# NTSB ERA15LA186: Piper PA-28-235, N8803W, Woodstock, GA, March 21, 2015 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: March 21, 2015, 18:07 local (22:07 UTC) - Place: Woodstock, GA - Coordinates: 34.105834, -84.448333 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.1058&lon=-84.4483&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report May 16, 2016 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA, Piper Aircraft - NTSB case key (mKey): 91032 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA15LA186 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91032/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91032 - Page: https://openairdocs.org/ntsb/ERA15LA186 ## Probable cause The pilot's failure to attain the proper touchdown point on the short, wet, turf runway. Contributing to the accident was the pilot’s use of a high approach speed. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-235, 28 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102810), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-235, 16 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7102810), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Runway/land/takeoff/taxi surface: wet surface](https://openairdocs.org/ntsb-findings/03023010): Environmental issues › Physical environment · Effect on operation (probable cause); cases with it: [Piper PA-28-235, 1 case](https://openairdocs.org/ntsb-findings/03023010/cases.md?model=7102810), [All aircraft, 141 cases](https://openairdocs.org/ntsb-findings/03023010/cases.md) - [Performance/control parameters: descent/approach/glide path](https://openairdocs.org/ntsb-findings/01062040): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-28-235, 5 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md?model=7102810), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/01062040/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-28-235, 7 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7102810), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Performance/control parameters: surface speed/braking](https://openairdocs.org/ntsb-findings/01062045): Aircraft › Aircraft oper/perf/capability · Not attained/maintained; cases with it: [Piper PA-28-235, 1 case](https://openairdocs.org/ntsb-findings/01062045/cases.md?model=7102810), [All aircraft, 238 cases](https://openairdocs.org/ntsb-findings/01062045/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: Runway excursion](https://openairdocs.org/ntsb-events/300) (defining event); 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 airline transport pilot was conducting a personal cross-country flight. The pilot reported that he landed the airplane with the flaps fully extended on the short, wet, turf runway and that the hand-actuated brakes were ineffective at touchdown but that they became effective after he pumped them several times with about 300 ft of runway remaining. A witness at the airport reported that the airplane was "too high for the approach and too fast" and that the airplane touched down midfield and then "bounced-ballooned" down the runway, skidding on the turf each time it touched down. The airplane continued off the departure end of the runway, traveled down an embankment, nosed over, and then came to rest inverted. Intermittent tire skid marks from about midfield (1,000 ft) to the crash site were visible, consistent with the witness's statement. About 8.5 flight hours before the accident, the brakes were replaced, and the brake fluid system was bled. According to the airplane manufacturer, although the method that the mechanic reported that he used to bleed the brakes was not in accordance with the manufacturer's maintenance manual, it achieved the desired results, and the airplane owner stated that the performance of the brakes since their replacement was satisfactory. Postaccident examination of the brake handle revealed that there was no pressure when the brake handle was actuated but that brake pressure would build if the handle was pumped. The airplane's brake reservoir was open at the top, and the fill line for the reservoir was well below the top of the container, which would have allowed air in the system to escape. Consequently, during the time the airplane was inverted following the accident, the air that had been in the top of the reservoir was trapped and moved to the highest point in the system, which was the brake calipers. Brake fluid would have continued to leak from the system and been replaced by air until the airplane was returned to the upright position. Because of trapped air in the system, the brakes did not function normally until the air was removed and the fluid replaced when the handle was pumped during postaccident testing. ## Factual narrative On March 21, 2015, at 1807 eastern daylight time, a Piper PA-28-235, N8803W, was substantially damaged during a runway excursion and nose-over event after landing at Air Acres Airport (5GA4), Woodstock, Georgia. The airline transport pilot and the passenger/owner were not injured. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight, which was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. The flight departed Monroe-Walton County Airport (D73), Monroe, Georgia, about 1735.In a written statement, the pilot said the accident flight was a return flight from D73 after he had performed glider-tow flights in another airplane there. While on final approach for landing to runway 36, the pilot detected a tailwind, and visually confirmed his suspicion by smoke trails off small fires nearby. He elected to go around, and return for a landing on runway 18. The pilot stated his approach airspeed was 80 to 85 miles per hour (MPH), and that he slipped the airplane to a firm landing in order to begin braking "as soon as possible" on the wet, turf runway, which was 2,000 feet long. The pilot felt no "pressure" or braking action when he actuated the brake handle. Pressure in the system built as he pumped the brake handle, and braking action was restored when about 300 feet of the runway remained. The airplane departed the end of the runway, traveled down an embankment, nosed over, and came to rest inverted. The pilot stated that he elected not to abort the landing because of the obstacles and a water treatment plant off the departure end of runway 18. According to one witness, whose home was midfield at 5GA4, the airplane completed an approach downwind and subsequently performed a go-around. He decided to reposition to the edge of the runway, and watch the second landing attempt. The witness said that, while on short final at the north end of the field, the pilot appeared to be "cross-controlling into a slip to possibly try to lose altitude. The aircraft was too high for the approach and too fast." The witness stated the airplane touched down on its nose landing gear about midfield, "bounced-ballooned" into the air, and continued about 300 yards before it touched down again. The airplane remained in ground effect, and each time it touched down it skidded on the runway until it skidded off the departure end and nosed over. Examination of photographs revealed that fresh, visible skid marks began about the mid-point of the runway, and continued intermittently off the departure end, consistent with the witness's statement. The Federal Aviation Administration (FAA) inspector who responded to the accident described the runway as "a wet grass surface." The pilot held an airline transport pilot certificate with a rating for airplane multi-engine land, and a commercial pilot certificate with a rating for airplane single engine land. He reported 28,500 total hours of flight experience, of which 250hours were in the accident airplane make and model. His most recent FAA second class medical certificate was issued in March 2015. Examination of the airplane by the FAA inspector revealed substantial damage to the vertical fin and empennage. The flaps were fully extended. There was "no pressure" when the brake handle was actuated, but brake pressure would build if the handle was pumped. The airplane was manufactured in 1964 and was equipped with hand-actuated brakes only. According to the FAA inspector, the most recent annual inspection was completed in January 2015, at which time the brakes were replaced, and the brake fluid system was bled. He stated that all required inspections and all airworthiness directives were in compliance. The airplane had accrued 8.5 hours since the inspection and according to the pilot; the brake function was "ok" during that time. The mechanic prepared a statement which outlined the method he used to bleed the brake system after his work was completed. A representative of the aircraft manufacturer reviewed statements by the mechanic, the FAA inspector, and the NTSB Preliminary Report. He stated that while the method used to bleed the brakes did not comport with the manufacturer's maintenance manual, it the desired results could be expected upon completion. The brake reservoir on this aircraft was open at the top, and the fill line for the reservoir was well below the top of the container, to allow air in the system to escape. Consequently, during the time the airplane was inverted following the accident, the air which had been in the top of the reservoir was trapped and moved to the highest point in the system, which was the brake calipers. Brake fluid would have continued to leak from the system, being replaced by air, until the airplane was returned to the upright position. Because of trapped air in the system, the brakes would not function normally until the air was removed and the fluid replaced. ADDITIONAL INFORMATION According to the Pilot's Operating Handbook, Normal Procedures: The airplane should be trimmed to an approach speed of about 90 MPH and flaps extended. The flaps can be lowered at speeds up to 115 MPH, if desired. The amount of flap used during landings and the speed of the aircraft at contact with the runway should be varied according to the landing surface and existing conditions, both windwise and loadwise. It is generally good practice to contact the ground at the minimum possible safe speed consistent with existing conditions. Normally, the best technique for short and slow landings is to use full flap and enough power to maintain the desired airspeed and approach flight path. Reduce the speed during the flareout and contact the ground close to the stalling speed (60 to 70 MPH). After ground contact, hold the nose wheel off as long as possible. As the airplane slows down, gently lower the nose and apply the brakes. Braking is most effective when flaps are raised and back pressure is appliedto the control wheel, putting most of the aircraft weight on the main wheels. ## Aircraft - Registration: [N8803W](https://openairdocs.org/deregistered/N8803W-2018-03-30), registration cancelled 2018-03-30, S/N 28-10328, built 1964 (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: 28-10328 - Year built: 1964 - Engines: LYCOMING O-540 SERIES 250 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, January 1, 2015, 8 hours before - Departed: D73, MONROE, GA - Destination: 5GA4, Woodstock, GA - Airport: 5GA4, Air Acres, runway 18, 2,000 × 100 ft, grass/turf ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: none; flight instructor, airline transport, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; seat: left; restraint: 3-point; flight hours: 28,500 total, 250 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 330° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 66 °F, dew point 41 °F - Altimeter: 30.07 inHg - Observed at: RYY, 9 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). - [Incident 20150321003669I](https://openairdocs.org/incident/20150321003669I), Mar 21, 2015: Piper PA-28-235, Woodstock, GA, Substantial damage. Pilot was on approach to airport, after touchdown he actuated the brake handle with no braking ability. Pilot pumped brakes to build pressure. Finally the… ## Other investigations on N8803W (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 MKC67F0218](https://openairdocs.org/ntsb/MKC67F0218), Sep 12, 1966: Piper PA-28 (N8803W), Webb City, MO, substantial damage ## Docket (9 files) The files NTSB released with the investigation on April 5, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91032. 4.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438464&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot's Statement (item 2, .PDF, 921 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438465&FileExtension=.PDF&FileName=Pilot%27s%20Statement-Master.PDF - Witness (item 3, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438466&FileExtension=.PDF&FileName=Witness-Master.PDF - Mechanic Statement (item 4, .PDF, 20 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438467&FileExtension=.PDF&FileName=Mechanic%20Statement-Master.PDF - FAA Inspector's Statement (item 5, .PDF, 20 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438468&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Statement-Master.PDF - Brake Maintenance Procedure (item 6, .PDF, 164 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438469&FileExtension=.PDF&FileName=Brake%20Maintenance%20Procedure-Master.PDF - Reports from Parties to the Investigation (item 7, .PDF, 91 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438470&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 8, .PDF, 226 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438472&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Photos (Courtesy of Landowner) (item 9, .PDF, 7 photos, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438471&FileExtension=.PDF&FileName=Photos%20(Courtesy%20of%20Landowner)-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.