SEA93LA176

NTSB accident investigation · Cessna 185C · Stibnite, ID · August 12, 1993

Accident · No injuriesLimited investigationFinal report
Date
August 12, 1993, 10:00 local (16:00 UTC)
Place
Stibnite, ID
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N2690ZCessna 185C
Weather
Visual (VMC) · Day
Status
Completed · report September 26, 1994
Report
Approved by Office Director
FAA report
19930812029159A
Case key
41749

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

Leakage of hydraulic brake fluid and improper maintenance by the pilot in command. A factor contributing to the accident was inadequate inspection by the mechanic.

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 - failure,partial
Fluid,hydraulic - leakCause
Maintenance,replacement - improperPilot in commandCause
Maintenance,inspection - inadequateOther maintenance personnelFactor

Analysis

During landing rollout the pilot lost left brake pressure and the aircraft ground looped. Post crash examination revealed that the 'b-nut' on the left brake line, where it passes through the fuselage, was loose. Additionally, hydraulic fluid was observed inside the fuselage in the vicinity of the fitting, and the left brake master cylinder contained only a small amount of fluid. The pilot reported that he was assisting a mechanic in maintenance on the left landing gear support bracket and could not remember tightening the 'b-nut' or if the mechanic inspected the work he accomplished.

Factual narrative

On August 12, 1993, at approximately 1000 hours mountain daylight time (MDT), a Cessna 185C, N2690Z, registered to and being operated/flown by Guy A. Pere, an airline transport rated pilot doing business as Pere Air, sustained substantial damage during a loss of control while landing at the Pistol Creek private airstrip near Stibnite, Idaho. The pilot reported that he and his two passengers were uninjured and that visual meteorological conditions prevailed at the time of the mishap. A company flight plan was in effect. The flight, which was an unscheduled passenger flight, was to have been operated in accordance with the requirements set forth in 14CFR135 and originated from the Friedman Memorial Airport, Hailey, Idaho, at approximately 0900 hours.

The pilot reported that during the landing rollout he lost the left brake and the aircraft ground looped 180 degrees impacting the left wing.

Post crash examination of the aircraft by FAA Inspector Russell Graves revealed brake fluid inside the fuselage where the left brake line passes from outside to inside the fuselage. There was no other evidence of fluid leakage associated with the brake system. Additionally, Inspector Graves reported that all "B-nuts" were found to be tight with the exception of "the outside nut that is attached to the bulkhead fitting that goes through the fuselage (and) was loosened easily with a wrench." No mechanical defects were found during the examination of the brake system and the left brake master cylinder contained only a small amount of fluid" (refer to attached statement of Russell E. Graves). The aircraft airframe log contained an entry dated 08/11/93 which read in part "Replaced L/H outboard landing gear support bracket with new unit from P. Ponk Aviation, P/N PPA 1301-1. See 337 Form. Removed cargo pack, revised W & B and equipment list." The entry was signed off by Tim W. Charles, A & P 519886010.

Pilot Pere reported to the Investigator in Charge during a telephonic conversation that he assisted the mechanic in the maintenance work accomplished on 08/11/93, including the tightening of the left brake lines inside the fuselage. He stated that he did not recall tightening the B-nut and was uncertain as to whether the mechanic inspected the work he accomplished.

Aircraft

Registration
N2690Z
Reported as
Cessna 185C
Category
Airplane
Serial number
1850690
Airframe hours
4,115
Engine
Continental IO-470R, 260 horsepower, reciprocating
Damage
Substantial damage
Flight
Part 135
Operator
Pere Air, doing business as Pere Air
Registered owner
Pere Air
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 31, 1993 · 55 hours before
Departed
SUN · Ketchum, ID
Flight plan
Company VFR
Airport
Pistol Creek, runway 23, 2,500 × 30 ft, dirt

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
37
Certificates
Airline transport, Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
4,900 total

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
30 statute miles
Lowest ceiling
None
Temperature
70 °F

FAA reports on this event · 1

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