WPR23LA076

NTSB accident investigation · Cessna 210N · Morgan, UT · December 26, 2022

Accident · No injuriesClass 3 · LimitedFinal report
Date
December 26, 2022, 16:45 local (23:45 UTC)
Place
Morgan, UT · airport environment
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N210CUCessna 210N
Defining event
Landing-landing roll: 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
20221226019859A
Case key
106498

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

Failure of the brake system O-rings on the left landing gear trunnion, which allowed the hydraulic fluid to drain from the left brake system, resulting in a runway excursion and impact with a fence.

Findings · 4

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 · InoperativeCessna 210N: 1 caseAll aircraft: 297 casesProbable cause
Fluids: hydraulic fluidAircraft › Fluids/misc hardware · Fluid levelCessna 210N: 1 caseAll aircraft: 33 casesProbable cause
Performance/control parameters: directional controlAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleCessna 210N: 1 caseAll aircraft: 3,958 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 a failure of the left brake during the landing roll. The airplane departed the runway surface and impacted a fence, which cause substantial damage to the empennage, right elevator, and horizontal stabilizers. Postaccident examination of the brake system revealed that the left brake master cylinder reservoir was completely empty. It was serviced and tested with no failure or leaks identified. Further examination of the brake system included the removal of the main landing gear pivot trunnion. It revealed that the O-rings, while not visibly damaged, were flat and stiff, which likely allowed the brake fluid to leak out from the main landing gear trunnion to the actuator interface joint when the landing gear was retracted.

Factual narrative

On December 26, 2022, at 1645 mountain standard time, a Cessna 210N, N210CU, was substantially damaged when it was involved in an accident at Morgan County Airport (42U), Morgan, Utah. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot of the airplane reported that, after conducting an uneventful flight to Spanish Fork, Utah, he then flew to 42U. He landed normally, and after the nose landing gear touched down, he began to apply the brakes. The pilot stated that the left pedal “had zero pressure” when he applied the brakes, He stated that he pumped the left brake to “pump the brake up,” but that did not work. The pilot stated at that point, there was not enough time to safely reconfigure the airplane for a go-around. He maintained runway centerline with steering and the right brake until the airplane eventually departed the runway surface and impacted a fence. The empennage, right elevator, and horizontal stabilizers sustained substantial damage. The pilot stated that there had been a recurring issue with the left brake and maintenance was performed to correct the malfunction. Since that time, he had flown more than 10 hours with over 25 takeoffs and landings without any issue. The pilot further reported that he did not see hydraulic fluid on the airplane’s undercarriage. Postaccident examination of the brake system revealed that when the left brake was actuated there was no pressure and did not function properly. The right brake operated normally when brake force was applied. The seats and floor panels were removed to facilitate further inspection of the brakes. The left brake master cylinder was removed and disassembled with no evidence of a hydraulic fluid leak of the master cylinder or brake lines in the forward cabin subfloor area. However, the left master cylinder reservoir was completely empty of hydraulic fluid. The O-ring and master cylinder were in a serviceable condition. The brake system was reassembled and serviced with fluid. The left brake was activated with a maximum pressure applied for 5 minutes with no failure or leakages identified. The left landing gear leg and pivot assembly were removed, and the O-rings from the brake fluid transition assembly were undamaged, normally shaped, and flexible to the touch. The main landing gear pivot trunnion was disassembled, and the O-rings did not have visible damage; however, they appeared “flattened and stiff.” There was a significant amount of brake fluid under the aft cabin floor in front of the bulkhead forward of the landing gear door and brake line pivot fitting.

Aircraft

Registration
N210CU
Reported as
Cessna 210N
Category
Airplane
Serial number
21064452
Built
1981
Airframe hours
2,501
Engine
Continental IO-550-F, 310 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Condition · September 25, 2022
Departed
SPK · Spanish Fork, UT
Destination
Same as departure
Airport
42U · Morgan County, runway 21, 3,904 × 50 ft, asphalt
Equipment
Electronic multifunction display, Electronic flight bag or handheld device, Auto-pilot, ADS-B, Stall warning system, Electronic primary flight display

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
22
Injuries
None
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
April 27, 2022
Seat
Left
Restraint
3-point
Flight hours
973.2 total · 64.1 in this make and model · 648.6 as pilot in command · 79.2 in the last 90 days · 20.5 in the last 30 days · 3.6 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
41 °F, dew point 34 °F
Altimeter
30.17 inHg
Observed at
KHIF, 9 nm away
METAR
METAR KHIF 262355Z AUTO 00000KT 10SM CLR 05/01 A3017 RMK AO2 SLP215 T00520006 10079 20034 55014 FZRANO $=

Docket · 4

The files NTSB released with the investigation on June 20, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 11.8 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.