# NTSB CHI04LA080: Piper PA-28-236, N8438B, Bourbon, IN, February 28, 2004 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: February 28, 2004, 10:30 local (15:30 UTC) - Place: Bourbon, IN - Coordinates: 41.364444, -86.063331 - Nearby events: https://openairdocs.org/map.md?lat=41.3644&lon=-86.0633&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report February 24, 2005 - Report: Approved by Office Director - Parties: FAA - NTSB case key (mKey): 58842 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI04LA080 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58842/pdf - Page: https://openairdocs.org/ntsb/CHI04LA080 ## Probable cause The inadequate annual inspection in that the worn brake disks were not replaced which resulted in diminished braking capability during the landing roll. A factor associated with the accident was the utility pole that the airplane contacted. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Overrun, landing - roll - maintenance,annual inspection - inadequate, other maintenance personnel (cause) - landing gear,normal brake system - worn (cause) - brakes(normal) - diminished (cause) - remedial action - attempted, pilot in command - On ground/water collision with object, landing - roll - object - utility pole (contributing factor) ## Analysis The airplane contacted a utility pole during an overrun landing on a 1,280 foot long, damp, upsloping grass airstrip. The pilot stated he touched down with the throttle at idle, in a full stall with full flaps and noticed he was having difficulty slowing the airplane. The pilot reported he applied "stand-on-the-brakes emergency stopping pressure," but he only received minimal braking. The airplane continued off the airstrip, across a country road, and onto a concrete driveway where the left wing contacted a utility pole swinging the airplane around 90 degrees prior to it stopping. Tire marks in the grass revealed the right main gear touched down 272 feet past the runway threshold and the left main touched down 42 feet later. The airplane traveled 30 feet 6 inches past the departure end of the airstrip prior to contacting the utility pole. The pilot reported that although tire marks were visible on the airstrip, the only skid marks visible were when the airplane spun around after contacting the pole. The pilot purchased the airplane on October 1, 2003. The last annual inspection was dated September 27, 2003. The airframe logbook indicates that new brake linings were installed at the last annual inspection. The pilot reported he flew the airplane 46 hours prior to the accident. The pilot reported he did not experience any problems with the brakes prior to this accident. Examination of the airplane revealed the brake disks were worn to the point that they were concave. The inspector reported that only 20 percent of the brake pads were in contact with the disks. ## Factual narrative On February 28, 2004, about 1030 eastern standard time, a Piper PA-28-236, N8438B, operated by a commercial pilot, sustained substantial damage when it contacted a utility pole during a landing roll at the Rust Landing Airstrip (II95) in Bourbon, Indiana. The flight was operated under 14 CFR Part 91. Visual meteorological conditions prevailed at the time of the accident. The pilot and one passenger sustained no injuries. The local flight originated at the airstrip in Bourbon, Indiana, at 0945. The pilot reported he used runway 09 (1,280 feet by 80 feet, grass) for the landing. He reported the grass runway was damp, not wet, and there is a slight upslope while landing to the east. The pilot reported the local winds were from 160 degrees at 5 miles per hour. He stated he touched down with the throttle at idle, in a full stall with full flaps and noticed he was having difficulty slowing the airplane. The pilot reported he applied "stand-on-the-brakes emergency stopping pressure," but he only received minimal braking. The airplane continued off the airstrip, across a country road, and onto a concrete driveway where the left wing contacted a utility pole swinging the airplane around 90 degrees prior to it stopping. The pilot reported that according to tire marks on the airstrip, the right main gear touched down 272 feet past the runway threshold and the left main touched down 42 feet later. The airplane traveled 30 feet 6 inches past the departure end of the airstrip prior to contacting the utility pole. The pilot reported that although tire marks were visible on the airstrip, the only skid marks visible were when the airplane spun around after contacting the pole. Examination of the airplane by an inspector from the Federal Aviation Administration South Bend, Indiana, Flight Standards District Office revealed the brake disks (rotors) were worn to the point that they were concave. The inspector reported that only 20 percent of the brake pads were in contact with the disks. The pilot purchased the airplane on October 1, 2003. The last annual inspection was dated September 27, 2003. The airframe logbook indicates that new brake linings were installed at the last annual inspection. The pilot reported he flew the airplane 46 hours prior to the accident. Logbook records show the brake disks were last replaced on January 7, 1994. The airplane had been operated 994 hours since that time. The pilot reported he did not experience any problems with the brakes prior to this accident. ## Aircraft - Registration: [N8438B](https://openairdocs.org/deregistered/N8438B-2024-10-29), registration cancelled 2024-10-29, S/N 28-8211002, built 1981 (OpenAirDocs) - Reported make and model: Piper PA-28-236 - Registry model: [Piper PA-28-236](https://openairdocs.org/model/piper-pa-28-236) (registry code 7102815) (OpenAirDocs) - Registry engine: [Lycoming O-540-J3A5D](https://openairdocs.org/engine/lycoming-o-540-j3a5d) (registry code 42358, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-8211002 - Airframe hours: 1790 - Engines: Lycoming O-540-J3A5D 235 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Universal Safety Associates, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 27, 2003, 46 hours before - Departed: II95, Bourbon, IN - Destination: II95, Bourbon, IN - Airport: II95, Rust Landing Airstrip, runway 09, 1,280 × 80 ft, grass/turf ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 51; injuries: none; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; last flight review July 6, 2003; seat: left; flight hours: 1,300 total, 40 in this make and model, 1,222 as pilot in command, 5 in the last 90 days, 1 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 200° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 43 °F, dew point 30 °F - Altimeter: 30.04 inHg - Observed at: KASW, 17 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 20040228006169A](https://openairdocs.org/incident/20040228006169A), Feb 28, 2004: Piper PA28236, Bourbon, IN, Substantial damage. (-23) Accident investigation revealed excessive brake wear. About 20% brake surface being utilized on both brake discs combined. Last annual inspection did… ## Other investigations on N8438B (1) 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. - [NTSB CEN24LA144](https://openairdocs.org/ntsb/CEN24LA144), Apr 1, 2024: Piper PA28 (N8438B), Muncie, IN, destroyed, 1 fatal. Probable cause: The pilot’s spatial disorientation and subsequent loss of control while maneuvering outside established instrument approach procedures in instrument meteorological conditions, which resulted in an… 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.