# NTSB WPR09LA168: Cessna 182Q, N97467, Sedona, AZ, March 28, 2009 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: March 27, 2009, 17:15 local (Mar 28, 2009, 00:15 UTC) - Place: Sedona, AZ - Coordinates: 34.843055, -111.796112 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.8431&lon=-111.7961&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing: Landing area overshoot](https://openairdocs.org/ntsb-events/380) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report November 9, 2009 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Scottsdale FSDO - NTSB case key (mKey): 73568 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR09LA168 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73568/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73568 - Page: https://openairdocs.org/ntsb/WPR09LA168 ## Probable cause The pilot's failure to achieve the proper touchdown point during a full-stop landing attempt. Contributing to the accident were the pilot's failure to ensure that the aircraft was properly configured for landing, his not initiating a go-around, and a malfunction in one of the main landing gear braking systems. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Landing gear system: landing gear brakes system](https://openairdocs.org/ntsb-findings/01023240): Aircraft › Aircraft systems · Malfunction (probable cause); cases with it: [Cessna 182Q, 1 case](https://openairdocs.org/ntsb-findings/01023240/cases.md?model=2072732), [All aircraft, 92 cases](https://openairdocs.org/ntsb-findings/01023240/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 182Q, 15 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2072732), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Performance/control parameters: descent/approach/glide path](https://openairdocs.org/ntsb-findings/01062040): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 182Q, 5 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md?model=2072732), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/01062040/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 182Q, 34 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2072732), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Flight control system: tE flap control system](https://openairdocs.org/ntsb-findings/01022750): Aircraft › Aircraft systems · Incorrect use/operation; cases with it: [Cessna 182Q, 2 cases](https://openairdocs.org/ntsb-findings/01022750/cases.md?model=2072732), [All aircraft, 74 cases](https://openairdocs.org/ntsb-findings/01022750/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 182Q, 6 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=2072732), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing: Landing area overshoot](https://openairdocs.org/ntsb-events/380) (defining event); cases with it: [Cessna 182Q, 3 cases](https://openairdocs.org/ntsb-events/380/sequence.md?model=2072732), [All aircraft, 400 cases](https://openairdocs.org/ntsb-events/380/sequence.md) - [Landing-landing roll: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330); cases with it: [Cessna 182Q, 2 cases](https://openairdocs.org/ntsb-events/330/sequence.md?model=2072732), [All aircraft, 994 cases](https://openairdocs.org/ntsb-events/330/sequence.md) - [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Cessna 182Q, 17 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=2072732), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 182Q, 28 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072732), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis While making a visual-flight-rules approach to a full-stop landing, the pilot was distracted by the thermal turbulence and inadvertently allowed his final approach to be high, long, and fast. He therefore executed a go-around. During the go-around the pilot did not feel the expected sinking of the airplane when he repositioned the cockpit flap control. Because he did not feel the sinking sensation, and because he had not visually confirmed the position of the flaps at any time since entering the pattern, the pilot incorrectly assumed that the flaps were not functioning properly. He therefore elected to make his second landing with the flaps still in the position they were at after the go-around (ultimately determined to be 10 percent). During the second approach he inadvertently landed about 80 percent of the way down the runway, and then attempted to stop the airplane with maximum braking. During the braking attempt, the brake on the left main gear did not provide any braking action. Before the pilot could get it stopped, the airplane departed the end of the runway, impacted a fence, and nosed over onto its back. A postaccident functionality test determined that the flaps were working properly. A Federal Aviation Administration inspector examined the left brake system and determined that the left pedal master cylinder was low on fluid. The examination also determined that very little braking or pedal resistance was present when the brake pedal was pushed toward its applied position, and there was likely very little, if any, left wheel braking action during the pilot's attempt to stop the airplane after landing long. ## Factual narrative On March 27, 2009, about 1715 mountain standard time, a Cessna 182Q, N97467, hit a fence and nosed over after departing the end of the runway during a landing at Sedona Airport, Sedona, Arizona. The airline transport pilot, who was the sole occupant, was not injured, but the airplane, which was registered to Linear Management Corporation, sustained substantial damage. The 14 Code of Federal Regulations Part 91 cross-country positioning flight, which departed Cable Airport, Upland, California, about 1430 Pacific daylight time, was being operated in visual meteorological conditions. No flight plan had been filed. During the investigation the NTSB Investigator-In-Charge (IIC) and the Federal Aviation Administration (FAA) Inspector who assisted with the investigation both conducted follow-up interviews with the pilot in order to clarify the sequence of events that he provided on the day of the accident and in the narrative of the NTSB Form 6120.1 that he submitted. According to the information derived from these interviews, when the pilot entered the downwind for runway 21 at Sedona, he selected a flap position of ten degrees, but because he was distracted by nearby hilly terrain and the presence of thermal turbulence, he did not visually confirm the position of the flaps. According to the pilot, when he turned onto final, he selected a flap position of 30 degrees, but once again did not visually check their position because of the distraction created by the turbulence. He further stated that although he did not visually check their position, he assumed the flaps were at 30 degrees on final, and at that point in time did not suspect any anomaly associated with the flap system. As he continued his final approach, the pilot realized that he was coming in too high, fast, and long, so he decided to execute a go-around. At the beginning of the go-around he repositioned the flaps to the 20 degree position, but reportedly did not feel the sinking sensation that he normally associated with a partial retraction of the flaps. According to the pilot, because of the profile of his final approach, and since he did not feel the sinking sensation that he expected on the go-around, he thought that it was possible that the flaps might not be operating properly. Based upon that possibility, and because he had not visually confirmed their position at any time since entering the pattern, the pilot decided to leave the flaps where they were for the second approach. During the second approach, the pilot proceeded as if he were making a no-flap landing, establishing an airspeed on final around 70 to 75 knots. Reportedly, his flare during this approach was near the halfway point of the runway, and he eventually touched down at the 4,000 foot point of the 5,183 foot long runway. He then attempted to apply maximum braking, but the brake pedal on the left brake rotated forward to its fully applied position with almost no resistance, and no braking action occurred at the leftwheel. The pilot then tried to stop the airplane with only the one functional brake, but was unable to do so before the airplane exited the end of the runway. After the airplane departed the runway, it impacted a perimeter fence and nosed over onto its back. An on-scene inspection found the flaps at 10 degrees. After the accident, when the pilot was advised by the FAA that they were going to go inspect the airplane, he stated that they would find the flap handle in the 10 degree position, and that he thought the flaps were probably at 10 degrees during the second approach. In a further interview with the NTSB IIC, the pilot stated that the flaps were most likely functioning properly during both of his approaches, but that the turbulence may have masked that fact. During a post-accident function test performed by the airplane's owner, the flaps operated normally in all selector switch positions. In addition, the pilot reported that since he had not flown this airplane before this flight, prior to departure he performed a functionality check on all the airplane's systems, and no anomalies had been found. As part of the investigation, an FAA Inspector inspected the left brake system, and it was determined that the left pedal master cylinder was low on fluid. It was also determined that very little braking or pedal resistance was present when the brake pedal was pushed toward its applied position, and according to the Inspector there was likely very little, if any, left wheel braking action during the pilot's attempt to stop the airplane after landing long. ## Aircraft - Registration: [N97467](https://openairdocs.org/aircraft/N97467), registered now, S/N 18267104, built 1979 (OpenAirDocs) - Reported make and model: CESSNA 182Q - Registry model: [Cessna 182Q](https://openairdocs.org/model/cessna-182q) (registry code 2072732) (OpenAirDocs) - Registry engine: [Continental O-470 series](https://openairdocs.org/engine/continental-o-470-series) (registry code 17026, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 18267104 - Airframe hours: 867 - Engines: CONT MOTOR O-470 SERIES 230 horsepower reciprocating - Damage: Substantial damage - Flight: Positioning, Part 91 - Operator: Cody W. Greaves - Registered owner: Linear Management Corp - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 1, 2008 - Departed: KCCB, Upland, CA - Destination: KSEZ, Sedona, AZ - Airport: KSEZ, Sedona, runway 21, 5,183 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 29; injuries: none; flight instructor, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review January 25, 2009; seat: left; flight hours: 3,170 total, 27 in this make and model, 1,375 as pilot in command, 111 in the last 90 days, 30 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: variable at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 50 °F - Altimeter: 30.00 inHg ## 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 20090327004089A](https://openairdocs.org/incident/20090327004089A), Mar 27, 2009: Cessna 182Q, Sedona, AZ, Substantial damage. (-23) On 03/27/09 the pilot landed on ruwnay 21 at Sedona Airport, on touchdown the pilot lost control of the aircraft and went off the end of the ruwnay. As… ## Docket (2 files) The files NTSB released with the investigation on July 3, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73568. 609 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 553 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314327&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Record of Conversation (item 2, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314328&FileExtension=.PDF&FileName=Record%20of%20Conversation-Master.PDF 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.