ERA19LA030

NTSB accident investigation · Piper PA28 · Simsbury, CT · October 28, 2018

Accident · Minor injuriesLimited investigationFinal report
Date
October 28, 2018, 16:45 local (20:45 UTC)
Place
Simsbury, CT
Injuries
1 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N8132XPiper PA28
Defining event
Landing-landing roll: Part(s) separation from AC
Weather
Visual (VMC) · Day
Status
Completed · report April 20, 2020
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20181028022319A
Case key
98565

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

Maintenance personnel's inadequate inspection of the wheel brake system during the airplane's most recent 100-hour inspection, which resulted in a loss of hydraulic fluid and the pilot's inability to control the airplane during the landing.

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 · Inadequate inspectionPiper PA-28-161: 1 caseAll aircraft: 297 casesProbable cause
Inspection: scheduled/routine inspectionPersonnel issues › Task performance · Maintenance personnelPiper PA-28-161: 3 casesAll aircraft: 167 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotPiper PA-28-161: 40 casesAll aircraft: 9,295 casesProbable cause
Performance/control parameters: directional controlAircraft › Aircraft oper/perf/capability · Attain/maintain not possiblePiper PA-28-161: 27 casesAll aircraft: 3,958 casesProbable cause
TerrainEnvironmental issues › Physical environment · Contributed to outcomePiper PA-28-161: 1 caseAll aircraft: 267 cases

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 commercial pilot was practicing approaches and touch-and-go landings. The pilot reported that, during taxi for takeoff, the wheel brakes were "sluggish"; when he was attempting a full-stop landing at the destination airport, the brakes "failed." The pilot steered the airplane off the runway to avoid a fence and collided with a ditch, which resulted in substantial damage to the left wing. A postaccident examination of the airplane revealed that the left main landing gear separated from the airplane during the ground collision, and there was evidence of pre-existing hydraulic fluid leakage where the fluid line fitting connected to the wheel brake assembly. Additionally, the right main landing gear wheel brake assembly was not attached to the trunnion by the required AN bolts, and the hydraulic fluid line fitting was not attached to the brake assembly. According to the maintenance logbooks, a 100-hour inspection was completed 18 days before the accident. The logbook entry noted servicing of all tires, wheels, brakes, and brake fluid. Given that the right main landing gear hydraulic fluid line was detached from its respective brake assembly, it is likely that maintenance personnel did not adequately inspect the wheel brake system, and the right brake failed due to a loss of hydraulic fluid.

Factual narrative

On October 28, 2018, about 1645 eastern daylight time, a Piper PA-28-161, N8132X, was substantially damaged after a runway excursion and collision with a ditch at Simsbury Airport (4B9) Simsbury, Connecticut. The commercial pilot and pilot-rated passenger were not injured. The airplane was operated by Interstate Aviation, Inc. under the provisions of 14 Code of Federal Regulations part 91 as a personal flight. Visual meteorological conditions prevailed, and no flight plan was filed for the flight that originated at Bradley International Airport (BDL), Windsor Locks, Connecticut, about 1635. According to pilot, he was in the traffic pattern at 4B9 practicing approaches and touch-and-go landings. After touchdown on runway 21 for a full stop landing, the brakes "failed." He elected to steer the airplane to the right in an effort to avoid a fence and slow the airplane in the grass. The airplane departed the runway surface and collided with a ditch. The pilots exited the airplane and were met by first responders. The pilot also reported that, during taxi out for takeoff, the wheel brakes were "sluggish." An inspector with the Federal Aviation Administration responded to the accident site and examined the wreckage. He reported that the left wing sustained structural damage during the landing. The left main landing gear separated and was found adjacent to the wreckage. The inboard and outboard brake pads exhibited normal wear. The brake assembly was attached in its normal position by two AN bolts. The brake assembly puck to brake pad and the brake supply hydraulic line also showed evidence of leaking hydraulic fluid. An examination of the right main landing gear wheel brake assembly revealed that it was missing from its proper mounting position on the right gear trunnion. The assembly was not installed onto the main wheel brake rotor with the required AN bolts. The hydraulic fluid line and elbow fitting were also not attached to the brake assembly. A review of the airplane maintenance records revealed that a 100-hr inspection was completed on October 10, 2018, or 18 days before the accident. The inspection entry included the following: "Serviced all tires, wheels, brakes, brake reservoir fluid." The main landing gear tires were also replaced during this inspection. The last maintenance entry where brake parts were replaced was on October 16, 2017.

Aircraft

Registration
N8132X
Reported as
Piper PA28 (161)
Category
Airplane
Serial number
28-8016162
Built
1979
Airframe hours
3,198
Engine
Lycoming O-320-D3G, 161 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · October 10, 2018 · 32 hours before
Departed
BDL · Windsor Locks, CT
Destination
4B9 · Simsbury, CT
Airport
4B9 · Simsbury Airport, runway 21, 2,205 × 50 ft, asphalt
Equipment
Stall warning system, Auto-pilot

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
70
Injuries
Minor
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
May 26, 2017
Seat
Right
Restraint
3-point
Flight hours
2,866 total · 83 in this make and model · 2,725 as pilot in command
Role
Pilot-rated passenger
Age
55
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
BasicMed, With waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
700 total

Weather

Conditions
Visual (VMC) · Day
Wind
210° at 5 knots
Visibility
10 statute miles
Lowest ceiling
3,500 ft broken
Temperature
50 °F, dew point 39 °F
Altimeter
29.75 inHg
Observed at
BDL, 4 nm away

Docket · 7

The files NTSB released with the investigation on February 20, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 9.3 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.