Individually Owned: 150,657
Corporate Owned: 137,281
Meadows Field Airport
Aircraft Accident/Incident Report
Bakersfield, California 93308
Thursday, March 10, 2011 7:45 PST
NTSB Narrative Summary Released at Completion of Accident
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.
NTSB Probable Cause Narrative
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.
Event Information
| Type of Event | Accident |
| Event Date | 3/10/2011 |
| Event Day of the Week | Thursday |
| Time of Event | 745 |
| Event Time Zone | Pacific Standard Time |
| Event City | Bakersfield |
| Event State | CALIFORNIA |
| Event Country | -- |
| Zipcode of the event site | 93308 |
| Event Date Year | 2011 |
| Event Date Month | 3 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | 352531N |
| Event Location Longitude | 1190225W |
| Event Location Airport | Meadows Field Airport |
| Event Location Nearest Airport ID | BFL |
| Indicates whether the acc/inc occurred off or on an airport | On Airport |
| Distance from airport in statute miles | 1 |
| Degrees magnetic from airport | -- |
| Airport Elevation | 510 |
| Weather Briefing Completeness | -- |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 754 Pacific Standard Time |
| Direction of event from weather observation facility (degrees) | -- |
| Weather Observation Facility ID | BFL |
| Elevation of weather observation facility | -- |
| Distance of event from weather observation facility (units?) | 1 |
| Time Zone of the weather observation | PST |
| Lighting Conditions | Day |
| Lowest Ceiling Height | -- |
| Lowest Non-Ceiling Height | -- |
| Sky/Lowest/Cloud Conditions | Clear |
| Sky Condition for Lowest Ceiling | None |
| Visibility Runway Visual Range (Feet) | -- |
| Visibility Runway Visual Value (Statute Miles) | -- |
| Visibility (Statute Miles) | 5 |
| Air Temperature at event time (in degrees celsius) | 12 |
| Dew Point at event time (in degress fahrenheit) | 8 |
| Wind Direction (degrees magnetic) | 120 |
| Variable Wind Indicator | Wind direction could be determined |
| Wind Speed (knots) | 5 |
| Wind Velocity Indicator | -- |
| Wind Gust Indicator | Not Gusting |
| Wind Gust (knots) | -- |
| Altimeter Setting at event time (in. Hg) | 30.21 |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | -- |
| METAR weather report | METAR KBFL 101554Z 12005KT 5SM HZ CLR 12/08 A3021 |
| Event Highest Injury | None |
| On Ground, Fatal Injuries | -- |
| On Ground, Minor Injuries | -- |
| On Ground, Serious Injuries | -- |
| Injury Total Fatal | -- |
| Injury Total Minor | -- |
| Injury Total None | 1 |
| Injury Total Serious | -- |
| Injury Total All | -- |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 32565 |
| NTSB Notification Source | WP ROC |
| NTSB Notification Date | -- |
| NTSB Notification Time | -- |
| Fiche Number and/or location -used to find docket information | -- |
| Date of most recent change to record | Apr 16 2014 6:31PM |
| User who most recently changed record | stam |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N930FE |
| NTSB Number | WPR11FA158 |
| Missing Aircraft Indicator | -- |
| Federal Aviation Reg. Part | Part 135: Air Taxi & Commuter |
| Type of Flight Plan filed | IFR |
| Flight plan Was Activated? | Yes |
| Damage | Substantial |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | CESSNA |
| Aircraft Model | 208B |
| Aircraft Series Identifier | -- |
| Aircraft Serial Number | 208B0030 |
| Certified Max Gross Weight | -- |
| Aircraft Category | Airplane |
| Aircraft Registration Class | -- |
| Aircraft is a homebuilt? | No |
| Flight Crew Seats | -- |
| Cabin Crew Seats | -- |
| Passenger Seats | -- |
| Total number of seats on the aircraft | 12 |
| Number of Engines | 1 |
| Fixed gear or retractable gear | Fixed |
| Aircraft, Type of Last Inspection | AAIP |
| Date of Last Inspection | Dec 17 2011 12:00AM |
| Airframe hours since last inspection | -- |
| Airframe Hours | 10532 |
| ELT Installed | Yes |
| ELT Activated | No |
| ELT Aided Location of Event Site | Unknown |
| ELT Type | C126 |
| Aircraft Owner Name | FEDERAL EXPRESS CORPORATION |
| Aircraft Owner Street Address | VP SUPPLEMENTAL AIR OPERATIONS |
| Aircraft Owner City | MEMPHIS |
| Aircraft Owner State | TN |
| Aircraft Owner Country | USA |
| Aircraft Owner Zipcode | 38118-1547 |
| Operator is an individual? | No |
| Operator Name | West Air, Inc. |
| Operator Same as Owner? | No |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | No |
| Operator Street Address | 5005 E. Andersen Ave. |
| Operator City | Fresno |
| Operator State | CA |
| Operator Country | USA |
| Operator Zip code | 93727 |
| Operator Code | AWHA |
| Owner has at least one certificate | Yes - certificate holder |
| Other Operator of large aircraft? | -- |
| Certified for Part 133 or 137 Operation | -- |
| Operator Certificate Number | -- |
| Indicates whether an air carrier operation was scheduled or not | Non-scheduled |
| Indicates Domestic or International Flight | Domestic |
| Operator carrying Pax/Cargo/Mail | Cargo |
| Type of Flying (Per_Bus / Primary) | -- |
| Second Pilot on Board | No |
| Departure Point Same as Event | No |
| Departure Airport Code | ONT |
| Departure City | Ontario |
| Departure State | CA |
| Departure Country | USA |
| Departure Time | 642 |
| Departure Time Zone | PST |
| Destination Same as Local Flt | crash at destination city |
| Destination Airport Code | BFL |
| Destination City | Bakersfield |
| Destination State | CA |
| Destination Country | USA |
| Specific Phase of Flight | -- |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Apr 16 2014 6:31PM |
| User who most recently changed record | stam |
| Since inspection or accident | Last Inspection |
| Event Location Runway Number and Location | 30R |
| Runway Length | 10855 |
| Runway Width | 150 |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |