Piper PA-28-235 accident near Woodstock, Georgia, March 21, 2015

The NTSB's narrative final · quoted from the NTSB record

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 Brake fluid would have continued to leak from the system and been replaced by air until the airplane was returned to the upright position.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.

The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.