# NTSB SEA98LA178: Cessna 414, Burley, ID, September 28, 1998 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: September 28, 1998, 11:55 local (17:55 UTC) - Place: Burley, ID - Coordinates: 42.390285, -113.780555 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.3903&lon=-113.7806&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 5 uninjured - Status: Completed, report January 11, 2000 - Report: Approved by Office Director - NTSB case key (mKey): 44060 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA98LA178 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/44060/pdf - Page: https://openairdocs.org/ntsb/SEA98LA178 ## Probable cause A brake system failure for undetermined reasons. An intentional ground loop was a factor. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, landing - roll - landing gear,normal brake system - failure (cause) - reason for occurrence undetermined (cause) - Abrupt maneuver, landing - roll - ground loop/swerve - intentional, pilot in command (contributing factor) - Gear collapsed, landing - roll ## Analysis The flight crew reported that while taxiing after their first landing, the co-pilot reported to the captain that the left brake did not feel normal. The captain agreed and they taxied the aircraft to a maintenance facility for inspection. The mechanic visually inspected the brake system and did not find anything. The flight crew reported that the brake lines had recently been replaced and the mechanic instructed the flight crew to pump the brakes in case of air in the lines. The flight crew reported that they pumped the brakes prior to takeoff and felt that the pressure was now okay. The flight crew reported that during the second landing ground roll, the left braking action failed. The captain made a decision to apply hard right rudder and right brake to deliberately ground loop the aircraft before it ran off the end of the runway and into a river. The brake system was inspected and the left side brake master cylinder was removed for testing. During the functional test, it was found that the master cylinder assembly met all engineering requirements. The spot putty in place locking the cover to the body was consistent with Cessna production assembly practices which indicated that the cylinder had never been overhauled. The unit was disassembled and no evidence of wear, scratches or pitting were found. ## Factual narrative On September 28, 1998, at 1155 mountain daylight time, a Cessna 414, C-GLHP, registered to and operated by Skyward Aviation as a Canadian non-scheduled air carrier passenger flight, experienced a brake failure and subsequent landing gear collapse during the landing roll at the Burley Municipal Airport, Burley, Idaho. Visual meteorological conditions prevailed at the time and an instrument flight rules flight plan was filed. The airplane was substantially damaged, and the airline transport pilot, commercial pilot, and the three passengers were not injured. The flight had originated from Billings, Montana, about 50 minutes prior to the accident. The flight crew reported that the flight departed from Winnipeg, Manitoba, Canada, at 0715, and was destined for Billings, Montana. The second pilot landed the airplane at Billings, and during taxi, reported to the Captain that the left brake did not feel normal. The Captain tried the brake and agreed that it was not normal. The aircraft was taxied to a maintenance facility where a mechanic visually inspected the brakes. The mechanic did not visually detect a problem and instructed the flight crew to pump the brakes in case of air in the lines. The flight crew reported that as they taxied out for departure, the brakes were pumped and felt that the pressure was okay. The flight crew reported that a short field landing was performed at Burley. The aircraft touched down within 500 feet of the threshold and braking action began. The Captain reported that the landing roll and braking action were normal until about three quarters of the way down the runway when the left braking action failed. The second pilot maintained directional control as the aircraft approached the end of the runway. The Captain reported that a decision was made to apply hard right rudder and right brake to deliberately "ground loop" the aircraft before it ran off the end of the runway and into a river. During the right turn, the right main landing gear collapsed and the aircraft struck an airport sign. On September 21, 1998, the maintenance records indicate the completion of a hundred hour inspection. The records indicate that the brake master cylinders were serviced. During the inspection, the left main gear brake line was found badly chafed. The line was replaced. After the accident, the brake system was inspected. No anomalies were noted. The left side Brake Master Cylinder was removed for a functional test. The results of the test revealed that the master cylinder assembly met all engineering requirements. The spot putty in place locking the cover to the body was consistent with 1970 Cessna production assembly practices. The unit was disassembled and no evidence of wear, scratches or pitting were found. The Cessna Aircraft Company Model 414 Service Manual indicates time limit inspections of the brake system plumbing for leaks; hoses for bulges and deterioration; and the parking brake for operation. The service manual also indicates time limit inspections for servicing the brake master cylinder. There are no time limits specified for overhaul of the brake master cylinder. ## Aircraft - Registration: CGLHP (not matched to a registry record) - Reported make and model: Cessna 414 - Category: Airplane - Serial number: 414-0099 - Airframe hours: 5442 - Engines: Continental TSIO 520-NB 335 horsepower reciprocating - Damage: Substantial damage - Flight: Part 91 - Operator: Skyward Aviation, doing business as Skyward Aviation - Registered owner: Skyward Aviation - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, September 23, 1998, 2 hours before - Departed: BIL, BILLINGS, MT - Flight plan: IFR - Airport: BYI, Burley Municipal, runway 2, 4,094 × 80 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 43; airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: right; flight hours: 7,800 total, 50 in this make and model, 5,334 as pilot in command, 150 in the last 90 days, 50 in the last 30 days, 10 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 360° at 3 knots - Visibility: 25 statute miles - Lowest ceiling: none - Temperature: 66 °F, dew point 48 °F - Altimeter: 30.00 inHg - Observed at: BYI From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.