NTSB CAROL · Event
Event LAX95LA230
Aircraft involved
Probable cause & findings
complete brake failure due to improper replacement and service of the brakes by company maintenance personnel.
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. 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. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_1995_LAX95LA230.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (maintenance). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- Embry-Riddle Scholarly Commons 2026 · Journal article (IJAAA)
From Reactive to Predictive: A hybrid Trust-Mediated Adoption Framework for Data-Driven Maintenance in Distributed-Authority Aviation Environments
Modern aviation maintenance operates within increasingly data-intensive technological environments, yet the operational integration of predictive maintenance into routine decision-making remains incon…
- Semantic Scholar 2025 · Article (Applied Sciences)
Decision-Making Framework for Aviation Safety in Predictive Maintenance Strategies
The implementation of predictive maintenance (PM) in aviation presents unique challenges due to strict safety requirements, complex operational environments, and regulatory constraints.
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
Low-Resource Automatic Speech Recognition Domain Adaptation – A Case-Study in Aviation Maintenance
With timeliness and efficiency being critical in the aviation maintenance industry, the need has been growing for smart technological solutions that optimize and streamline the different underlying ta…
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
A New Trajectory in UAV Safety: Leveraging Reinforcement Learning for Distance Maintenance Under Wind Variations
In the field of aviation, safety is a critical cornerstone, and the operation of Unmanned Aerial Vehicle (UAV) systems is deeply connected with this principle.
- Embry-Riddle Scholarly Commons 2024 · Journal article (IJAAA)
Just Culture in Aviation: A Metaphorical Study on Aircraft Maintenance Students
Just Culture, a sub-dimension of safety culture, has been a prominent and debated topic in aviation safety in recent years.
- Embry-Riddle Scholarly Commons 2024 · Journal article (IJAAA)
Performance PRISM: A Comprehensive Framework For Performance Measurement In Aircraft Maintenance
Aircraft maintenance is governed by rigorous safety requirements and high operational complexity, demanding robust performance measurement frameworks to ensure optimal maintenance practices.
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