CEN19LA314

NTSB accident investigation · Piper PA28 · Colorado Springs, CO · September 11, 2019

Accident · No injuriesClass 3 · LimitedFinal report
Date
September 11, 2019, 13:15 local (19:15 UTC)
Place
Colorado Springs, CO
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Taxi
Aircraft
N8384EPiper PA28
Defining event
Taxi: Fire/smoke (non-impact)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Federal Aviation Administration; DEN FSDO
FAA report
20190911014569A
Case key
100234

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot's improper taxi speed and his excessive use of brakes, which resulted in a brake fire and substantial thermal damage to the airplane.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Landing gear system: brakeAircraft › Aircraft systems · Capability exceededPiper PA-28-181: 5 casesAll aircraft: 297 casesProbable cause
Action: incorrect action performancePersonnel issues › Action/decision · PilotPiper PA-28-181: 11 casesAll aircraft: 1,386 casesProbable cause
Aircraft capability: braking capabilityAircraft › Aircraft oper/perf/capability · Capability exceededPiper PA-28-181: 1 caseAll aircraft: 57 casesProbable cause
Performance/control parameters: surface speed/brakingAircraft › Aircraft oper/perf/capability · Incorrect use/operationPiper PA-28-181: 3 casesAll aircraft: 238 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotPiper PA-28-181: 10 casesAll aircraft: 1,391 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot was taxiing the airplane to a parking ramp after landing when the airplane lost left and right main landing gear braking effectiveness. The pilot continued the taxi and planned on performing turning maneuvers to slow the airplane enough to make a right turn onto the next taxiway and to perform 360° turns, if needed, to stop the airplane. When he tried two shallow turns to slow the airplane, he heard a loud bang and the airplane veered left and stopped. When he exited the airplane, he saw that the left brake was on fire. Postaccident examination of the airplane revealed fire damage that extended from the left main landing gear wheel brake assembly to the left wing structure. There was also thermal damage to the right main wheel brake assembly. Examination revealed no mechanical anomalies of the airplane brake system that would have precluded normal operation. It is likely that the pilot's excessive taxi speed and use of braking resulted in a brake fire while taxiing.

Factual narrative

**This report was modified on January 15, 2020. Please see the public docket for this accident to view the original report.** On September 11, 2019, at 1315 mountain daylight time, a Piper PA-28-181 airplane, N8384E, experienced a left main landing gear fire during landing rollout at City of Colorado Springs Municipal Airport (COS), Colorado Springs, Colorado. The commercial pilot and a passenger were uninjured, and the airplane left wing sustained substantial damage. The airplane was registered to G & M Aircraft Inc, used as a rental airplane by Rocky Mountain Flight School, and was operated by the pilot under Title 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed at the time of the accident. The flight originated from Tradewind Airport (TDW), Amarillo, Texas, at 1131 central daylight time, and was destined to COS. The pilot stated he landed the airplane on runway 35R and taxied off at E5. He was cleared by air traffic control (ATC) to taxi to general aviation via taxiways E and H and cleared to cross runway 35L. He said that being unfamiliar with the airport, he taxied north on taxiway E. He said ATC asked him to pick up the pace, if able, and he responded that he could make room ahead if needed. He stated that as the airplane exited taxiway E onto H, near taxiway P, he noticed the brakes were no longer available. He tried the emergency brake [parking brake], but it was unresponsive. He planned on performing "zig-zags" to slow the airplane down enough to make right turn onto the next taxiway and to perform 360° turns, if he needed to stop the airplane since the ramp looked clear. When he tried two shallow zig-zags to slow the airplane down, he heard a loud bang and the airplane veered left. He stomped on the rudder which had little effect and it seemed not even about second later when he heard the passenger yell "fire." When he exited the airplane, he saw that the left main landing gear was on fire. The pilot stated that there was a mechanical malfunction/failure of the brakes. According to the Federal Aviation Administration (FAA) inspector assigned to the accident investigation, the pilot stated in his initial conversation with the FAA inspector that he probably rode the airplane brakes longer than he should have, but later stated that it was a normal landing and he hardly touched the brakes. The pilot, following the issuance of the factual report, stated that the statement by the FAA inspector was "incorrect," and he "never said that [he] applied the brakes too hard." The airplane brake system consisted of toe brakes on each rudder pedal with brake cylinders for each toe brake. The left toe brake master cylinder independently controlled the left main landing gear wheel brake, and the right toe brake master cylinder independently controlled the right main landing gear wheel brake. The parking brake cylinder simultaneously controlled the left and right main landing gear wheels.Post-accident examinations by a FAA inspector and the National Transportation Safety Board (NTSB) Investigator-in-Charge (IIC) revealed the presence of fire damage that extended from the left main landing gear wheel brake assembly to the left wing structure and thermal damage from the right main wheel brake assembly. There were no mechanical anomalies of the airplane brake system that would have precluded normal operation. Post-accident examination of the airplane brakes by the NTSB IIC, revealed that all the rudder pedal brake cylinders and the parking brake cylinder were attached and secure. When the rudder pedal brakes and parking brake were exercised using hand pressure applied to the rudder pedals and parking brake control, there was no binding in movement of the their respective actuator springs, and all the springs returned to their uncompressed positions each time the brakes and parking brake were exercised. There were no mechanical anomalies of the airplane brake system that would have precluded normal operation. The FAA's Airplane Flying Handbook (FAA-H-8083-3B), Chapter 2, Ground Operations, stated in part: "A safe taxiing speed must be maintained. The primary requirements for safe taxiing are positive control, the ability to recognize any potential hazards in time to avoid them, and the ability to stop or turn where and when desired, without undue reliance on the brakes. Pilots should proceed at a cautious speed on congested or busy ramps. Normally, the speed should be at the rate where movement of the airplane is dependent on the throttle. That is, slow enough so when the throttle is closed, the airplane can be stopped promptly."

Aircraft

Registration
N8384E
Reported as
Piper PA28 (181)
Category
Airplane
Serial number
28-8190236
Built
1981
Airframe hours
5,052
Engine
Lycoming O-360-A1D, 180 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Operator
Pilot, doing business as Rocky Mountain Flight School
Registered owner
G & M Aircraft Inc
Airworthiness certificate
Standard, Normal; Standard, Utility
Last inspection
Annual · September 9, 2019
Departed
TDW · Amarillo, TX
Destination
COS · Colorado Springs, CO
Airport
COS · City of Colorado Springs Munic, runway 35R, 13,501 × 150 ft, concrete

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
33
Injuries
None
Certificates
Private, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
June 14, 2019
Seat
Right
Restraint
3-point
Flight hours
407 total · 242 in this make and model · 270 as pilot in command · 15 in the last 90 days · 14 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
200° at 20 knots, gusting 26
Visibility
10 statute miles
Lowest ceiling
None
Temperature
82 °F, dew point 34 °F
Altimeter
30.03 inHg
Observed at
COS

Docket · 6

The files NTSB released with the investigation on December 12, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.2 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.