NYC07LA227

NTSB accident investigation · Beech A23-24 · West Chester, PA · September 14, 2007

Accident · Serious injuriesLimited investigationFinal report
Date
September 14, 2007, 10:49 local (14:49 UTC)
Place
West Chester, PA
Injuries
1 serious, 1 minor
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N5073TBeech A23-24
Weather
Visual (VMC) · Day
Status
Completed · report May 28, 2008
Report
Approved by Office Director
Parties
FAA/FSDO
FAA report
20070914829779A
Case key
66670

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 total failure of the left brake disc due to corrosion.

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
Landing gear,normal brake system - corrodedCause
On ground/water encounter with terrain/waterLanding - roll
Terrain condition - berm

Analysis

The airplane touched down more than halfway beyond the approach end of runway 9; a 3,347-foot-long, 50-foot-wide, asphalt runway. The pilot applied heavy braking, and the airplane veered off the right side of the runway. Examination of the wreckage revealed that the left brake disc had separated from its housing. The right brake disc had cracked, but remained attached to its housing. The left and right brake discs exhibited corrosion. The airplane's most recent annual inspection was completed about 4 months prior to the accident. The mechanic that performed the annual inspection stated that he did not observe corrosion on the brakes at that time. Airworthiness Directive (AD) 71-06-08 addressed repetitive brake disc inspections and replacements; however, the make and model brake disk on the accident airplane was not included on the AD. The reported weather at an airport near the accident site, about the time of the accident, included winds from 160 degrees at 8 knots, varying between 120 degrees and 200 degrees.

Factual narrative

On September 14, 2007, at 1049 eastern daylight time, a Beech A23-24, N5073T, was substantially damaged while landing at Brandywine Airport (OQN), West Chester, Pennsylvania. The certificated private pilot sustained minor injuries, and the passenger was seriously injured. Visual meteorological conditions prevailed for the flight that departed Sussex County Airport (GED), Georgetown, Delaware, about 0930. No flight plan was filed for the local personal flight conducted under 14 Code of Federal Regulations Part 91.

The airplane landed on runway 9; a 3,347-foot-long, 50-foot-wide, asphalt runway. The pilot reported that the airplane touched down on centerline. He then retracted the flaps and checked the brakes. The pilot let the airplane roll out, and applied continuous braking near the last one-third of the runway. While braking, the left pedal "went away," and the airplane turned right. The airplane traveled off the right side of the runway, down a berm, and came to rest next to a building. The airplane sustained substantial damage to the firewall area, and all three landing gear had separated from the airframe.

The pilot reported a total flight experience of 1,260 hours; of which, 570 hours were in the same make and model as the accident airplane. He flew 6 hours during the 90 days preceding the accident. The pilot estimated the winds were from the east-southeast at 9 knots, gusting to 14 knots.

A Federal Aviation Administration (FAA) inspector stated that he interviewed a witness, who reported that the accident airplane had to go-around during the first landing attempt, as it was "high and fast."

The FAA inspector also viewed a surveillance video that captured the landing accident. The video revealed that the airplane touched down more than halfway down the runway, the pilot applied "heavy" braking, and the airplane veered off the right side of the runway.

The FAA inspector added that examination of the wreckage revealed that the left brake disk had separated from its housing. The right brake disc had cracked, but remained attached to its housing. The left and right brake discs exhibited corrosion. The airplane's most recent annual inspection was completed on May 24, 2007. The FAA inspector interviewed the mechanic that performed that inspection, who stated that he did not observe corrosion on the brakes at that time.

The FAA inspector further stated that airworthiness directive (AD) 71-06-08 addressed repetitive brake disc inspections and replacements; however, the make and model brake disk on the accident airplane was not included in the AD.

Review of the AD revealed a requirement to inspect the brake discs for cracks, or other obvious defects, using a 10-power glass or equivalent. If any defects were found, the brake discs needed to be replaced with a specified new model brake disc. In addition, the inspection needed to be repeated after every 50 hours of operation, or until the specified new brake discs were installed.

The inspector subsequently filed a malfunction or defect report (similar to a service difficulty report) to bring awareness to the situation and have the make and model brake disc added to the AD.

The reported weather at an airport located about 15 miles south of the accident site, at 1054, was: wind from 160 degrees at 8 knots, varying between 120 degrees and 200 degrees; visibility 10 miles; few clouds at 3,000 feet; broken ceiling at 4,900 feet; broken ceiling at 6,000 feet; temperature 22 degrees Celsius (C); dew point 16 degrees C; altimeter 30.14 inches of mercury.

Aircraft

Registration
N5073T
Reported as
Beech A23-24
Category
Airplane
Serial number
MA-319
Airframe hours
2,300
Engine
Lycoming IO-360, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Warren B Knowles
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 1, 2007 · 8 hours before
Departed
GED · Georgetown, DE
Destination
OQN · West Chester, PA
Airport
OQN · Brandywinde Airport, runway 9, 3,347 × 50 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
71
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
October 1, 2006
Seat
Left
Flight hours
1,260 total · 570 in this make and model · 1,040 as pilot in command · 6 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
160° at 8 knots
Visibility
10 statute miles
Lowest ceiling
4,900 ft broken
Temperature
72 °F, dew point 61 °F
Altimeter
30.13 inHg
Observed at
PTW, 15 nm away

FAA reports on this event · 1

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