected to make a flight with an inoperative right brake. He found that the brake was inoperative during his pre-flight inspection, from a write-up left by the previous pilot. He talked to the CAP wing maintenance officer, and together they agreed that the pilot would ferry the airplane to another airport for maintenance. He departed without incident. In the landing pattern at the destination airport, the pilot elected to land with a 10-knot quartering tailwind with no flaps. He was unable to stop the airplane on the 5,000-foot runway, and it ran off the departure end. The airplane went through a ditch, and came to rest inverted in a cornfield. An aluminum brake line attached to the right side tubular steel landing gear strut had chaffed against the aluminum covering over the strut, and developed a leak near the lower end of the strut. Dried hydraulic fluid was found inside the aluminum covering. The mechanic who performed the last inspection stated that he did not normally remove the aluminum fairings which were installed over the tubular steed landing gear strut.

Factual narrative

On August 23, 2001, about 1645 eastern daylight time, a Cessna 182R, N5419E, was substantially damaged during a landing overrun at Addington Field Airport, Elizabethtown, Kentucky. The certificated airline transport pilot and passenger were not injured. Visual meteorological conditions prevailed for the positioning flight. A company visual flight rules flight plan had been filed for the flight that was conducted under 14 CFR Part 91.

The airplane was operated by the Kentucky Wing of the Civil Air Patrol (CAP). The flight originated from Godman Army Airfield, Fort Knox, Kentucky.

According to a written statement by the pilot, when he checked the airplane prior to departure, the right brake had been listed as inoperative in the airplane logbook. There was no maintenance available for civilian airplanes at Fort Knox. The pilot checked the airplane further, and found that the right brake pedal went all the way down before he felt any resistance. An external examination of the airplane, and the ground underneath it revealed no evidence of leaking hydraulic fluid. The pilot telephoned the CAP wing maintenance officer and discussed the logbook write-up, and his findings with him. The wing maintenance officer had not previously been made aware of the inoperative right brake. He asked the pilot if he felt comfortable flying the airplane to another airport for maintenance. The pilot accepted the flight. The pilot also reported that while taxiing for departure, he checked the right brake, and although the pedal went to the floor, he thought there was some braking capability from it, and continued with the departure.

En route to Elizabethtown, the pilot checked the Elizabethtown Automated Weather Observation Station (AWOS), and found that the winds were from 280 degrees at 10 knots. He initially planned to land on runway 23, but then decided that with the wind and bad brake on the right side, he would land on runway 5. The pilot reported that he made this decision due to his previous experience in the Maule airplane, and its lack of tendency to weather vane into the wind with a crosswind. In addition, the pilot performed the approach with no flaps, and a faster airspeed to further minimize any crosswind controllability problems. He reported that he touched down 500 feet past the approach end of runway 5 at 70 knots. Each time he applied the brakes, the airplane swerved to the left. He would then release the brakes, and bring the airplane back to runway centerline with rudder control and then reapply the brakes. About 1,000 feet prior to reaching the departure end of the runway, he accepted the left swerve and increased braking pressure. The airplane had slowed, but still departed the left edge of the runway at the departure end, with a speed of about 10 mph. The terrain beyond the end of the runway sloped down to a ditch, with a corn field beyond the ditch. The airplane accelerated as it went downhill, and the nose landing gear was sheared off as the airplane went through the ditch. The airplane came to rest inverted in the corn field.

According to information from the Federal Aviation Administration (FAA), runway 5 was 5,001 feet long, and 100 feet wide, with an asphalt surface.

Examination of the airplane revealed that the main wheel brake hydraulic lines were attached to the trailing edge of the tubular steel landing gear struts. The aluminum brake line had chaffed against the aluminum covering over the strut, and had developed a leak near where the brake line had attached to the brake caliper. Dried hydraulic fluid was found inside the aluminum covering, and on the main landing gear strut. .

According to 14 CFR 43, Appendix D:

"...Each person performing an annual or 100 hour inspection shall, before that inspection, remove or open all necessary inspection plates, access doors, fairing, and cowling. He shall thoroughly clean the aircraft and aircraft engine...."

According to the inspection form from Cessna Aircraft Co, under landing gear and brakes it states:

"...Main Gear Tube - Inspect for cracks, dents, corrosion, condition of paint or other damage...."

According to an FAA inspector, the mechanic who had performed the last annual inspection did not remove the aluminum covering from over the landing gear strut. The mechanic also stated that he did not normally remove the covering during an annual inspection. The last time the covering was removed was not determined.

According to a memo from the Kentucky CAP Wing operations/maintenance officer:

"...Aircraft discrepancies that affect dispatch reliability or safety of flight should be reported immediately to the Wing Aircraft Maint. Off. This would include exterior lights, engine problems, avionics problems and so forth...."

The pilot of the preceding flight reported that when he taxied for departure from Fort Knox, he noticed that the right brake was "mushy," but useable. At the completion of his CAP mission, he landed at London, Kentucky, and the right brake was still "mushy." However, when he returned to Fort Knox, the brake pedal was "very mushy", and he made a write-up in the airplane log sheet. He did not observe any fluid leaks. The pilot was also asked if he was aware of the order to notify the wing maintenance officer of maintenance discrepancies. He reported that he was aware of the order, and forgot to make the notification after the flight.

Examination of the airplane log sheets from the accident airplane revealed that a number of maintenance discrepancies had been entered. However, none of the discrepancies had been cleared.

The pilot listed his total flight experience as 5,068 hours, with 238 hours in single engine airplanes, and 24.9 hours in the Cessna 182.

Aircraft

Registration
N5419E
Reported as
Cessna 182R
Category
Airplane
Serial number
18268317
Airframe hours
2,672
Engine
Teledyne Cont O-470-U24B, 230 horsepower, reciprocating
Damage
Substantial damage
Flight
Positioning · Part 91
Registered owner
Civil Air Patrol
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 29, 2001 · 76.7 hours before
Departed
FTK · Fort Knox, KY
Destination
EKX · Elizabethtown, KY
Flight plan
Company VFR
Airport
EKX · Addington Field Airport, runway 05, 5,001 × 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
52
Injuries
None
Certificates
Airline transport, Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
September 12, 1999
Seat
Left
Flight hours
5,068 total · 25 in this make and model · 3,445 as pilot in command · 53 in the last 90 days · 39 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
350° at 8 knots
Visibility
7 statute miles
Lowest ceiling
20,000 ft broken
Temperature
88 °F, dew point 68 °F
Altimeter
30.00 inHg
Observed at
EKX

Docket · 8

The files NTSB released with the investigation on November 13, 2001, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.1 MB in all.

FAA reports on this event · 1

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

Other investigations on N5419E · 1

Matched to the same aircraft by N-number and date.