WPR18LA094

NTSB accident investigation · Soko Galeb G 2 · Elko, NV · February 21, 2018

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
February 21, 2018, 10:15 local (18:15 UTC)
Place
Elko, NV
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N90SRSoko Galeb G 2
Defining event
Approach: Sys/Comp malf/fail (non-power)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20180221002939A
Case key
96779

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

An improperly installed brake cylinder, which resulted in insufficient hydraulic pressure being provided to three of the brake cylinders and the left brake being inoperable during landing.

Findings · 1

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.

Landing gear system: brakeAircraft › Aircraft systems · FailureSoko GALEB G-2: 1 caseAll aircraft: 297 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 pilot reported that, upon initial landing the airplane, the left brake was inoperative, and he chose to conduct a go-around and set up for a single-brake landing. The subsequent landing was uneventful, but the left brake was still inoperative. The pilot reported that, with about 1,500 ft of runway remaining, he chose to veer the airplane off the runway to the right to avoid running off the end. Subsequently, the airplane struck a drainage ditch berm, which resulted in substantial damage to the fuselage. Examination and disassembly of the hydraulically driven left brake assembly revealed that the No. 2 brake cylinder had not been properly installed, which allowed the brake pucks to move and resulted in three of them separating from the brake assembly. The separation of the brake pucks resulted in the No. 2 cylinder's piston being moved to the full-scale inward position. Subsequently, the No. 2 cylinder's piston then fully deflected, which resulted in a hydraulic leak that subsequently led to insufficient hydraulic pressure being provided to the other brake cylinders and subsequently to the left brake being inoperative during landing.

Factual narrative

On February 21, 2018, about 1015 Pacific standard time, an experimental, amateur-built G-2 airplane N90SR, sustained substantial damage when it was involved in an accident near Elko, Nevada. The pilot sustained serious injuries. The airplane was operated as a 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, upon landing, the airplane's left brake was inoperative, and he chose to conduct a go-around and set up for a single-brake landing. The subsequent landing was uneventful; however, the left brake was still inoperative. The pilot reported that, with about 1,500 ft of runway, he chose to veer to the right off the runway surface to avoid running off the end. Subsequently, the airplane struck a drainage ditch berm. The wheel brake system was hydraulically driven, and each brake operated independently from the front or rear cockpit and from the right or left side. A hydraulic fluid reservoir was located in the front cockpit, and its quantity was indicated in a fluid quantity window. Examination of the airplane revealed that the fuselage had sustained substantial damage and that the nose and left main landing gear struts had separated from the airplane. When the right brake pedal was depressed, continuity to the right brake was established; however, when the left brake pedal was depressed, hydraulic fluid moved through the brake lines and expelled from a severed portion of the lines under the left wing. The hydraulic fluid reservoir located on the front cockpit’s left side contained a normal quantity of fluid, and the fluid quantity window indicated between the maximum and minimum level. No hydraulic fluid leaks were noted in the cockpit area or on the interior or exterior of the left wing. Hydraulic fluid was noted on the left main landing wheel area. The fluid was clear and red and appeared to be fresh. Additionally, three separated brake pucks were found in the left wheel area. Examination of the left brake assembly revealed that the separated ends of the hydraulic lines were still secured and appropriately safety wired. Two brake rotors were found loose, and the No. 2 brake cylinder worn pin indicator was recessed. The other three brake cylinders’ wear pins were found in the normal position. Disassembly of the No. 2 brake cylinder revealed that it was not properly installed, which allowed the brake pucks to move. The movement of the brake pucks resulted in three of them separating from the brake assembly. The separation of the brake pucks could result in the No. 2 cylinder's piston being moved to the full-scale, inward position. Subsequently, the full-scale deflection of the No. 2 cylinder's piston could result in a hydraulic leak and cause insufficient hydraulic pressure to be provided to the other brake cylinders, rendering the brake inoperative. According to the airport manager’s report and a review of photographs of the accident site, during the landing, the airplane exited the runway with about 1,675 ft ofrunway remaining.

Aircraft

Registration
N90SR
Reported as
Soko Galeb G 2 (A)
Category
Airplane
Serial number
FVSG23107
Built
1966
Airframe hours
3,000
Engine
Rolls Royce Viper 2Mk22/6, 2,500 lbs thrust, turbo jet
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Annual · July 13, 2017
Departed
RTS · Reno, NV
Destination
EKO · Elko, NV
Flight plan
VFR
Airport
EKO · Elko Rgnl, runway 06, 7,454 × 150 ft, asphalt
Equipment
Handheld GPS

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
60
Injuries
Serious
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Waiver time limited special
Last flight review
June 5, 2017
Seat
Front
Restraint
5-point
Flight hours
21,800 total · 45 in this make and model · 14,800 as pilot in command · 65 in the last 90 days · 25 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
7,500 ft broken
Temperature
25 °F, dew point 5 °F
Altimeter
30.09 inHg
Observed at
EKO

Docket · 5

The files NTSB released with the investigation on March 4, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.4 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.