ERA14LA268

NTSB accident investigation · Piper PA-28-161 · Melbourne, FL · April 4, 2014

Accident · No injuriesLimited investigationFinal report
Date
April 4, 2014, 10:14 local (14:14 UTC)
Place
Melbourne, FL
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Standing
Aircraft
N642FTPiper PA-28-161
Defining event
Standing-engine(s) start-up: Fire/smoke (non-impact)
Weather
Visual (VMC) · Day
Status
Completed · report December 15, 2014
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20140404005039I
Case key
89311

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The flight instructor’s overpriming of the engine during multiple unsuccessful engine start attempts on an active runway, which resulted in an engine compartment fire.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Action: incorrect action performancePersonnel issues › Action/decision · Instructor/check pilotPiper PA-28-161: 8 casesAll aircraft: 1,386 casesProbable cause
Fuel system: fuel distributionAircraft › Aircraft systems · Incorrect use/operationPiper PA-28-161: 1 caseAll aircraft: 141 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The flight instructor reported that, while taxiing off the runway after landing and when the airplane was just before the hold short lines, the engine quit. The flight instructor contacted the tower air traffic controller and asked for permission to push the airplane completely off the runway, but the tower controller declined and instructed him to advise whether he could get the engine started. The flight instructor attempted to start the engine using procedures for a hot and cold engine and then noticed smoke coming from the engine cowling. The flight instructor secured the airplane, and, after evacuating it, noticed flames coming from the engine cowling, which he was unable to extinguish using the on-board fire extinguisher. Airport rescue and firefighting personnel responded and extinguished the fire. Postaccident examination of the carburetor revealed that the loosening torque values of the screws that secure the throttle body to the carburetor bowl were lower than the tightening torque value specified for overhaul. However, repair station personnel reported that it was not uncommon for in-service units to exhibit no loosening torque value. The engine fire was likely caused by the flight instructor's overpriming of the engine during multiple unsuccessful engine start attempts, which likely resulted from his feeling rushed to get the engine started while the airplane was still on an active runway. The reason for the loss of engine power could not be determined.

Factual narrative

On April 4, 2014, about 1014 eastern daylight time, a Piper PA-28-161, N642FT, experienced an engine compartment fire after landing at Melbourne International Airport (MLB), Melbourne, Florida. The certified flight instructor (CFI) and pilot-rate student were not injured. The airplane was substantially damaged. The airplane was registered to and operated by FIT Aviation, LLC, under the provisions of 14 Code of Federal Regulations (CFR) Part 91 as an instructional flight. Visual meteorological conditions prevailed at the time and no flight plan was filed for the local flight, which originated about 1 hour 4 minutes earlier. The CFI stated that after landing on runway 27R, while taxiing off the runway onto taxiway "Q" just prior to the hold short lines, the engine quit. He contacted the tower and asked for permission to push the airplane completely off the runway to give himself, "…time to think", but the tower controller declined and instructed them to advise whether they could start the engine. They used the procedures for a hot and cold engine, but was unable to start the engine. They began to notice smoke coming from the engine cowling, and secured the airplane. After evacuating it, they noticed flames from the engine cowling. The CFI attempted to extinguish the fire using the on-board hand held fire extinguisher, but was unable. Airport fire rescue responded and extinguished the fire. During repairs of the airplane to return it to service, the engine mount was inspected and overhauled; however, the firewall required replacement. The carburetor, a MA4-SPA, part number 10-5217, serial number CK47312 was removed, and taken to a FAA certified repair station for inspection and testing with FAA oversight. According to the report, the examination of the carburetor revealed the unit exhibited charring on the exterior and also inside the carburetor throat or venture. Bench testing revealed no issues related to the float shut off and accelerator pump discharge. The removal torque forces of the throttle body to bowl screws were checked and all were reported to be greater than 10 inch pounds, although the technician recalled the values were between 25 and 35 inch pounds (tightening torque specification is 35 to 45 inch pounds). Personnel of the repair station indicate it is not unusual for units in service returned to them for overhaul to exhibit no loosening torque values of the screws that secure the throttle body to the carburetor bowl. Review of the maintenance records revealed the carburetor was overhauled last on December 13, 2013, and installed on the accident airplane on March 21, 2014, where it remained installed until removed postaccident. The carburetor had accrued approximately 37 hours since overhaul at the time of the engine fire. Review of the Pilot's Operating Handbook and FAA Approved Airplane Flight Manual revealed that it specifies that engine fires during start are usually the result of overpriming.

Aircraft

Registration
N642FT
Reported as
Piper PA-28-161
Category
Airplane
Serial number
2842319
Built
2008
Airframe hours
4,498
Engine
Lycoming O-320-D3G, 160 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Instructional · Part 91
Operator
Fit Aviation, LLC
Registered owner
Fit Aviation, LLC
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
100 hour · March 20, 2014 · 37 hours before
Departed
MLB · Melbourne, FL
Destination
MLB · Melbourne, FL
Airport
MLB · Melbourne International Arpt, runway 27R, 6,000 × 150 ft, asphalt
Equipment
Stall warning system, Electronic primary flight display, Electronic multifunction display

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
20
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Right
Flight hours
570 total · 524 as pilot in command · 141 in the last 90 days · 64 in the last 30 days · 5 in the last 24 hours
Role
Student pilot
Age
29
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 1, With waivers/limitations
Last flight review
November 23, 2013
Seat
Left
Flight hours
126 total · 117 in this make and model · 66 as pilot in command · 4 in the last 90 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
200° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
75 °F, dew point 63 °F
Altimeter
30.06 inHg
Turbulence
Unknown
Observed at
MLB

Docket · 13

The files NTSB released with the investigation on October 23, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.7 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.