# NTSB WPR09CA084: Cessna U206E, N9428G, Crane Island, San Juan Is., WA, January 14, 2009 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: January 14, 2009, 10:15 local (18:15 UTC) - Place: Crane Island, San Juan Is., WA - Coordinates: 48.596389, -122.995552 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=48.5964&lon=-122.9956&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report April 15, 2009 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 73241 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR09CA084 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73241/pdf - Page: https://openairdocs.org/ntsb/WPR09CA084 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Runway/land/takeoff/taxi surface: wet surface](https://openairdocs.org/ntsb-findings/03023010): Environmental issues › Physical environment · Effect on operation; cases with it: [Cessna U206E, 1 case](https://openairdocs.org/ntsb-findings/03023010/cases.md?model=2073350), [All aircraft, 141 cases](https://openairdocs.org/ntsb-findings/03023010/cases.md) - [Airport facilities/design: runway/landing area length](https://openairdocs.org/ntsb-findings/03017037): Environmental issues › Operating environment · Effect on operation; cases with it: [Cessna U206E, 1 case](https://openairdocs.org/ntsb-findings/03017037/cases.md?model=2073350), [All aircraft, 34 cases](https://openairdocs.org/ntsb-findings/03017037/cases.md) - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna U206E, 1 case](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=2073350), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Landing gear system: brake](https://openairdocs.org/ntsb-findings/01023242): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Cessna U206E, 1 case](https://openairdocs.org/ntsb-findings/01023242/cases.md?model=2073350), [All aircraft, 297 cases](https://openairdocs.org/ntsb-findings/01023242/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna U206E, 2 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2073350), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna U206E, 1 case](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=2073350), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Cessna U206E, 1 case](https://openairdocs.org/ntsb-events/230/sequence.md?model=2073350), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Landing-landing roll: Abnormal runway contact](https://openairdocs.org/ntsb-events/090); cases with it: [Cessna U206E, 1 case](https://openairdocs.org/ntsb-events/090/sequence.md?model=2073350), [All aircraft, 1,506 cases](https://openairdocs.org/ntsb-events/090/sequence.md) ## 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](https://openairdocs.org/aircraft/N9428G), registered now, S/N U20601628, built 1970 (OpenAirDocs) - Reported make and model: CESSNA U206E - Registry model: [Cessna U206E](https://openairdocs.org/model/cessna-u206e) (registry code 2073350) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: U20601628 - Airframe hours: 9467 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 29; injuries: none; 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 (OpenAirDocs). - [Accident 20090114000349A](https://openairdocs.org/incident/20090114000349A), Jan 14, 2009: Cessna U206E, Crane Island, WA, Substantial damage. Crane Island airport is a Private runway, 1270’, with wet grass at the time of the accident. Airman landed the aircraft with insufficient runway remaining to… ## Other investigations on N9428G (2) 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. - [NTSB SEA05LA141](https://openairdocs.org/ntsb/SEA05LA141), Jul 8, 2005: Cessna 206E (N9428G), Stuart Island, WA, substantial damage. Probable cause: The pilot's excessive airspeed on final for the current runway surface conditions, and the intentional obstruction avoidance maneuver he executed when it became clear the aircraft was about to go off… - [NTSB SEA98LA034](https://openairdocs.org/ntsb/SEA98LA034), Oct 9, 1997: Cessna U-206E (N9428G), Friday Harbor, WA, substantial damage. Probable cause: the pilot's failure to park with the aircraft headed into the wind in high wind conditions. A factor include the high wind condition. 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.