# NTSB ERA19LA030: Piper PA28, N8132X, Simsbury, CT, October 28, 2018 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: October 28, 2018, 16:45 local (20:45 UTC) - Place: Simsbury, CT - Coordinates: 41.91611, -72.776947 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.9161&lon=-72.7769&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Part(s) separation from AC](https://openairdocs.org/ntsb-events/338) - Highest injury: Minor injuries - Injuries: 1 minor, 1 uninjured - Status: Completed, report April 20, 2020 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 98565 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19LA030 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98565/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98565 - Page: https://openairdocs.org/ntsb/ERA19LA030 ## 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 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 · Inadequate inspection (probable cause); cases with it: [Piper PA-28-161, 1 case](https://openairdocs.org/ntsb-findings/01023242/cases.md?model=7102803), [All aircraft, 297 cases](https://openairdocs.org/ntsb-findings/01023242/cases.md) - [Inspection: scheduled/routine inspection](https://openairdocs.org/ntsb-findings/02061520): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-28-161, 3 cases](https://openairdocs.org/ntsb-findings/02061520/cases.md?model=7102803), [All aircraft, 167 cases](https://openairdocs.org/ntsb-findings/02061520/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-161, 40 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102803), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [Piper PA-28-161, 27 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=7102803), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Terrain](https://openairdocs.org/ntsb-findings/03021000): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-28-161, 1 case](https://openairdocs.org/ntsb-findings/03021000/cases.md?model=7102803), [All aircraft, 267 cases](https://openairdocs.org/ntsb-findings/03021000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Piper PA-28-161, 2 cases](https://openairdocs.org/ntsb-events/040/sequence.md?model=7102803), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Landing-landing roll: Part(s) separation from AC](https://openairdocs.org/ntsb-events/338) (defining event); cases with it: [Piper PA-28-161, 1 case](https://openairdocs.org/ntsb-events/338/sequence.md?model=7102803), [All aircraft, 563 cases](https://openairdocs.org/ntsb-events/338/sequence.md) - [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Piper PA-28-161, 30 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=7102803), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-161, 58 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102803), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N8132X-2020-02-13), registration cancelled 2020-02-13, S/N 28-8016162, built 1979 (OpenAirDocs) - Reported make and model: Piper PA28 (161) - Registry model: [Piper PA-28-161](https://openairdocs.org/model/piper-pa-28-161) (registry code 7102803) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-8016162 - Year built: 1979 - Airframe hours: 3198 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 70; injuries: minor; 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 - Pilot-rated passenger; age 55; injuries: none; 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 ## 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 20181028022319A](https://openairdocs.org/incident/20181028022319A), Oct 28, 2018: Piper PA-28-161, Simsbury, CT, Substantial damage. Simsbury, CT (4B9): N8132X, a model PA28-161, after conducting touch and go's at local airports, landed at (4B9) Simsbury and reported no brakes on touchdown.… ## Docket (7 files) The files NTSB released with the investigation on February 20, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98565. 9.3 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40470456&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - PIC Written Statement - Constantine (item 2, .PDF, 100 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40470457&FileExtension=.PDF&FileName=PIC%20Written%20Statement%20-%20Constantine-Master.PDF - Pilot-Rated Passenger Statement - Burtness (item 3, .PDF, 672 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40470458&FileExtension=.PDF&FileName=Pilot-Rated%20Passenger%20Statement%20-%20Burtness-Master.PDF - FAA Statements and Correspondence (item 4, .PDF, 3.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40470459&FileExtension=.PDF&FileName=FAA%20Statements%20and%20Correspondence-Master.PDF - Hobbs Time Sheet (item 5, .PDF, 155 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40470460&FileExtension=.PDF&FileName=Hobbs%20Time%20Sheet-Master.PDF - Excerpts - Maintenance Logbooks (item 6, .PDF, 422 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40470461&FileExtension=.PDF&FileName=Excerpts%20-%20Maintenance%20Logbooks-Master.PDF - Photo Array (item 7, .PDF, 8 photos, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40470462&FileExtension=.PDF&FileName=Photo%20Array-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.