# NTSB GAA18CA432: Piper PA28, N9267H, Oregon, WI, July 19, 2018 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: July 19, 2018, 14:00 local (19:00 UTC) - Place: Oregon, WI - Coordinates: 42.927501, -89.418052 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.9275&lon=-89.4181&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: 1 uninjured - Status: Completed, report September 26, 2019 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 97852 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA18CA432 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/97852/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=97852 - Page: https://openairdocs.org/ntsb/GAA18CA432 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-181, 21 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7102807), [All aircraft, 3,100 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Landing gear system: brake](https://openairdocs.org/ntsb-findings/01023242): Aircraft › Aircraft systems · Malfunction (probable cause); cases with it: [Piper PA-28-181, 5 cases](https://openairdocs.org/ntsb-findings/01023242/cases.md?model=7102807), [All aircraft, 297 cases](https://openairdocs.org/ntsb-findings/01023242/cases.md) - [Object/animal/substance: residence/building](https://openairdocs.org/ntsb-findings/03022022): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-28-181, 2 cases](https://openairdocs.org/ntsb-findings/03022022/cases.md?model=7102807), [All aircraft, 58 cases](https://openairdocs.org/ntsb-findings/03022022/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: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-181, 69 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102807), [All aircraft, 10,152 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300) (defining event); cases with it: [Piper PA-28-181, 35 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=7102807), [All aircraft, 3,656 cases](https://openairdocs.org/ntsb-events/300/sequence.md) ## 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](https://openairdocs.org/deregistered/N9267H-2024-10-22), registration cancelled 2024-10-22, S/N 2843027, built 1996 (OpenAirDocs) - Reported make and model: Piper PA28 (181) - Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (OpenAirDocs) - Registry engine: [Lycoming 0-360-A1D](https://openairdocs.org/engine/lycoming-0-360-a1d) (registry code 41504, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 2843027 - Year built: 1996 - Airframe hours: 3394.7 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 22; injuries: none; 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 ## 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 20180719011729A](https://openairdocs.org/incident/20180719011729A), Jul 19, 2018: Piper PA-28-181, Oregon, WI, Substantial damage. On July 19, 2018, around 1400 CST, N9267H registered as a 1996 Piper pa 28-181 archer, piloted by a private pilot, was substanially damaged on landing at… ## Docket (3 files) The files NTSB released with the investigation on May 9, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=97852. 2.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472765&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Memorandum for Record - FAA (item 2, .PDF, 124 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472766&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20FAA-Master.PDF - Photo (item 3, .PDF, 1 photo, 77 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472767&FileExtension=.PDF&FileName=Photo-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.