Pilot Debrief

CESSNA 425 near Bismarck, ND — 2023-02-06

Final reportCEN23LA103
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Date
2023-02-06
Location
Bismarck, ND, USA
Airport
KBIS
Aircraft
CESSNA 425
Registration
N425Z
Category
Airplane
Highest injury
Minor
Fatalities
0
Phase of flight
Ground

Probable cause

A loss of braking due to inadequate servicing of brake fluid by the pilot/mechanic, which resulted in a loss of airplane control on the ground.

NTSB narrative

The pilot taxied to the ramp after an uneventful flight. After moving the throttles toward the ground idle position while in front of the marshaller, the airplane turned left, and the pilot observed that the right brake was inoperative. He attempted to stop the airplane by placing both propeller levers to the feather position and subsequently moved both throttles toward the reverse (beta) position. The airplane continued forward and struck a hangar, which resulted in substantial damaged to the left wing. Postaccident examination of the braking system revealed the brake master cylinders were nearly empty of brake fluid, with no leaks observed. The pilot, who was also a mechanic, recorded completion of a phase inspection about nine months before the accident. The inspection included servicing the brake master cylinders, but the pilot reported he did not check the fluid levels of the master cylinders.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Pilot did not check brake fluid levels during the Phase 3 inspection.

NTSB coding

Evidence available

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

Docket documents6

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