# NTSB LAX95LA230: Piper PA-34-200, N56484, Avalon, CA, June 24, 1995 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: June 24, 1995, 11:50 local (18:50 UTC) - Place: Avalon, CA - Coordinates: 33.380481, -118.450752 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.3805&lon=-118.4508&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed, report November 30, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 29131 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX95LA230 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/29131/pdf - Page: https://openairdocs.org/ntsb/LAX95LA230 ## Probable cause complete brake failure due to improper replacement and service of the brakes by company maintenance personnel. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Overrun, landing - roll - landing gear,normal brake system - failure,total (cause) - maintenance,service of aircraft/equipment - improper, company maintenance personnel (cause) - On ground/water collision with object, landing - roll - object - fence ## Analysis AFTER TOUCHDOWN ON THE 3,240-FOOT-LONG RUNWAY, THE PILOT EXPERIENCED TOTAL BRAKE FAILURE AND WAS UNABLE TO STOP THE AIRCRAFT BEFORE OVERRUNNING THE RUNWAY. THE AIRPLANE COLLIDED WITH AN AIRPORT BOUNDARY FENCE. FAA AIRWORTHINESS INSPECTORS EXAMINED THE AIRCRAFT AND FOUND THAT THE HYDRAULIC RESERVOIR WAS 3/4 FULL AND THE BRAKE PADS LOOKED NEW. BOTH BRAKE PEDALS WERE SPONGY AND WOULD GO TO THE FLOOR. AIR WAS FOUND IN THE BRAKE LINES. THE BRAKES WERE REPLACED AND SERVICED ON JUNE 23, 1995. THE ACCIDENT FLIGHT WAS THE FIRST ONE SINCE THE WORK ON THE BRAKES WAS ACCOMPLISHED. ## Factual narrative On June 24, 1995, at 1150 hours Pacific daylight time, a Piper PA-34-200, N56484, overran runway 22 while landing and collided with a fence at Catalina Airport, Avalon, California. The aircraft was operated by Aero Club of Van Nuys, California, and was rented by the pilot for a personal cross-country flight to Catalina Island. The airplane was substantially damaged and the certificated airline transport pilot and his two passengers were not injured. The flight originated at Van Nuys, California, on the day of the accident at 1100. Visual meteorological conditions prevailed. In a verbal statement, the pilot reported that after touchdown he experienced a brake failure and could not stop the aircraft prior to overrunning the 3,240-foot-long runway and colliding with a boundary fence. Federal Aviation Administration (FAA) airworthiness inspectors examined the airplane and found that the hydraulic reservoir was 3/4 full, and the brake pads looked new. He also reported that the brake pedals were spongy and would go to the floor. He also stated that there was air in the brake lines. In a telephone interview, the owner of Aero Club stated that the brakes were replaced and serviced on June 23, 1995. The accident flight was the first one since the work on the brakes was accomplished. Neither the pilot nor the operator responded to repeated written and telephone requests to complete a National Transportation Safety Board Pilot Operator Aircraft Accident Report, NTSB Form 6120.1/2. ## Aircraft - Registration: [N56484](https://openairdocs.org/deregistered/N56484-2013-09-24), registration cancelled 2013-09-24, S/N 34-7350338, built 1973 (OpenAirDocs) - Reported make and model: PIPER PA-34-200 - Registry model: [Piper PA-34-200](https://openairdocs.org/model/piper-pa-34-200) (registry code 7103405) (OpenAirDocs) - Registry engine: [Lycoming I0360 SER A&C](https://openairdocs.org/engine/lycoming-i0360-ser-a-c) (registry code 41511, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 34-7350338 - Airframe hours: 5025 - Engines: LYCOMING IO-360-C1E6 200 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Aero Club - Registered owner: Roxy Corp. - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, May 19, 1995, 15 hours before - Departed: VNY, VAN NUYS, CA - Destination: AVX, CA - Airport: AVX, Catalina Airport, runway 22, 3,240 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 47; airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: left; flight hours: 2,300 total ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 15 statute miles - Lowest ceiling: none - Temperature: 75 °F ## 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 19950624047209A](https://openairdocs.org/incident/19950624047209A), Jun 24, 1995: Piper PA34200, Avalon, CA, Substantial damage. Brakes failed landing. Overran runway into fence. First flight since brakes replaced had air in lines. ## Other investigations on N56484 (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 LAX03FA065](https://openairdocs.org/ntsb/LAX03FA065), Jan 11, 2003: Piper PA-34-200 (N56484), Westlake Villag, CA, destroyed. Probable cause: a fatigue crack in the propeller hub due to the inadequate design location of the grease fitting and the chamfering process. 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.