NTSB CAROL · Event
Event CEN19LA314
Registry · N8384E
FAA Aircraft Registry record.
Make / Model
PIPER PA-28-181
Year of manufacture
1981 · 38 years old at event
Engine
LYCOMING 0-360-A1D (180 hp)
Seats / Engines
4 seats · 1 engine
Last airworthiness date
19810408
ADS-B equipped
Yes — Mode-S AB78FB
Registrant of record
G & M AIRCRAFT INC
Source: FAA Aircraft Registry (releasable master file).
Aircraft involved
Probable cause & findings
The pilot's improper taxi speed and his excessive use of brakes, which resulted in a brake fire and substantial thermal damage to the airplane.
Factual narrative
**This report was modified on January 15, 2020. Please see the public docket for this accident to view the original report.** On September 11, 2019, at 1315 mountain daylight time, a Piper PA-28-181 airplane, N8384E, experienced a left main landing gear fire during landing rollout at City of Colorado Springs Municipal Airport (COS), Colorado Springs, Colorado. The commercial pilot and a passenger were uninjured, and the airplane left wing sustained substantial damage. The airplane was registered to G & M Aircraft Inc, used as a rental airplane by Rocky Mountain Flight School, and was operated by the pilot under Title 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed at the time of the accident. The flight originated from Tradewind Airport (TDW), Amarillo, Texas, at 1131 central daylight time, and was destined to COS. The pilot stated he landed the airplane on runway 35R and taxied off at E5. He was cleared by air traffic control (ATC) to taxi to general aviation via taxiways E and H and cleared to cross runway 35L. He said that being unfamiliar with the airport, he taxied north on taxiway E. He said ATC asked him to pick up the pace, if able, and he responded that he could make room ahead if needed. He stated that as the airplane exited taxiway E onto H, near taxiway P, he noticed the brakes were no longer available. He tried the emergency brake [parking brake], but it was unresponsive. He planned on performing "zig-zags" to slow the airplane down enough to make right turn onto the next taxiway and to perform 360° turns, if he needed to stop the airplane since the ramp looked clear. When he tried two shallow zig-zags to slow the airplane down, he heard a loud bang and the airplane veered left. He stomped on the rudder which had little effect and it seemed not even about second later when he heard the passenger yell "fire." When he exited the airplane, he saw that the left main landing gear was on fire. The pilot stated that there was a mechanical malfunction/failure of the brakes. According to the Federal Aviation Administration (FAA) inspector assigned to the accident investigation, the pilot stated in his initial conversation with the FAA inspector that he probably rode the airplane brakes longer than he should have, but later stated that it was a normal landing and he hardly touched the brakes. The pilot, following the issuance of the factual report, stated that the statement by the FAA inspector was "incorrect," and he "never said that [he] applied the brakes too hard." The airplane brake system consisted of toe brakes on each rudder pedal with brake cylinders for each toe brake. The left toe brake master cylinder independently controlled the left main landing gear wheel brake, and the right toe brake master cylinder independently controlled the right main landing gear wheel brake. The parking brake cylinder simultaneously controlled the left and right main landing gear wheels. Post-accident examinations by a FAA inspector and the National Transportation Safety Board (NTSB) Investigator-in-Charge (IIC) revealed the presence of fire damage that extended from the left main landing gear wheel brake assembly to the left wing structure and thermal damage from the right main wheel brake assembly. There were no mechanical anomalies of the airplane brake system that would have precluded normal operation. Post-accident examination of the airplane brakes by the NTSB IIC, revealed that all the rudder pedal brake cylinders and the parking brake cylinder were attached and secure. When the rudder pedal brakes and parking brake were exercised using hand pressure applied to the rudder pedals and parking brake control, there was no binding in movement of the their respective actuator springs, and all the springs returned to their uncompressed positions each time the brakes and parking brake were exercised. There were no mechanical anomalies of the airplane brake system that would have precluded normal operation. The FAA's Airplane Flying Handbook (FAA-H-8083-3B), Chapter 2, Ground Operations, stated in part: "A safe taxiing speed must be maintained. The primary requirements for safe taxiing are positive control, the ability to recognize any potential hazards in time to avoid them, and the ability to stop or turn where and when desired, without undue reliance on the brakes. Pilots should proceed at a cautious speed on congested or busy ramps. Normally, the speed should be at the rate where movement of the airplane is dependent on the throttle. That is, slow enough so when the throttle is closed, the airplane can be stopped promptly." The pilot was taxiing the airplane to a parking ramp after landing when the airplane lost left and right main landing gear braking effectiveness. The pilot continued the taxi and planned on performing turning maneuvers to slow the airplane enough to make a right turn onto the next taxiway and to perform 360° turns, if needed, to stop the airplane. When he tried two shallow turns to slow the airplane, he heard a loud bang and the airplane veered left and stopped. When he exited the airplane, he saw that the left brake was on fire. Postaccident examination of the airplane revealed fire damage that extended from the left main landing gear wheel brake assembly to the left wing structure. There was also thermal damage to the right main wheel brake assembly. Examination revealed no mechanical anomalies of the airplane brake system that would have precluded normal operation. It is likely that the pilot's excessive taxi speed and use of braking resulted in a brake fire while taxiing. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).
- C Aircraft-Aircraft systems-Landing gear system-Brake-Capability exceeded - C
- C Personnel issues-Action/decision-Action-Incorrect action performance-Pilot - C
- — Aircraft-Aircraft oper/perf/capability-Aircraft capability-Braking capability-Capability exceeded
- — Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Surface speed/braking-Incorrect use/operation
- — Personnel issues-Task performance-Use of equip/info-Use of equip/system-Pilot
Verbatim from NTSB's published report. Source file
NTSB_2019_CEN19LA314.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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