SEA03LA201

NTSB accident investigation · Cessna 172S · Anacortes, WA · September 18, 2003

Accident · No injuriesLimited investigationFinal report
Date
September 17, 2003, 19:35 local (Sep 18, 2003, 02:35 UTC)
Place
Anacortes, WA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Taxi
Aircraft
N3555LCessna 172S
Weather
Visual (VMC) · Dusk
Status
Completed · report June 30, 2004
Report
Approved by Office Director
Parties
FAA-FSDO
FAA report
20030917022419A
Case key
58288

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 NTSB’s determination of the probable cause, and any contributing factors.

The pilot attempting to taxi the airplane with a known system deficiency. Factors include worn wheel brakes and a drainage ditch.

Analysis

The pilot reported he experienced a complete wheel brake failure while taxiing for takeoff. The pilot said that he applied brakes, with little response, as the airplane neared the end of the inclined taxiway. He reported that he was not able to stop the airplane, and it continued off the end of the taxiway. After exiting the taxiway, the airplane encountered rough uneven terrain and eventually came to rest, nose down, in a drainage ditch. In a written statement, the pilot reported that on the previous landing, the airplane "shuttered violently" when he applied wheel brakes during the landing roll. He stated that after parking the airplane he noticed brake fluid "dripping" from the area of the wheel brakes. The pilot also stated that after discovering the problem with the brakes, he contacted the operator of the airplane concerning the problem. The pilot reported that the operator instructed him to "...ferry the aircraft back to ORS [Orcas Island] for maintenance." In a written report dated November 20, 2003, the operator stated that the pilot advised him that only a small amount of brake fluid had leaked from the system. Post accident examination of the wheel brake components by an investigator from the National Transportation Safety Board revealed that the brake pads were worn beyond limits, which allowed the caliper seals (O-ring) to unseat resulting in a loss of brake fluid.

Factual narrative

On September 17, 2003, about 1935 Pacific daylight time, a Cessna 172S, N3555L, sustained substantial damage during a taxiway overrun at the Anacortes Airport, Anacortes, Washington. The airplane is registered to Rugby Aviation of East Sound, Washington, and was being piloted by the private pilot as a visual flight rules (VFR) cross-county flight under the provisions of 14 CFR Part 91. The pilot, and the one passenger aboard the airplane were not injured. Visual meteorological conditions prevailed and no flight plan had been filed for the proposed flight to East Sound, Washington.

During a telephone conversation with the National Transportation Safety Board IIC on November 3, the pilot reported he experienced a complete wheel brake failure while taxiing for takeoff. The pilot said that he applied brakes, with little response, as the airplane neared the end of the inclined taxiway. He reported that he was not able to stop the airplane, and it continued off the end of the taxiway. After exiting the taxiway, the airplane encountered rough uneven terrain and eventually came to rest, nose down, in a drainage ditch.

In a written report dated November 3, 2004, the pilot stated that on the previous landing, the airplane "shuttered violently" when he applied wheel brakes during the landing roll. He stated that after parking the airplane he noticed brake fluid "dripping" from the area of the wheel brakes.

In the written report, the pilot states that after discovering the problem with the brakes, he contacted the operator of the airplane. According to his report, the operator instructed the pilot to "...ferry the aircraft back to ORS [Orcas Island] for maintenance."

In a written report dated November 20, 2003, the operator stated that the pilot advised him that only a small amount of brake fluid had leaked from the system.

Post accident examination of the wheel brake components by an investigator from the National Transportation Safety Board revealed that the brake pads were worn beyond limits, which allowed the caliper seals (O-ring) to unseat resulting in a loss of brake fluid.

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/malfunctionTaxi
Landing gear,normal brake system - wornFactor
OverrunTaxi
Operation with known deficiencies in equipment - attemptedPilot in commandCause
On ground/water encounter with terrain/waterTaxi
Terrain condition - ditchFactor

Aircraft

Registration
N3555L
Reported as
Cessna 172S
Category
Airplane
Serial number
172S8865
Airframe hours
785
Engine
Lycoming IO-360-L2A, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Rugby Aviation
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 4, 2003 · 85 hours before
Departed
ORS · Eastsound, WA
Destination
74S · Anacortes, WA
Airport
74S · Anacortes, runway 18, 3,015 × 60 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
49
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--w/ waivers/lim
Last flight review
September 6, 2003
Seat
Left
Flight hours
151 total · 132 in this make and model · 85 as pilot in command · 11 in the last 90 days · 5 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Dusk
Visibility
10 statute miles
Lowest ceiling
6,000 ft overcast
Temperature
54 °F, dew point 54 °F
Altimeter
30.17 inHg
Observed at
BVS, 20 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.