Accident Cessna 208B Grand Caravan N930FE, Thursday 10 March 2011
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Date:Thursday 10 March 2011
Time:07:45
Type:Silhouette image of generic C208 model; specific model in this crash may look slightly different    
Cessna 208B Grand Caravan
Owner/operator:West Air, Inc.
Registration: N930FE
MSN: 208B0030
Year of manufacture:1987
Total airframe hrs:10532 hours
Engine model:P&W PT6A SERIES
Fatalities:Fatalities: 0 / Occupants: 1
Other fatalities:0
Aircraft damage: Substantial
Category:Accident
Location:Meadows Field Airport, Bakersfield, California -   United States of America
Phase: Taxi
Nature:Cargo
Departure airport:Ontario, CA (ONT)
Destination airport:Bakersfield, CA (BFL)
Investigating agency: NTSB
Confidence Rating: Accident investigation report completed and information captured
Narrative:
The pilot of the cargo flight reported that, after landing at the destination airport, he taxied about 1.9 miles using the customary route toward the assigned cargo unloading area. The airplane turned right and then left without experiencing any anomalies. The pilot then applied full right rudder and brake pressure to negotiate the last 90-degree turn; however, the airplane did not turn as expected and subsequently impacted two trucks and a van. A witness reported that the airplane's taxi speed appeared normal throughout its approach and final turn.

The examination of the accident master brake cylinders and the cylinders from two other airplanes that had reportedly failed revealed several anomalies that could have caused or contributed to the airplane's failure to turn as expected. The examination revealed that the right pedal assembly may interfere with the adjacent floorboard when the brake pedal is compressed to or near the full-internal cylinder travel stop, which may cause an additional stop and limit the overall travel of the cylinder. The examination also revealed that numerous components or items may prevent the master brake cylinders from fully extending after the brakes are released and adequate travel (reduced pressure) when the brakes are subsequently actuated. Additionally, the examination revealed that the brake fluid may bypass the piston O-ring or Stat-O-Seal if parts are damaged or excessively worn. The cylinder manufacturer, in conjunction with the FAA, published Service Bulletin CAB-32-01, Revision 1, to address the noted mechanical anomalies.
Probable Cause: The malfunction of a master brake cylinder, which resulted in a loss of braking action and subsequent loss of directional control and collision with three vehicles during taxi. Contributing to the accident was the inappropriate design and manufacture of the master brake cylinders.

Accident investigation:
cover
  
Investigating agency: NTSB
Report number: WPR11FA158
Status: Investigation completed
Duration: 3 years and 2 months
Download report: Final report

Sources:

NTSB
FAA register: 2. FAA: http://registry.faa.gov/aircraftinquiry/NNum_Results.aspx?NNumbertxt=930FE

4. https://flightaware.com/live/flight/PCM8662/history/20110310/1445Z/KONT/KBFL

Location

Revision history:

Date/timeContributorUpdates
10-Mar-2011 20:55 bizjets101 Added
11-Mar-2011 10:09 gregory Updated [Narrative]
13-Dec-2016 23:18 Dr. John Smith Updated [Time, Location, Departure airport, Destination airport, Source, Narrative]
21-Dec-2016 19:25 ASN Update Bot Updated [Time, Damage, Category, Investigating agency]
27-Nov-2017 16:46 ASN Update Bot Updated [Operator, Other fatalities, Departure airport, Destination airport, Source, Narrative]

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