Pilot Debrief

PIPER PA-28-235 near Woodstock, GA — 2015-03-21

Final reportERA15LA186
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Date
2015-03-21
Location
Woodstock, GA, USA
Airport
5GA4
Aircraft
PIPER PA-28-235
Registration
N8803W
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Landing

Probable cause

The pilot's failure to attain the proper touchdown point on the short, wet, turf runway. Contributing to the accident was the pilot’s use of a high approach speed.

NTSB narrative

The airline transport pilot was conducting a personal cross-country flight. The pilot reported that he landed the airplane with the flaps fully extended on the short, wet, turf runway and that the hand-actuated brakes were ineffective at touchdown but that they became effective after he pumped them several times with about 300 ft of runway remaining. A witness at the airport reported that the airplane was "too high for the approach and too fast" and that the airplane touched down midfield and then "bounced-ballooned" down the runway, skidding on the turf each time it touched down. The airplane continued off the departure end of the runway, traveled down an embankment, nosed over, and then came to rest inverted. Intermittent tire skid marks from about midfield (1,000 ft) to the crash site were visible, consistent with the witness's statement. About 8.5 flight hours before the accident, the brakes were replaced, and the brake fluid system was bled. According to the airplane manufacturer, although the method that the mechanic reported that he used to bleed the brakes was not in accordance with the manufacturer's maintenance manual, it achieved the desired results, and the airplane owner stated that the performance of the brakes since their replacement was satisfactory. Postaccident examination of the brake handle revealed that there was no pressure when the brake handle was actuated but that brake pressure would build if the handle was pumped. The airplane's brake reservoir was open at the top, and the fill line for the reservoir was well below the top of the container, which would have allowed air in the system to escape. Consequently, during the time the airplane was inverted following the accident, the air that had been in the top of the reservoir was trapped and moved to the highest point in the system, which was the brake calipers. Brake fluid would have continued to leak from the system and been replaced by air until the airplane was returned to the upright position. Because of trapped air in the system, the brakes did not function normally until the air was removed and the fluid replaced when the handle was pumped during postaccident testing.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Pilot could have aborted landing due to obstacles and wet runway conditions.

NTSB coding

Evidence available

  • Photos
  • 9 docket documents
View NTSB final reportView NTSB docket

Docket documents9

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