# NTSB CEN12LA023: Piper PA-28-235, N9444W, Wadsworth, OH, October 8, 2011 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: October 8, 2011, 13:00 local (17:00 UTC) - Place: Wadsworth, OH - Coordinates: 41.028331, -81.798332 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.0283&lon=-81.7983&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330) - Highest injury: No injuries - Injuries: 4 uninjured - Status: Completed, report January 18, 2012 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Admininstration - NTSB case key (mKey): 82083 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN12LA023 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/82083/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=82083 - Page: https://openairdocs.org/ntsb/CEN12LA023 ## Probable cause The failure of the brake system during the landing roll, which was caused by a loss of hydraulic fluid as a result of a leak in the piston seal due to brake plates worn beyond their service limits. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Landing gear system: brake](https://openairdocs.org/ntsb-findings/01023242): Aircraft › Aircraft systems · Failure (probable cause); cases with it: [Piper PA-28-235, 1 case](https://openairdocs.org/ntsb-findings/01023242/cases.md?model=7102810), [All aircraft, 297 cases](https://openairdocs.org/ntsb-findings/01023242/cases.md) - [Maintenance](https://openairdocs.org/ntsb-findings/02062000): Personnel issues › Task performance · Maintenance personnel; cases with it: [Piper PA-28-235, 1 case](https://openairdocs.org/ntsb-findings/02062000/cases.md?model=7102810), [All aircraft, 143 cases](https://openairdocs.org/ntsb-findings/02062000/cases.md) - [Object/animal/substance: runway/taxi/approach light](https://openairdocs.org/ntsb-findings/03022012): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-28-235, 2 cases](https://openairdocs.org/ntsb-findings/03022012/cases.md?model=7102810), [All aircraft, 106 cases](https://openairdocs.org/ntsb-findings/03022012/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-landing roll: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330) (defining event); cases with it: [Piper PA-28-235, 2 cases](https://openairdocs.org/ntsb-events/330/sequence.md?model=7102810), [All aircraft, 994 cases](https://openairdocs.org/ntsb-events/330/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-235, 35 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102810), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Piper PA-28-235, 14 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=7102810), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) ## Analysis The pilot reported that, prior to the flight, he noted no anomalies with the airplane or its braking system. After touchdown, the pilot applied the brakes to slow the airplane to exit the runway, but the airplane did not slow down. The airplane then departed the runway surface and the right wing contacted the visual approach slope indicator system. The airplane came to rest upright adjacent to the runway. A postaccident examination of the airplane revealed that the left brake caliper was leaking hydraulic fluid; no fluid was found in the brake system’s reservoir. Hydraulic fluid was then added to the reservoir, and a leak was noticed at the brake caliper without any brake pressure being applied to the system. The brake caliper and brake plates were removed and the brake plates were found to be worn beyond service limits, which resulted in an overextension of the brake piston and failure of the piston seal. The failure of the piston seal resulted in the loss of hydraulic fluid. ## Factual narrative On October 8, 2011, approximately 1300 eastern daylight time, a Piper PA-28-235 single-engine airplane, N9444W, sustained substantial damage when it impacted the visual approach slope indicator equipment during landing at Weltzien Skypark Airport (15G), Wadsworth, Ohio. The commercial pilot and three passengers were not injured. The airplane was registered to a private individual and operated by the pilot. Visual meteorological conditions prevailed, and a flight plan was not filed for the 14 Code of Federal Regulations Part 91 personal flight. The flight departed Parkersburg, West Virginia, approximately 1215. According to the pilot, he and the passengers departed 15G earlier in the day to attend a breakfast in Parkersburg. The pilot reported that prior to the flight to Parkersburg and the return flight to Wadsworth, no anomalies were noted with the airplane and its brake system. After touchdown at 15G, the pilot applied the brakes to slow the airplane to exit the runway and "nothing happened." The airplane departed the runway surface, and the right wing contacted the visual approach slope indicator (VASI) system. The airplane came to rest upright adjacent to the runway. Postaccident examination of the airplane by the Federal Aviation Administration inspectors and the airplane owner revealed the left brake caliper was leaking fluid, and no fluid was noted in the brake system reservoir. Fluid was then added to the reservoir and a leak was noticed at the brake caliper without any brake pressure being applied to the system. The brake caliper and brake plates were removed. The brake plates showed that they were worn beyond service limits, which resulted in an over extension of the brake piston and failure of the piston seal. The failure of the piston seal resulted in the loss of hydraulic fluid. A review the airframe logbooks showed the most recent annual inspection was completed in March 2011. The brakes were replaced in 2008 and no additional entries in the logbooks were noted that specified the brake system. Since 2008, the airplane had completed approximately 55 landings, and 12 landings since the most recent annual inspection. ## Aircraft - Registration: [N9444W](https://openairdocs.org/aircraft/N9444W), registered now, S/N 28-11163, built 1969 (OpenAirDocs) - Reported make and model: PIPER PA-28-235 - Registry model: [Piper PA-28-235](https://openairdocs.org/model/piper-pa-28-235) (registry code 7102810) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-11163 - Airframe hours: 4964 - Engines: LYCOMING IO-540-B405 235 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 1, 2011 - Departed: PKB, Parkersburg, WV - Destination: 15G, Wadsworth, OH - Airport: 15G, Weltzien Skypark Airport, runway 21, 2,410 × 37 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 69; injuries: none; flight instructor, commercial, private; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review June 3, 2011; seat: left; flight hours: 6,900 total, 210 in this make and model, 6,714 as pilot in command, 52 in the last 90 days, 31 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Visibility: 6 statute miles - Lowest ceiling: none - Temperature: 50 °F - Observed at: BJJ, 10 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20111008025569A](https://openairdocs.org/incident/20111008025569A), Oct 8, 2011: Piper PA-28-235, Wadsworth, OH, Substantial damage. Aircraft enroute from uni to 15G, landed 15G runway 3 without incident. On rollout pilot attempted to apply brakes, there was no braking action. Emergency… ## Docket (3 files) The files NTSB released with the investigation on December 1, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=82083. 3.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 267 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40359020&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Photo - Brake System Components (item 2, .PDF, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40359022&FileExtension=.PDF&FileName=Photo%20-%20Brake%20System%20Components-Master.PDF - Record of Conversation - FAA Inspector (item 3, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40359023&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20FAA%20Inspector-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.