WPR09CA084

NTSB accident investigation · Cessna U206E · Crane Island, San Juan Is., WA · January 14, 2009

Accident · No injuriesData collectionFinal report
Date
January 14, 2009, 10:15 local (18:15 UTC)
Place
Crane Island, San Juan Is., WA
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N9428GCessna U206E
Defining event
Landing-landing roll: Loss of control on ground
Weather
Visual (VMC) · Day
Status
Completed · report April 15, 2009
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20090114000349A
Case key
73241

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 failure to maintain directional control during landing. Contributing to the accident was the pilot's improper application of brakes.

Findings · 6

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Runway/land/takeoff/taxi surface: wet surfaceEnvironmental issues › Physical environment · Effect on operationCessna U206E: 1 caseAll aircraft: 141 cases
Airport facilities/design: runway/landing area lengthEnvironmental issues › Operating environment · Effect on operationCessna U206E: 1 caseAll aircraft: 34 cases
Performance/control parameters: directional controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna U206E: 1 caseAll aircraft: 3,958 casesProbable cause
Landing gear system: brakeAircraft › Aircraft systems · Incorrect use/operationCessna U206E: 1 caseAll aircraft: 297 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotCessna U206E: 2 casesAll aircraft: 9,295 casesProbable cause
Action: incorrect action performancePersonnel issues › Action/decision · PilotCessna U206E: 1 caseAll aircraft: 1,386 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The operator's Director of Operations reported that the flight was dispatched from their home base to pickup a waiting passenger for a flight under their 14 Code of Federal Regulations Part 135 operating certificate. Upon arriving over the airstrip, the pilot made a traffic pattern approach and observed that the wind was calm. The pilot stated that his airspeed and approach path were approximately normal and that he was familiar with the airstrip, having landed there in a southerly direction on previous days. The airplane touched down near the beginning of the short, 1,350-foot-long grass runway. The pilot further reported that he used light to firm brake pressure and that the airplane began sliding. He stated that the south portion of the runway (near its departure end) was soggy. He attempted a rapid left turn to avoid encountering the drop-off adjacent to the runway's end. As the airplane turned left, the right wing dipped down, impacted the ground, and broke. The Cessna Aircraft Company's "Landing Distance Table" in the U206 operating handbook provides guidelines for ascertaining the approximate landing distance needed under various conditions. The performance data in the handbook indicated that on a dry grass runway, a distance of at least 897 feet is needed to stop the airplane. The table data does not provide distance information for a "soggy" wet grass runway.

Factual narrative

The operator's Director of Operations (DO) reported that the flight was dispatched from their home base (first) airport under their Federal Aviation Administration's air carrier operating certificate (14 Code of Federal Regulations, Part 135). A passenger was on board the airplane. Upon arriving at the second airport, the passenger disembarked. The pilot departed without passengers or cargo for the third (accident) airstrip, with the intent of picking up a waiting passenger. Upon arriving over the airstrip, the pilot made a traffic pattern approach and observed that the wind was calm. The pilot stated that his airspeed and approach path were approximately normal, and he was familiar with the airstrip, having landed there in a southerly direction on previous days. The airplane touched down near the beginning of the short, 1,350-foot-long grass runway. The pilot further reported that he used light to firm brake pressure, and the airplane began sliding. He stated that the south portion of the runway (near its departure end) was soggy, and there was a drop-off adjacent to the runway's end. So, to avoid that peril, he attempted a rapid left turn to avoid encountering the drop-off. As the airplane turned left, the right wing dipped down, impacted the ground, and broke. Both the pilot and the DO acknowledged to the National Transportation Safety Board investigator that no runway condition information was ascertained prior to departure for the uncharted, uncontrolled, private airstrip. The DO further reported that flight to the accident airstrip required "special permission," which he granted, having operational control of the airplane. The operator's "General Operations Manual" states that, during the preparation for a flight, it is the pilot-in-command's responsibility to comply with 14 CFR Part 91.103, "Preflight Action." This regulation states that the pilot "...shall, before beginning a flight, become familiar with all available information concerning that flight." The Cessna Aircraft Company's "Landing Distance Table" provides guidelines for ascertaining the approximate landing distance needed under various conditions. Following the accident, the pilot calculated and provided the Safety Board investigator with table data that indicated on a dry grass runway, a distance of at least 897 feet are needed to stop the airplane. The table data does not provide distance information for a "soggy" wet grass runway.

Aircraft

Registration
N9428G
Reported as
Cessna U206E
Category
Airplane
Serial number
U20601628
Airframe hours
9,467
Engine
Cont Motor IO-520-F, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Positioning · Part 91
Operator
Rugby Aviation LLC, doing business as Northwest Sky Ferry
Registered owner
Aircraft Adventures LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · November 21, 2008 · 26 hours before
Departed
FHR · Friday Harbor, WA
Destination
None · Crane Island, WA
Flight plan
Company VFR
Airport
None · Crane Island, San Juan Island, runway 12, 1,350 × 60 ft, grass/turf

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
29
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
June 26, 2008
Seat
Left
Flight hours
1,600 total · 200 in this make and model · 1,324 as pilot in command · 124 in the last 90 days · 13 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Visibility
10 statute miles
Lowest ceiling
6,000 ft broken
Temperature
48 °F
Altimeter
30.54 inHg
Observed at
FHR, 5 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.

Other investigations on N9428G · 2

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