# NTSB WPR10CA101: Cessna 195B, N2171C, Palm Springs, CA, January 7, 2010 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Data collection · Final report - Date: January 7, 2010, 13:00 local (21:00 UTC) - Place: Palm Springs, CA - Coordinates: 33.626667, -116.159446 - Nearby events: https://openairdocs.org/map.md?lat=33.6267&lon=-116.1594&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report March 23, 2010 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: FAA FSDO - NTSB case key (mKey): 75245 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR10CA101 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/75245/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=75245 - Page: https://openairdocs.org/ntsb/WPR10CA101 ## Probable cause The pilot's improper use of brakes during landing. ## 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 · Incorrect use/operation (probable cause); cases with it: [Cessna 195B, 1 case](https://openairdocs.org/ntsb-findings/01023240/cases.md?model=2073112), [All aircraft, 92 cases](https://openairdocs.org/ntsb-findings/01023240/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 195B, 3 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=2073112), [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 roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096) (defining event); cases with it: [Cessna 195B, 4 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=2073112), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The commercial pilot reported that he was landing the tailwheel-equipped airplane on a dry, hard-surfaced runway. He stated that during the landing rollout, as he was transitioning his feet from the bottom of the rudder pedals to the top, he applied too much brake pressure and the airplane nosed over. He further stated that he suffers from diabetic neuropathy and did not initially realize how much brake pressure he applied. The airplane sustained substantial damage to the fuselage and the tail assembly. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane. The pilot does not possess a current Federal Aviation Administration medical certificate. ## Factual narrative The commercial pilot reported he was landing the tail wheel-equipped airplane on a dry, hard-surfaced runway. He stated that during the landing roll out, as he was transitioning his feet from the bottom of the rudder pedals to the top, he applied too much brake pressure and the airplane nosed over. He further stated that he suffers from diabetic neuropathy and did not initially realize how much brake pressure he applied. The airplane sustained substantial damage to the fuselage and tail assembly. The pilot reported that there were no pre-accident mechanical failures or malfunctions with the airplane. The pilot does not possess a current FAA medical certificate. ## Aircraft - Registration: [N2171C](https://openairdocs.org/deregistered/N2171C-2018-03-01), registration cancelled 2018-03-01, S/N 16156, built 1954 (OpenAirDocs) - Reported make and model: CESSNA 195B - Registry model: [Cessna 195B](https://openairdocs.org/model/cessna-195b) (registry code 2073112) (OpenAirDocs) - Registry engine: [Jacobs R755B series](https://openairdocs.org/engine/jacobs-r755b-series) (registry code 35007, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 16156 - Engines: JACOBS R755B SERIES 275 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Danny R. Brignac - Registered owner: Danny R. Brignac - Airworthiness certificate: Standard, Normal - Last inspection: Annual, April 30, 2009 - Departed: KPVF, Placerville, CA - Destination: KTRM, Palm Springs, CA - Airport: KTRM, Jacqueline Cochran Regional, runway 17, 8,500 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 61; injuries: minor; commercial, airline transport; airplane ratings: single-engine sea, multi-engine land, single-engine land, multi-engine sea; instrument ratings: airplane; seat: left; flight hours: 19,600 total, 5 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none ## 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 20100107025919A](https://openairdocs.org/incident/20100107025919A), Jan 7, 2010: Cessna 195B, Thermal, CA, Substantial damage. On landing rollout, pilot applied to much pressure to the brake pedals subsequently causing the aircraft to flip straight over its nose onto its back ## Other investigations on N2171C (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 LAX93LA205](https://openairdocs.org/ntsb/LAX93LA205), May 9, 1993: Cessna 195B (N2171C), Placerville, CA, substantial damage. Probable cause: THE UNRELIABILITY OF THE NORMAL BRAKE SYSTEM AND THE LEAKING MASTER CYLINDER - [NTSB DEN7LFTE11](https://openairdocs.org/ntsb/DEN7LFTE11), Aug 6, 1975: Cessna 195 (N2171C), Denver, CO, substantial damage ## Docket (1 files) The files NTSB released with the investigation on January 25, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=75245. 804 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 804 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324391&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.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.