Sunday, April 14, 2019

Nose Over: Cessna 140, N1902V, accident occurred July 26, 2018 at Healdsburg Municipal Airport (KHES), Sonoma County, California

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Oakland, California

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

http://registry.faa.gov/N1902V

Location: Healdsburg, CA
Accident Number: GAA18CA455
Date & Time: 07/26/2018, 1100 PDT
Registration: N1902V
Aircraft: Cessna 140
Aircraft Damage: Substantial
Defining Event: Nose over/nose down
Injuries: 2 None
Flight Conducted Under: Part 91: General Aviation - Personal 

Analysis 

According to the pilot in the tailwheel-equipped airplane, he had performed two previous touch-and-go takeoffs and landings. During the third landing roll, the tailwheel settled on the runway, and then the airplane nosed over. He reported that he was “not certain whether I accidentally stepped on the brakes or the brakes seized."

The airplane sustained substantial damage to the vertical stabilizer and the rudder.

A Federal Aviation Administration inspector’s postaccident examination of the brake system revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's improper brake application during the landing roll, which resulted in a nose-over. 

Findings

Aircraft
Brake - Incorrect use/operation (Cause)

Personnel issues
Aircraft control - Pilot (Cause)

Factual Information

History of Flight

Landing-landing roll
Abnormal runway contact

Nose over/nose down (Defining event)

Pilot Information

Certificate: Private
Age: 70, Male
Airplane Rating(s):  Multi-engine Land; Multi-engine Sea; Single-engine Land; Single-engine Sea
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: Lap Only
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 03/28/2017
Occupational Pilot: No
Last Flight Review or Equivalent: 04/10/2017
Flight Time:  (Estimated) 4800 hours (Total, all aircraft), 4 hours (Total, this make and model), 4800 hours (Pilot In Command, all aircraft), 5 hours (Last 30 days, all aircraft), 2 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: Cessna
Registration: N1902V
Model/Series: 140 Undesignated
Aircraft Category: Airplane
Year of Manufacture: 1947
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 14093
Landing Gear Type: Tailwheel
Seats: 2
Date/Type of Last Inspection: Annual
Certified Max Gross Wt.: 1450 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 4333.5 Hours
Engine Manufacturer: Continental
ELT: Installed, not activated
Engine Model/Series: C85
Registered Owner: On file
Rated Power: 104 hp
Operator: On file
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KSTS, 114 ft msl
Distance from Accident Site: 10 Nautical Miles
Observation Time: 1753 UTC
Direction from Accident Site: 155°
Lowest Cloud Condition: Clear
Visibility:  9 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: Light and Variable /
Turbulence Type Forecast/Actual: /
Wind Direction: Variable
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 29.99 inches Hg
Temperature/Dew Point: 21°C / 12°C
Precipitation and Obscuration: Moderate - Smoke; No Obscuration; No Precipitation
Departure Point: Healdsburg, CA (HES)
Type of Flight Plan Filed: None
Destination: Healdsburg, CA (HES)
Type of Clearance: None
Departure Time: 1045 PDT
Type of Airspace: Class G

Airport Information

Airport: Healdsburg Muni (HES)
Runway Surface Type: Asphalt
Airport Elevation: 280 ft
Runway Surface Condition: Dry
Runway Used: 13
IFR Approach: None
Runway Length/Width: 2652 ft / 60 ft
VFR Approach/Landing:  Stop and Go; Traffic Pattern

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: 1 None
Aircraft Fire:  None
Ground Injuries: N/A
Aircraft Explosion:  None
Total Injuries:  2 None
Latitude, Longitude:  38.652778, -122.898611 (est)

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