NTSB CAROL · Event
Event CEN23LA103
Aircraft involved
Probable cause & findings
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.
Factual narrative
On February 6, 2023, about 1545 central standard time, a Cessna 425, N425Z, was substantially damaged when it was involved in an accident at Bismarck Municipal Airport (BIS), Bismarck, North Dakota. The pilot was not injured and the two passengers sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported an uneventful flight and landing at BIS. After taxiing to the ramp, the pilot proceeded to stop the airplane in front of a marshaller. After moving the throttles toward the ground idle position, the pilot observed the airplane turn left and reported that the right brake was inoperative. The pilot reported moving 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 substantially damaged the left wing. Postaccident examination of the braking system revealed the brake master cylinders were nearly empty of brake fluid, with no leaks observed. A review of maintenance logs revealed that the pilot, who was also a mechanic, recorded completion of the Phase 3 inspection of the Cessna 425 maintenance manual on May 21, 2022. The Phase 3 inspection includes servicing the brake master cylinders. The pilot/mechanic reported that during this inspection he checked the brake pads and checked for leaks around the brakes and the master cylinders. He depressed the brake pedals to find there was resistance; however, he reported that he did not check the fluid levels of the master cylinders during the inspection. 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. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).
- — Personnel issues-Action/decision-Action-Incorrect action selection-Pilot
- — Personnel issues-Task performance-Maintenance-Scheduled/routine maintenance-Maintenance personnel
- — Aircraft-Aircraft systems-Landing gear system-Landing gear brakes system-Incorrect service/maintenance
- — Environmental issues-Physical environment-Object/animal/substance-Residence/building-Effect on equipment
- — Aircraft-Fluids/misc hardware-Fluids-(general)-Fluid level
Verbatim from NTSB's published report. Source file
NTSB_2023_CEN23LA103.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (icing, maintenance). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- Embry-Riddle Scholarly Commons 2023 · Faculty research project
Reconfigurable Guidance and Control Systems for Emerging On-Orbit Servicing, Assembly, and Manufacturing (OSAM) Space Vehicles
Dynamic response to emergent situations is a necessity in the on-orbit servicing, assembly, and manufacturing (OSAM) field, because traditional on-orbit guidance and control (G&C) cannot respond effic…
- Embry-Riddle Scholarly Commons 2019 · Journal article (IJAAA)
Satellite Maintenance: An Opportunity to Minimize the Kessler Effect
Recently, there has been an emphasis on the growing problem of orbital debris. While the advantages of placing satellites into space are numerous, advances in satellite technology combined with the gr…
- Embry-Riddle Scholarly Commons 2015 · Conference paper
The Implementation of Safety Management Systems in Maintenance Operations
Literature for Safety Management Systems (SMS) that apply to flight operations is abundant, but there is a limited supply of SMS-related literature for maintenance operations.
- Embry-Riddle Scholarly Commons 2026 · Journal article (IJAAA)
From Reactive to Predictive: A hybrid Trust-Mediated Adoption Framework for Data-Driven Maintenance in Distributed-Authority Aviation Environments
Modern aviation maintenance operates within increasingly data-intensive technological environments, yet the operational integration of predictive maintenance into routine decision-making remains incon…
- NASA NTRS 2026 · Contractor Report (CR)
Icing Physics Studies Using the 3D SIDRM Test Article: 2023 Icing Tests Analysis
In-flight icing is an important safety issue and is a factor that affects aircraft design and performance. Newer regulations are driving a need for improvements in airframe and engine icing simulation…
- arXiv 2025 · arXiv preprint
Multi-Agent Deep Reinforcement Learning for UAV-Assisted 5G Network Slicing: A Comparative Study of MAPPO, MADDPG, and MADQN
The growing demand for robust, scalable wireless networks in the 5G-and-beyond era has led to the deployment of Unmanned Aerial Vehicles (UAVs) as mobile base stations to enhance coverage in dense urb…
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