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Atlas / NTSB / CEN23LA103

NTSB CAROL · Event

Event CEN23LA103

2023-02-06 Bismarck, North Dakota, United States Airport · KBIS Minor 1 aircraft Status: Completed

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 ↗.

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.

Browse the full corpus — academia portal ↗