Aviation Accident Summaries

Aviation Accident Summary ERA19LA268

St. Augustine, FL, USA

Aircraft #1

N5300E

Beech K35

Analysis

The pilot was conducting a personal flight when, about halfway through the landing rollout and before the pilot could apply the brakes, the airplane suddenly veered to the right. The pilot attempted to correct the veer with left pedal and brake but was unsuccessful. The airplane departed the runway into the grass, struck a berm, flipped over, and came to rest inverted. The airplane sustained substantial damage to the forward fuselage, horizontal stabilizers, and left ruddervator. Postaccident examination of the airplane revealed that the right main landing gear tire had a flat spot in its tread that was worn to the reinforcement chords. The tire left a black skid mark on the runway that led from the right edge to the grass, consistent with a locked right wheel. The wheel rotated smoothly during recovery of the airplane; therefore, damage or malfunction of the wheel’s bearings was unlikely. The airplane did not have the optional copilot-side brake pedals installed. Examination of the brake system revealed that the brakes functioned normally; however, the right caliper was found to have some play between the two anchor bolts and their bushings in the torque plate. Excessive caliper play can result in too much clearance between the brake pads and the brake disc. The excessive clearance can cause the brake pads to shift out of place and jam against the brake disc, which could result in an unintended brake application. Disassembly and further examination of the primary brake system components revealed no other anomalies that would have precluded normal operation. Therefore, the right brake was likely applied unintentionally due to the play between the caliper anchor bolts and their bushings. The play likely developed due to wear on the anchor bolts, the bushings, or both.

Factual Information

On September 11, 2019, about 1730 eastern daylight time, a Beech K35, N5300E, was involved in an accident at Northeast Florida Regional Airport (SGJ), St. Augustine, Florida. The commercial pilot and pilot-rated passenger sustained minor injuries, and the airplane was substantially damaged. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. According to the pilot, about halfway through the landing rollout on runway 13, the airplane suddenly veered to the right with the engine power at idle. She attempted to correct the turn with left pedal and brake but was unsuccessful. She confirmed with the pilot-rated passenger that the power was at idle. The airplane departed the runway into the grass, struck a berm, flipped over, and came to rest inverted. The pilot further stated that the veer to the right occurred before she could apply the brakes or retract the flaps from the 10° position. The airplane did not have the optional copilot-side brake pedals installed. The airplane’s most recent brake maintenance was performed on January 24, 2019, the same day as the airplane’s most recent annual inspection (when the airframe had accrued a total time of 6,462 flight hours). During that maintenance, the right brake caliper was replaced. The airplane had flown about 60 hours since that time. A Federal Aviation Administration inspector examined the wreckage and the accident site. The examination revealed substantial damage to the fuselage forward of the windscreen, both horizontal stabilizers, and the left ruddervator. A black skid mark was found on the runway that led from the right edge of the runway to the grass. Both wheel brakes and ruddervators and the nosewheel steering functioned normally when the rudder pedals were pressed. The parking brake was found disengaged. Visual inspection of the brake components revealed no mechanical or thermal damage to the brake discs, calipers, or pad material. No hydraulic leaks were visible on any of the fittings or components. Both main landing gear wheels rolled smoothly when the airplane was moved during recovery. The right main landing gear tire had a flat spot worn through the reinforcement cords in the tire tread. Review of a video clip that the pilot provided revealed that the right brake caliper had some play between the two anchor bolts (often called “pins”) and the bushings in the torque plate (the flange to which the caliper is attached). The caliper shifted about the bolts when moved by hand in a twisting motion. The right brake master cylinder was removed and disassembled. The o-rings were intact with no signs of leakage. The return spring was intact. The cylinder exhibited no scoring or signatures of abnormal wear. The poppet valve operated normally. The parking brake actuator valve was sent to the NTSB’s Materials Laboratory for examination. The valve operated normally when compressed air was applied to the inlet port. The valve was then dissembled. The o-ring was intact, and the spring-loaded ball, ball seat, and plunger were undamaged. The plunger moved freely when the actuator arm was moved back and forth.

Probable Cause and Findings

An unintended brake application of the right main landing gear brake system during the landing rollout due to excessive play between the brake caliper anchor bolts and their bushings.

 

Source: NTSB Aviation Accident Database

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