Pilot Debrief

CESSNA 182Q near Sedona, AZ — 2009-03-28

Final reportWPR09LA168
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Date
2009-03-28
Location
Sedona, AZ, USA
Airport
KSEZ
Aircraft
CESSNA 182Q
Registration
N97467
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Approach

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.

NTSB narrative

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.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot did not visually confirm flap positions before final approach.

NTSB coding

Evidence available

  • 2 docket documents
View NTSB final reportView NTSB docket

Docket documents2

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