# NTSB MIA08LA123: Cirrus Design SR-20, N381CP, Williston, FL, June 20, 2008 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: June 20, 2008, 10:20 local (14:20 UTC) - Place: Williston, FL - Coordinates: 29.354166, -82.472778 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.3542&lon=-82.4728&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff-rejected takeoff: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report March 23, 2010 - Report: Approved by Office Director - Parties: Cirrus Design Corporation, CAPT, LLC, FAA/ FSDO - NTSB case key (mKey): 68281 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA08LA123 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/68281/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=68281 - Page: https://openairdocs.org/ntsb/MIA08LA123 ## Probable cause The student pilot’s failure to follow the manufacturer's recommended taxiing procedures. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: use of policy/procedure](https://openairdocs.org/ntsb-findings/02063032): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cirrus Design SR20, 1 case](https://openairdocs.org/ntsb-findings/02063032/cases.md?model=2130000), [All aircraft, 191 cases](https://openairdocs.org/ntsb-findings/02063032/cases.md) - [Performance/control parameters: surface speed/braking](https://openairdocs.org/ntsb-findings/01062045): Aircraft › Aircraft oper/perf/capability · Incorrect use/operation (probable cause); cases with it: [Cirrus Design SR20, 2 cases](https://openairdocs.org/ntsb-findings/01062045/cases.md?model=2130000), [All aircraft, 238 cases](https://openairdocs.org/ntsb-findings/01062045/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff-rejected takeoff: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150) (defining event); cases with it: [Cirrus Design SR20, 2 cases](https://openairdocs.org/ntsb-events/150/sequence.md?model=2130000), [All aircraft, 504 cases](https://openairdocs.org/ntsb-events/150/sequence.md) ## Analysis The student pilot was conducting a solo flight and had completed two full-stop landings with the intention of completing three more; however, he aborted the subsequent takeoff twice. When the student pilot attempted to stop during the second aborted takeoff, he noticed that the brakes were not functioning properly. As the airplane exited the runway on to the taxiway, smoke was emanating from under the wings. The student pilot, airport supervisor, and fire department extinguished fires on both main landing gear. Data retrieved from the airplane’s primary flight display and multi-functional display revealed that the student pilot executed two landings, followed by two sequential aborted takeoffs, within a time frame of 22 minutes. During that time, ground speeds reached 73 knots and engine power during taxi ranged from 920 to 1,270 rpm. Review of the airplane’s pilot operating handbook (POH) revealed that the maximum recommended continuous engine power for taxiing is 1,000 rpm. If the engine power is exceeded and proper braking procedures are not observed during taxi, wheel brake damage or fire could occur. The student pilot also did not comply with the safety information section in the POH, which recommended adequate cooling time for the brakes after heavy use. Examination of the landing gear brake assemblies revealed no evidence of a mechanical malfunction. The combination of the high-speed aborted takeoffs and the excessive taxi speed resulted in both wheel brakes failing and catching on fire. ## Factual narrative On June 20, 2008, at 1020 eastern daylight time, a Cirrus SR-20, N381CP, had the wheel brakes catch fire at the Williston Municipal Airport (X60), Williston, Florida. The student pilot reported no injuries and the airplane incurred substantial damage. The flight was operated by Commercial Airline Pilot Training, LLC, under the provisions of Title 14 Code of Federal Regulations Part 91, as an instructional flight. Visual meteorological conditions prevailed and a visual flight rules flight plan was filed. The student pilot, with 82 hours in the Cirrus SR-20, stated he was on a solo instructional cross-country flight from Flagler County Airport, Palm Coast, FL. While at X60, he completed 2 full stop landings and taxied back to the runway with the intent to make three additional landings at the airport. The pilot’s initial takeoff was aborted and he taxied back to the runway for a second takeoff. The pilot aborted the second takeoff. When he attempted to stop, he noticed that the brakes were not functioning properly. As the pilot exited the runway he noticed smoke coming from under the wings. He quickly secured the fuel and avionics and grabbed the on-board fire extinguisher before exiting the airplane. Despite the efforts of the pilot, the airport supervisor, and fire department, the right main landing gear was completely destroyed by the fire. The fire burned through the bottom of the fuselage, and continued up the right side of the cabin behind the wing. The lower surface of the right wing incurred thermal heat damage. The left main landing gear incurred thermal heat damaged on top of the wheel pant assembly. The left main landing gear assembly and the remaining components from the right main landing gear assembly were sent to the Parker Hannifin Wheel and Brake Division, Avon, OH, for a teardown examination with Federal Aviation Administration oversight. The examination revealed that the O-rings from the left-hand brake cylinder had deformed and taken on a “square appearance”. A subsequent functional inspection showed that the brake assembly held pressure in accordance with established production parameters. The right-hand landing gear assembly was destroyed by the magnesium fire and the remnants could not be tested. The airplane was equipped with an Avidyne avionics system which consisted of a primary flight display (PFD) and a multi-functional display (MFD). Each of these had the ability to store data. The data from the PFD and MFD were extracted and analyzed by the National Transportation Safety Board’s Vehicle Recorder Division. The data indicated that the pilot, within a time frame of 22 minutes, executed two landings at X60 followed by the 2 aborted takeoffs, with ground taxi speeds ranging from 35 knots to 73 knots between each event. The engine speed during taxi ranged from 920 RPM to 1270 RPM. The Cirrus SR-20 Pilot Operating Handbook (POH) states that the maximum continuous engine speed for taxing is 1000 RPM and if the engine speed isexceeded and proper braking procedures are not observed, wheel brake damage or fire could occur. At the time of the accident there were no references to high-speed aborted takeoff limitations in the POH. ## Aircraft - Registration: [N381CP](https://openairdocs.org/deregistered/N381CP-2012-08-01), registration cancelled 2012-08-01, S/N 1856, built 2007 (OpenAirDocs) - Reported make and model: CIRRUS DESIGN CORP SR-20 - Registry model: [Cirrus Design SR20](https://openairdocs.org/model/cirrus-design-sr20) (registry code 2130000) (OpenAirDocs) - Registry engine: [Continental IO-360-ES](https://openairdocs.org/engine/continental-io-360-es) (registry code 17160, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 1856 - Airframe hours: 272 - Engines: Continental IO-360 200 horsepower reciprocating - Damage: Substantial damage - Fire: On-Ground - Flight: Instructional, Part 91 - Operator: Capt LLC, doing business as Commercial Airline Pilot Training Program - Registered owner: Atg-Ga Leasing LLC - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, June 10, 2008, 29 hours before - Departed: X60, Williston, FL - Destination: X60, Williston, FL - Flight plan: VFR - Airport: X60, Williston Municipal Airport, runway 23, 6,390 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Student pilot; age 22; injuries: none; student; medical: class 2, without waivers/limitations; seat: left; flight hours: 82 total, 82 in this make and model, 52 in the last 90 days, 15 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 240° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 86 °F, dew point 66 °F - Altimeter: 30.04 inHg - Observed at: GNV, 23 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 20080620840679A](https://openairdocs.org/incident/20080620840679A), Jun 20, 2008: Cirrus SR20, Williston, FL, Destroyed. (-23) Pilot was on solo cross country when he landed at KX60. (Note: CR-20 requires differiential braking to turn the aircraft. Nose wheel is a caster only).… ## Docket (8 files) The files NTSB released with the investigation on December 7, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=68281. 3.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 427 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320809&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Reports from Federal Agencies: FAA Inspector's Statement, Wheel Brake Examination. (item 2, .PDF, 178 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320815&FileExtension=.PDF&FileName=Reports%20from%20Federal%20Agencies%3A%20FAA%20Inspector%27s%20Statement,%20Wheel%20Brake%20Examination.-Redacted.PDF - Miscellaneous: Cirrus Design Corporation, SR20 Pilot's Operating Handbook, Excerpt for Taxi/Brake Procedures. (item 3, .PDF, 226 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320818&FileExtension=.PDF&FileName=Miscellaneous%3A%20Cirrus%20Design%20Corporation,%20SR20%20Pilot%27s%20Operating%20Handbook,%20Excerpt%20for%20Taxi%2FBrake%20Procedures.-Master.PDF - Cockpit Displays - Specialist's Factual Report (item 4, .PDF, 293 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40308242&FileExtension=.PDF&FileName=Cockpit%20Displays%20-%20Specialist%27s%20Factual%20Report-Master.PDF - Cockpit Displays - Attachment 1 Tabular Data (item 5, .CSV, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40308243&FileExtension=.csv&FileName=Cockpit%20Displays%20-%20Attachment%201%20Tabular%20Data-Master.csv - Miscellaneous: Excerpt from Cirrus Design Corporation and Commercial Airline Pilot Training, LLC., Safety Improvement Results. (item 6, .PDF, 150 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320819&FileExtension=.PDF&FileName=Miscellaneous%3A%20Excerpt%20from%20Cirrus%20Design%20Corporation%20and%20Commercial%20Airline%20Pilot%20Training,%20LLC.,%20Safety%20Improvement%20Results.-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 7, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320812&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 8, .PDF, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320813&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.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.