GAA18CA432

NTSB accident investigation · Piper PA28 · Oregon, WI · July 19, 2018

Accident · No injuriesData collectionFinal report
Date
July 19, 2018, 14:00 local (19:00 UTC)
Place
Oregon, WI
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N9267HPiper PA28
Defining event
Landing-landing roll: Runway excursion
Weather
Visual (VMC) · Day
Status
Completed · report September 26, 2019
Report
Approved by Office Director
NTSB office
General Aviation Accidents
Parties
FAA
FAA report
20180719011729A
Case key
97852

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

The pilot's improper decision to take off with a known brake malfunction, which resulted in a collision with a barn during landing on a wet runway.

Findings · 3

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 · MalfunctionPiper PA-28-181: 5 casesAll aircraft: 297 casesProbable cause
Object/animal/substance: residence/buildingEnvironmental issues › Physical environment · Contributed to outcomePiper PA-28-181: 2 casesAll aircraft: 58 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

According to the pilot receiving instruction, during instrument training, she and the flight instructor noted that the left brake was less effective than the right brake during landing. Following the training, the pilot receiving instruction returned to her home airport, and during landing on the wet, grass runway, she executed a go-around because there was insufficient runway to safely stop the airplane. During the second landing, the airplane touched down with about two-thirds of the 2,600-ft-long runway remaining. During the landing roll, the pilot receiving instruction ensured that the throttle was in the idle position, and she retracted the flaps and applied aft pressure to the yoke. She applied the foot brakes and then the hand brake and again noted that the left brake was less effective than the right brake, and the airplane continued to slide on the wet grass. The airplane overran the runway and impacted a drainage culvert. Subsequently, the right wing struck a barn, and the left wing struck a trailer. The airplane sustained substantial damage to both wing's spars and ribs. According to the Federal Aviation Administration aviation safety inspector who examined the airplane, there was a pool of hydraulic fluid on the ground that appeared to be consistent with an O-ring failure or displacement. He affirmed that, although degraded, the brake would still have been functional but would have required more input by the pilot to build pressure within the brake line.

Factual narrative

According to the pilot, she had flown from her home airfield to another airport to receive instrument training. The departure to, and arrival at, the other airport had been uneventful, however during the training she and the instructor noted that the left brake was less effective than the right brake. The brakes had been serviced two days prior to the flight. Following the training, she returned to her home airport, and during landing on the wet grass runway, she aborted the landing because there was insufficient runway to safely stop the airplane. During the second landing she touched down with about 2/3 of the 2,600-foot-long runway remaining. During the landing roll she ensured that the throttle was in the idle position, and she retracted the flaps, and applied aft pressure to the yoke. She applied the foot brakes and then the hand brake, and again noted that the left brake was less effective than the right, but the airplane continued to slide on the wet grass. The airplane overran the runway and encountered a drainage culvert. Subsequently, the right wing struck a barn, and the left wing struck a trailer. The airplane sustained substantial damage to both wing's spars and ribs. According to the Federal Aviation Administration, Aviation Safety Inspector that examined the airplane, there had been a pool of hydraulic fluid on the ground that appeared to be consistent with an O-ring failure or displacement. He affirmed that although degraded, the brake would have been functional yet requiring a pumping action by the pilot to build pressure within the brake line. Two days prior to the accident, the pilot's grandfather noticed that the airplane had a "soft left brake." He flew the airplane to a maintenance facility and the brakes were serviced by adding brake fluid to the brake system and the brakes were blead. The grandfather flew the airplane home and was satisfied with the brake operation.

Aircraft

Registration
N9267H
Reported as
Piper PA28 (181)
Category
Airplane
Serial number
2843027
Built
1996
Airframe hours
3,394.7
Engine
Lycoming O-360-A1D, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Peterson Aviation Llc
Registered owner
Peterson Aviation Llc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 1, 2018
Departed
RYV · Watertown, WI
Destination
RYV · Watertown, WI
Airport
15WI · Peterson Field, runway 9, 2,600 × 150 ft, grass/turf
Equipment
Electronic flight bag or handheld device, Auto-pilot, ADS-B, Stall warning system, Onboard weather, Electronic primary flight display

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
22
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
August 18, 2017
Seat
Left
Restraint
3-point
Flight hours
191 total · 138 in this make and model · 136 as pilot in command · 48.4 in the last 90 days · 10.6 in the last 30 days · 1.8 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
190° at 10 knots
Visibility
10 statute miles
Lowest ceiling
11,000 ft broken
Temperature
75 °F, dew point 57 °F
Altimeter
29.90 inHg
Observed at
KMSN, 13 nm away

Docket · 3

The files NTSB released with the investigation on May 9, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.0 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.