# NTSB CEN19LA314: Piper PA28, N8384E, Colorado Springs, CO, September 11, 2019

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Class 3 · Limited · Final report
- Date: September 11, 2019, 13:15 local (19:15 UTC)
- Place: Colorado Springs, CO
- Coordinates: 38.805831, -104.700836 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=38.8058&lon=-104.7008&mi=10
- Phase of flight: [Taxi](https://openairdocs.org/ntsb-phases/250) (OpenAirDocs' grouping)
- Defining event: [Taxi: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150)
- Highest injury: No injuries
- Injuries: 2 uninjured
- Status: Completed
- Report: Approved by Office Director
- Investigation class: Class 3
- NTSB office: Central Region
- Parties: Federal Aviation Administration; DEN FSDO
- NTSB case key (mKey): 100234
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19LA314
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100234/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100234
- Page: https://openairdocs.org/ntsb/CEN19LA314

## 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

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 · Capability exceeded (probable cause); cases with it: [Piper PA-28-181, 5 cases](https://openairdocs.org/ntsb-findings/01023242/cases.md?model=7102807), [All aircraft, 297 cases](https://openairdocs.org/ntsb-findings/01023242/cases.md)
- [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-181, 11 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=7102807), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md)
- [Aircraft capability: braking capability](https://openairdocs.org/ntsb-findings/01061050): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Piper PA-28-181, 1 case](https://openairdocs.org/ntsb-findings/01061050/cases.md?model=7102807), [All aircraft, 57 cases](https://openairdocs.org/ntsb-findings/01061050/cases.md)
- [Performance/control parameters: surface speed/braking](https://openairdocs.org/ntsb-findings/01062045): Aircraft › Aircraft oper/perf/capability · Incorrect use/operation (probable cause); cases with it: [Piper PA-28-181, 3 cases](https://openairdocs.org/ntsb-findings/01062045/cases.md?model=7102807), [All aircraft, 238 cases](https://openairdocs.org/ntsb-findings/01062045/cases.md)
- [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-181, 10 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7102807), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Taxi: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150) (defining event); cases with it: [Piper PA-28-181, 5 cases](https://openairdocs.org/ntsb-events/150/sequence.md?model=7102807), [All aircraft, 504 cases](https://openairdocs.org/ntsb-events/150/sequence.md)

## 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](https://openairdocs.org/aircraft/N8384E), registered now, S/N 28-8190236, built 1981 (OpenAirDocs)
- Reported make and model: Piper PA28 (181)
- Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (OpenAirDocs)
- Registry engine: [Lycoming 0-360-A1D](https://openairdocs.org/engine/lycoming-0-360-a1d) (registry code 41504, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 28-8190236
- Year built: 1981
- Airframe hours: 5052
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 33; injuries: none; 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

## 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 20190911014569A](https://openairdocs.org/incident/20190911014569A), Sep 11, 2019: Piper PA-28-181, Colorado Spring, CO, Substantial damage. On 09/11/2019 at 1315 MDT, a single engine Piper PA-28-181, N8384E, was substantially damaged by fire after the aircraft landed at the Colorado springs, CO…

## Docket (6 files)

The files NTSB released with the investigation on December 12, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100234. 3.2 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478998&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF
- Mechanic's Statements (item 2, .PDF, 325 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478999&FileExtension=.PDF&FileName=Mechanic%27s%20Statements-Master.PDF
- Record of Conversation - FAA (item 3, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479000&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20FAA-Master.PDF
- Record of Examination (item 4, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479001&FileExtension=.PDF&FileName=Record%20of%20Examination-Master.PDF
- COS ASOS Reports (item 5, .PDF, 100 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479002&FileExtension=.PDF&FileName=COS%20ASOS%20Reports-Master.PDF
- Factual Narrative Changes (item 6, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479953&FileExtension=.PDF&FileName=Factual%20Narrative%20Changes-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.

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