ERA16LA119

NTSB accident investigation · Piper PA28 151 · St. Augustine, FL · February 22, 2016

Accident · No injuriesLimited investigationFinal report
Date
February 21, 2016, 20:15 local (Feb 22, 2016, 01:15 UTC)
Place
St. Augustine, FL
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Standing
Aircraft
N41618Piper PA28 151
Defining event
Standing-engine(s) start-up: Fire/smoke (non-impact)
Weather
Visual (VMC) · Night/bright
Status
Completed · report November 15, 2018
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20160222004569A
Case key
92781

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 start, which resulted in a carburetor fire. Contributing to the severity of accident was the flight instructor's failure to follow the Pilot Operating Handbook's engine fire during start emergency procedures.

Findings · 3

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.

Use of equip/info: use of equip/systemPersonnel issues › Task performance · Instructor/check pilotPiper PA-28-151: 2 casesAll aircraft: 1,391 casesProbable cause
Engine fuel and control: fuel control/carburetorAircraft › Aircraft power plant · Related operating infoPiper PA-28-151: 1 caseAll aircraft: 195 casesProbable cause
Use of equip/info: use of policy/procedurePersonnel issues › Task performance · Instructor/check pilotPiper PA-28-151: 2 casesAll aircraft: 191 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

According to the flight instructor, the airplane's engine stopped producing power during taxi immediately after landing. He attempted to restart the engine, but it caught fire. He stopped the airplane, and both the instructor and the student egressed, but they made no attempt to extinguish the fire because there was no fire extinguisher on board the airplane. Although the fire was eventually extinguished by first responders, it substantially damaged the airplane. Review of the Pilot's Operating Handbook (POH) revealed that engine fires during start were usually due to overpriming and that the first attempt to extinguish the fire should be to try to start the engine and draw the excess fuel back into the induction system. It is likely the flight instructor overprimed the engine, which resulted in an engine fire, and then failed to follow the POH procedure to extinguish the fire. Due to the instructor's failure to attempt to remediate the problem, the fire was not extinguished in a timely manner.

Factual narrative

On February 21, 2016, about 2015 eastern standard time, a Piper PA-28-151, N41618, was substantially damaged by an engine fire after landing at Northeast Florida Regional Airport (SGJ), St. Augustine, Florida. The flight instructor and his pilot-rated student were not injured. Night visual meteorological conditions prevailed, and no flight plan was filed for the local instructional flight, which was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. According to the flight instructor, the airplane's engine stopped producing power during taxi immediately after landing. An engine restart was attempted, and the engine caught fire. The airplane was stopped, and both the instructor and the student egressed the airplane, but made no attempt to extinguish the fire, as there was no fire extinguisher on board the airplane. Instead, the instructor dialed 911 on his cellular telephone. The fire department on the airport was closed, and local police and fire responded to the call. The police arrived first, and were delayed at a perimeter gate, which was subsequently opened by airport personnel. The first police officer on scene suppressed the fire with a hand-held fire extinguisher from his cruiser until firefighters arrived and ensured the fire was fully extinguished shortly thereafter. The firefighters gained access through an entry point previously briefed and rehearsed with the airport authority. Examination of the airplane by a Federal Aviation Administration (FAA) aviation safety inspector revealed that both the engine firewall and mount required replacement due to fire damage. The inspector asked the operator why no fire extinguisher was installed in the accident airplane. He said the airplane was a late addition to the school's fleet, and that he and his staff "forgot" to install one. All other airplanes at the school were equipped with fire extinguishers. The instructor held a commercial pilot and flight instructor certificates with ratings for airplane single engine land, multiengine land and instrument airplane. His most recent third-class medical certificate was issued on January 18, 2016. The pilot reported 153 total hours of flight experience, of which 65 hours were in the accident airplane make and model. The pilot held a private pilot certificate with a rating for airplane single engine land. His most recent first-class medical certificate was issued on January 27, 2016. The instructor reported 895 total hours of flight experience, of which 20 hours were in the accident airplane make and model. The four-seat, single-engine, low-wing airplane was manufactured in 1974 and was equipped with a Lycoming O-320 series engine. A review of logbook entries by the FAA inspector revealed the airplane's most recent 100-hour inspection was completed July 27, 2015, at 7,717 total aircraft hours. Review of the Pilot's Operating Handbook, Section 3, Emergency Procedures revealed that engine fires during start were usually theresult of overpriming, and that the first attempt to extinguish the fire should be to try to start the engine and draw the excess fuel back into the induction system.

Aircraft

Registration
N41618
Reported as
Piper PA28 151 (151)
Category
Airplane
Serial number
28-7415295
Built
1974
Airframe hours
7,816
Engine
Lycoming O-320 SERIES, 150 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Instructional · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · July 27, 2015 · 99 hours before
Departed
SGJ · St. Augustine, FL
Destination
SGJ · St. Augustine, FL
Airport
SGJ · Northeast Florida Rgnl, runway 13, 8,002 × 150 ft, asphalt

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
22
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
Restraint
3-point
Flight hours
895 total · 65 in this make and model · 800 as pilot in command · 210 in the last 90 days · 80 in the last 30 days · 8 in the last 24 hours
Role
Pilot
Age
37
Injuries
None
Certificate
Private
Airplane ratings
Single-engine sea
Medical
Class 3, With waivers/limitations
Seat
Right
Restraint
3-point
Flight hours
153 total · 20 in this make and model · 77 as pilot in command · 33 in the last 90 days · 26 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/bright
Wind
160° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
64 °F, dew point 57 °F
Altimeter
30.12 inHg
Observed at
KSGJ

Docket · 5

The files NTSB released with the investigation on October 18, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 9.4 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.

Other investigations on N41618 · 1

Matched to the same aircraft by N-number and date.