Pilot Debrief

CESSNA 414 near Leadville, CO — 2024-07-04

Final reportCEN24LA329
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Date
2024-07-04
Location
Leadville, CO, USA
Airport
LXV
Aircraft
CESSNA 414
Registration
N1652T
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Landing

Probable cause

A loss of brake fluid for reasons that could not be determined, which resulted in a loss of braking effectiveness during landing.

NTSB narrative

The pilot reported that the airplane’s brake system operated normally during the startup, taxi, and takeoff; however, while landing at the destination airport, he attempted to apply the brakes; however, there was no pressure on the brake pedals and no braking was available. There was also no pressure available on the co-pilot’s brake pedals. The airplane rolled the length of the runway. The pilot attempted to turn onto the perpendicular taxiway at the end of the runway, but the airplane departed the pavement and the nose landing gear collapsed. The nose landing gear trunnion and wheel well structure sustained substantial damage during the accident sequence. An examination of the brake system revealed that the left brake master cylinder was nearly empty and no pressure from the brake pedal to the wheel caliper was available. The right brake master cylinder contained about 1/4-inch of fluid remaining. Pressure to the wheel caliper was obtained with about three-quarter deflection of the brake pedal. The brake lines and calipers did not exhibit any evidence of leakage, and free movement of the caliper pistons was observed. Both the left and right brake linings exhibited minimal remaining thickness with signs of overheating. Airplane maintenance records noted that the landing gear was worked on during the most recent annual inspection, which was completed about two months before the accident. The pilot reported that the airplane had flown about 40 hours since the inspection. The mechanic who conducted the annual inspection reported that the brakes were inspected and no anomalies were observed at that time. Although the runway excursion was a result of the loss of brake fluid, the exact reason for the loss of brake fluid during the flight could not be determined.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Pilot could have checked brake fluid levels before the flight.

NTSB coding

Evidence available

  • Photos
  • 5 docket documents
View NTSB final reportView NTSB docket

Docket documents5

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