# NTSB ERA15LA369: Piper PA 28-161, N9887K, Pittsburg, PA, September 19, 2015

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Limited investigation · Final report
- Date: September 19, 2015, 10:15 local (14:15 UTC)
- Place: Pittsburg, PA
- Coordinates: 40.608612, -79.826385 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=40.6086&lon=-79.8264&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: 1 uninjured
- Status: Completed, report November 30, 2015
- Report: Approved by Office Director
- NTSB office: Eastern Region Aviation
- Parties: FAA/FSDO
- NTSB case key (mKey): 92039
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA15LA369
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/92039/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=92039
- Page: https://openairdocs.org/ntsb/ERA15LA369

## Probable cause

An engine fire, which resulted from the overpriming of a hot engine.

## 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 · 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)
- [Engine fuel and control: fuel control/carburetor](https://openairdocs.org/ntsb-findings/01057322): Aircraft › Aircraft power plant · Capability exceeded (probable cause); cases with it: [Piper PA-28-161, 4 cases](https://openairdocs.org/ntsb-findings/01057322/cases.md?model=7102803), [All aircraft, 195 cases](https://openairdocs.org/ntsb-findings/01057322/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 pilot reported that he landed the airplane and parked it to address an in-flight anomaly with his headset. He then performed a preflight inspection. Before starting the engine, he pumped the primer twice and then attempted to start the engine. Subsequently, he observed smoke emanating from the engine area. He continued attempting to start the engine while moving the mixture lever to the fuel "cutoff" position. He then observed flames emanating from under the engine cowling, discontinued attempting to start the engine, and exited the airplane. Postaccident examination revealed extensive fire damage to the engine and airframe that appeared to have originated in or around the carburetor. The Pilot's Operating Handbook provided no guidance on using the primer when starting a hot engine but stated that "engine fires during start are usually the result of overpriming." It is likely that the hot engine was overprimed, which resulted in excess fuel in the carburetor and the subsequent engine fire.

## Factual narrative

On September 19, 2015, about 1015 eastern daylight time, a Piper PA-28-161, N9887K, was substantially damaged by fire during an attempted engine start at Pittsburgh Northeast Airport (9G1), Pittsburgh, Pennsylvania. The private pilot was not injured. Visual meteorological conditions prevailed and no flight plan was filed for the personal flight, which was destined for Richmond International Airport (RIC), Richmond, Virginia. The airplane was owned by Tanstaafl Machine Tool Service, Inc. and operated by a private individual under the provisions of Title 14 Code of Federal Regulations Part 91.According to the pilot, the flight originated from the Butler County Airport (BTP), Butler, Pennsylvania earlier that day. During the flight he heard a "fluttering or abnormal noise" and elected to divert to 9G1. After parking the airplane on the ramp, he noticed his noise-canceling headset was not turned to the "ON" position. He subsequently performed a walk-around of the airplane and another preflight inspection. A few moments later he got back into the airplane, to continue his planned flight, as his normal procedure, primed the engine with "two pumps of the primer," and began cranking the engine. Subsequently, he observed smoke emanating from the engine area and continued to crank the engine while pulling the mixture to fuel cut-off. However, he observed flames coming out from under the cowling and exited the airplane. Due to limited resources in the immediate vicinity, the airplane continued to burn until first responders arrived, about 30 minutes later. According to a Federal Aviation Administration inspector who examined the airplane after the accident, there was substantial damage as a result of fire to the wings, cockpit, and engine area. Further examination revealed extensive fire damage in the area of the carburetor. The inspector reported that the fire "appeared to have started near the carburetor." Review of airplane maintenance records revealed that an entry, dated February 12, 2014, indicated repair following an engine fire during a start attempt. The repair included replacing various parts located on the aft side of the engine, including the carburetor. The repair was completed approximately 60 flight hours prior to the accident. The pilot reported that he was also the pilot during that engine fire event. The PA-28-161 Pilot's Operating Handbook addresses procedure for engine fire during start. Section 3, Emergency Procedures, states "Engine fires during start are usually the result of overpriming. The first attempt to extinguish the fire is to try to start the engine and draw the excess fuel back into the induction system. If a fire is present before the engine has started, move the mixture control to idle cut-off, open the throttle, and crank the engine…if fire continues more than a few seconds, the fire should be extinguished by the best available external means. The fuel selector valves should be 'OFF' and the mixture at idle cut-off if anexternal fire extinguishing method is to be used." Section 4, Normal Procedures, addresses starting the engine when "cold" and "hot." Only the guidance provided for starting the engine when cold addresses the need for priming the engine, there was no guidance on using the primer when the engine was hot.

## Aircraft

- Registration: [N9887K](https://openairdocs.org/deregistered/N9887K-2017-02-06), registration cancelled 2017-02-06, S/N 28-7816206, built 1977 (OpenAirDocs)
- Reported make and model: PIPER PA 28-161
- Registry model: [Piper PA-28-161](https://openairdocs.org/model/piper-pa-28-161) (registry code 7102803) (OpenAirDocs)
- Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 28-7816206
- Year built: 1977
- Airframe hours: 4663.78
- Engines: LYCOMING O-320-D3G 160 horsepower reciprocating
- Damage: Substantial damage
- Fire: On-Ground
- Flight: Personal, Part 91
- Airworthiness certificate: Standard, Normal; Standard, Utility
- Last inspection: Annual, April 3, 2015, 44 hours before
- Departed: 9G1, Pittsburg, PA
- Destination: RIC, Richmond, VA
- Airport: 9G1, Pittsburgh Northeast

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 61; injuries: none; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review February 17, 2014; seat: left; restraint: 3-point; flight hours: 2,506.1 total, 1,800 in this make and model, 2,506.1 as pilot in command, 33.2 in the last 90 days

## Weather

- Conditions: Visual (VMC), Day
- Wind: 190° at 8 knots, gusting 14
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 75 °F, dew point 61 °F
- Altimeter: 29.89 inHg
- Observed at: KBTP, 12 nm away

## FAA reports on this event (1)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Accident 20150919019049A](https://openairdocs.org/incident/20150919019049A), Sep 19, 2015: Piper PA-28-161, Tarentum, PA, Destroyed. At approximately 11:30 am on Saturday September 19, 2015, at Northeast Pittsburgh airport (K9G1) pa, N9887K, a Piper PA-28-161 became engulfed in fire while…

## Docket (8 files)

The files NTSB released with the investigation on October 27, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=92039. 2.7 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 375 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40433264&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF
- Memorandum of Record - Phone Conversation with Pilot (item 2, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40433265&FileExtension=.PDF&FileName=Memorandum%20of%20Record%20-%20Phone%20Conversation%20with%20Pilot-Master.PDF
- Email from Pilot about Fire Fighting Abilities at Airport (item 3, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40433266&FileExtension=.PDF&FileName=Email%20from%20Pilot%20about%20Fire%20Fighting%20Abilities%20at%20Airport-Master.PDF
- Pilot Operating Handbook [Excerpts] (item 4, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40433267&FileExtension=.PDF&FileName=Pilot%20Operating%20Handbook%20%5BExcerpts%5D-Master.PDF
- Maintenance Records (Excerpts) (item 5, .PDF, 565 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40433268&FileExtension=.PDF&FileName=Maintenance%20Records%20(Excerpts)-Master.PDF
- Memorandum for Records - Butler Airport Weather (item 6, .PDF, 125 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40433269&FileExtension=.PDF&FileName=Memorandum%20for%20Records%20-%20Butler%20Airport%20Weather-Master.PDF
- Memorandum for Record - FAA Inspector Notes on Damage (item 7, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40433270&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20FAA%20Inspector%20Notes%20on%20Damage-Master.PDF
- Photos (item 8, .PDF, 4 photos, 382 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40433271&FileExtension=.PDF&FileName=Photos-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.

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