# NTSB ERA14LA268: Piper PA-28-161, N642FT, Melbourne, FL, April 4, 2014 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: April 4, 2014, 10:14 local (14:14 UTC) - Place: Melbourne, FL - Coordinates: 28.1025, -80.644996 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=28.1025&lon=-80.6450&mi=10 - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Defining event: [Standing-engine(s) start-up: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report December 15, 2014 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 89311 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA14LA268 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/89311/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=89311 - Page: https://openairdocs.org/ntsb/ERA14LA268 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Piper PA-28-161, 8 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=7102803), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Fuel system: fuel distribution](https://openairdocs.org/ntsb-findings/01022820): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Piper PA-28-161, 1 case](https://openairdocs.org/ntsb-findings/01022820/cases.md?model=7102803), [All aircraft, 141 cases](https://openairdocs.org/ntsb-findings/01022820/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Standing-engine(s) start-up: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150) (defining event); cases with it: [Piper PA-28-161, 9 cases](https://openairdocs.org/ntsb-events/150/sequence.md?model=7102803), [All aircraft, 504 cases](https://openairdocs.org/ntsb-events/150/sequence.md) ## 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](https://openairdocs.org/aircraft/N642FT), registered now, S/N 2842319, built 2008 (OpenAirDocs) - Reported make and model: PIPER AIRCRAFT INC PA-28-161 - Registry model: [Piper PA-28-161](https://openairdocs.org/model/piper-pa-28-161) (registry code 7102834) (OpenAirDocs) - Registry engine: [Lycoming O-320-D3G](https://openairdocs.org/engine/lycoming-o-320-d3g) (registry code 42156, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 2842319 - Year built: 2008 - Airframe hours: 4498 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 20; injuries: none; 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 - Student pilot; age 29; injuries: none; 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 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Incident 20140404005039I](https://openairdocs.org/incident/20140404005039I), Apr 4, 2014: Piper Aircraft Inc PA-28-161, Melbourne, FL, Substantial damage. A Piper PA-28-161 aircraft assigned to fit encountered an engine compartment fire after landing. The crew reported that on roll out the engine stalled. They… ## Docket (13 files) The files NTSB released with the investigation on October 23, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=89311. 6.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418034&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Weather Report and Record (item 2, .PDF, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418035&FileExtension=.PDF&FileName=Weather%20Report%20and%20Record-Master.PDF - Report from Local Agency- City of Melbourne Airport Authority (item 3, .PDF, 384 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418036&FileExtension=.PDF&FileName=Report%20from%20Local%20Agency-%20City%20of%20Melbourne%20Airport%20Authority-Redacted.PDF - Report from Local Agency- Melbourne Airport Police Department (item 4, .PDF, 330 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418037&FileExtension=.PDF&FileName=Report%20from%20Local%20Agency-%20Melbourne%20Airport%20Police%20Department-Redacted.PDF - Carburetor FAA 8130 Form (item 5, .PDF, 166 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418038&FileExtension=.PDF&FileName=Carburetor%20FAA%208130%20Form-Redacted.PDF - Carburetor Logbook Entry (item 6, .PDF, 307 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418039&FileExtension=.PDF&FileName=Carburetor%20Logbook%20Entry-Redacted.PDF - Post Accident Carburetor Test Report (item 7, .PDF, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418040&FileExtension=.PDF&FileName=Post%20Accident%20Carburetor%20Test%20Report-Master.PDF - E-mail from FIT Director of Maintenance Advising Firewall Replacement (item 8, .PDF, 123 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418041&FileExtension=.PDF&FileName=E-mail%20from%20FIT%20Director%20of%20Maintenance%20Advising%20Firewall%20Replacement-Redacted.PDF - CFI’s Initial Statement (item 9, .PDF, 93 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418042&FileExtension=.PDF&FileName=CFI%E2%80%99s%20Initial%20Statement-Master.PDF - Excerpts from Pilot’s Operating Handbook and FAA Approved Airplane Flight Manual (item 10, .PDF, 225 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418043&FileExtension=.PDF&FileName=Excerpts%20from%20Pilot%E2%80%99s%20Operating%20Handbook%20and%20FAA%20Approved%20Airplane%20Flight%20Manual-Redacted.PDF - Excerpts of Checklist Provided by FIT Aviation (item 11, .PDF, 178 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418044&FileExtension=.PDF&FileName=Excerpts%20of%20Checklist%20Provided%20by%20FIT%20Aviation-Master.PDF - Photo 1 - Rescue Response (Photo Courtesy of Melbourne Airport Authority) (item 12, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418045&FileExtension=.PDF&FileName=Photo%201%20-%20Rescue%20Response%20(Photo%20Courtesy%20of%20Melbourne%20Airport%20Authority)-Master.PDF - Photo 2 - Fire Damage (Photo Courtesy of FIT Aviation) (item 13, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418046&FileExtension=.PDF&FileName=Photo%202%20-%20Fire%20Damage%20(Photo%20Courtesy%20of%20FIT%20Aviation)-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.