ERA16LA154

NTSB accident investigation · Piper PA28 · West Mifflin, PA · March 27, 2016

Accident · No injuriesLimited investigationFinal report
Date
March 27, 2016, 11:00 local (16:00 UTC)
Place
West Mifflin, PA
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Standing
Aircraft
N16366Piper PA28
Defining event
Standing-engine(s) start-up: Fire/smoke (non-impact)
Weather
Visual (VMC) · Day
Status
Completed · report September 10, 2018
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20160327006229A
Case key
92998

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 pilot's failure to follow checklist procedures for an engine fire during start.

Findings · 4

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 · PilotPiper PA-28-180: 16 casesAll aircraft: 1,391 casesProbable cause
Action: incorrect action performancePersonnel issues › Action/decision · PilotPiper PA-28-180: 10 casesAll aircraft: 1,386 casesProbable cause
Use of equip/info: use of checklistPersonnel issues › Task performance · PilotPiper PA-28-180: 3 casesAll aircraft: 336 casesProbable cause
Power plantAircraft › Aircraft power plant · Incorrect use/operationPiper PA-28-180: 3 casesAll aircraft: 198 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 private pilot stated that he attempted to start the airplane's engine but that it would not start. On the fifth attempt, he followed the "starting engine when flooded" checklist. As the propeller was turning with the starter motor engaged, white smoke began to emanate from the engine cowling. He then turned off the master switch, exited the airplane, and opened the engine cowling. Flames suddenly emanated from the left side of the engine. The engine and compartment subsequently sustained substantial fire and heat damage. The pilot added that there were no preaccident mechanical malfunctions with the airplane; examination of the wreckage revealed that the primer control was not in and locked. Review of a pilot's operating manual for the airplane revealed that, if an engine fire occurs during start, the pilot should move the mixture control to idle, move the throttle control to full open, and continue to turn the engine with the starter motor in an attempt to pull the fire into the engine. If the pilot had followed this procedure, it is likely that the fire would have been extinguished and prevented further damage to the airplane.

Factual narrative

On March 27, 2016, about 1100 eastern daylight time, a Piper PA28-180, N16366, was substantially damaged after a fire occurred during engine startup while the airplane was parked on the ramp at the Allegheny County Airport (AGC), West Mifflin, Pennsylvania. The private pilot was not injured. Visual meteorological conditions prevailed and no flight plan was filed for the intended local personal flight that was to be conducted under the provisions of Title 14 Code of Federal Regulations Part 91.The pilot stated that on the morning of the accident, he called the fuel supplier and asked for the airplane to be topped-off, in preparation for a local flight. After performing a preflight inspection, he attempted to start the engine but it would not start. He tried three additional times, without success. On the fifth attempt, he followed the "starting engine when flooded" checklist. As the propeller was turning with the starter, he noticed white smoke "pouring out" of the engine cowl. He turned off the master switch and exited the airplane. He then opened the top engine cowling, and flames suddenly emanated from the left side of the engine, and the color of the smoke changed from white to dark black. He returned to the cockpit to retrieve a handheld fire extinguisher; however, the cockpit was filling up with heavy black smoke and he was forced to egress and unable to suppress the engine fire. The pilot added that there were no preaccident mechanical malfunctions with the airplane. According to Federal Aviation Administration and maintenance records, the airplane was manufactured in 1973. The airplane's most recent annual inspection was completed on September 8, 2015. At the time of the accident, the airplane had accumulated 6,336 total hours of flight time. Examination of the airplane by an FAA inspector revealed that the engine and compartment had incurred substantial fire and heat damage. Inside the cockpit, the fuel primer knob was found in the out/unlocked position. Additionally, review of a pilot's operating manual for the make and model airplane revealed: "…Engine Fire (During Start): Engine fires during start are usually the result of overpriming. The following procedure is designed to draw the excess fuel back into the induction system. a. If engine has not started: (1) Mixture – Idle Cut-Off (2) Throttle – Open (3) Turn engine with starter (This is an attempt to pull the fire into the engine.)…"

Aircraft

Registration
N16366
Reported as
Piper PA28 (180)
Category
Airplane
Serial number
28-7305236
Built
1973
Airframe hours
6,336.6
Engine
Lycoming O-360-A4, 180 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · September 8, 2015
Departed
AGC · West Mifflin, PA
Destination
AGC · West Mifflin, PA
Airport
AGC · Allegheny County
Equipment
Handheld GPS, Auto-pilot, Angle of attack indicator, Stall warning system

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
79
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
September 19, 2013
Seat
Left
Flight hours
1,029 total · 623.7 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
140° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
57 °F, dew point 39 °F
Altimeter
30.14 inHg
Observed at
KAGC

Docket · 4

The files NTSB released with the investigation on July 25, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.1 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.