# NTSB ERA16LA119: Piper PA28 151, N41618, St. Augustine, FL, February 22, 2016 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: February 21, 2016, 20:15 local (Feb 22, 2016, 01:15 UTC) - Place: St. Augustine, FL - Coordinates: 29.959167, -81.339721 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.9592&lon=-81.3397&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 November 15, 2018 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 92781 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA16LA119 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/92781/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=92781 - Page: https://openairdocs.org/ntsb/ERA16LA119 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Piper PA-28-151, 2 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7102805), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Engine fuel and control: fuel control/carburetor](https://openairdocs.org/ntsb-findings/01057322): Aircraft › Aircraft power plant · Related operating info (probable cause); cases with it: [Piper PA-28-151, 1 case](https://openairdocs.org/ntsb-findings/01057322/cases.md?model=7102805), [All aircraft, 195 cases](https://openairdocs.org/ntsb-findings/01057322/cases.md) - [Use of equip/info: use of policy/procedure](https://openairdocs.org/ntsb-findings/02063032): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Piper PA-28-151, 2 cases](https://openairdocs.org/ntsb-findings/02063032/cases.md?model=7102805), [All aircraft, 191 cases](https://openairdocs.org/ntsb-findings/02063032/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-28-151, 1 case](https://openairdocs.org/ntsb-events/150/sequence.md?model=7102805), [All aircraft, 504 cases](https://openairdocs.org/ntsb-events/150/sequence.md) ## 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](https://openairdocs.org/aircraft/N41618), registered now, S/N 28-7415295, built 1974 (OpenAirDocs) - Reported make and model: PIPER PA28 151 (151) - Registry model: [Piper PA-28-151](https://openairdocs.org/model/piper-pa-28-151) (registry code 7102805) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-7415295 - Year built: 1974 - Airframe hours: 7816 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 22; injuries: none; 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 - Pilot; age 37; injuries: none; 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 ## 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 20160222004569A](https://openairdocs.org/incident/20160222004569A), Feb 22, 2016: Piper PA-28-151, Saint Augustine, FL, Substantial damage. On February 22 approximately 2000 local time instructor pilot landed with student on runway 13, Saint Augustine (sgj). They were returning from a training… ## Other investigations on N41618 (1) 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. - [NTSB IAD74DLJ46](https://openairdocs.org/ntsb/IAD74DLJ46), Jun 2, 1974: Piper PA-28 (N41618), Corapeake, NC, substantial damage ## Docket (5 files) The files NTSB released with the investigation on October 18, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=92781. 9.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 964 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467522&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot's Statement (item 2, .PDF, 139 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467523&FileExtension=.PDF&FileName=Pilot%27s%20Statement-Master.PDF - FAA Inspector's Statement (item 3, .PDF, 14 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467524&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Statement-Master.PDF - Emergency Procedure (item 4, .PDF, 415 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467525&FileExtension=.PDF&FileName=Emergency%20Procedure-Master.PDF - Photos (item 5, .PDF, 20 photos, 7.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467526&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. --- 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.