Primary finding
Probable cause
complete brake failure due to improper replacement and service of the brakes by company maintenance personnel.
Investigator assessment
Analysis narrative
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 record
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. -