# NTSB ERA16LA154: Piper PA28, N16366, West Mifflin, PA, March 27, 2016 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: March 27, 2016, 11:00 local (16:00 UTC) - Place: West Mifflin, PA - Coordinates: 40.354442, -79.929168 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.3544&lon=-79.9292&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 September 10, 2018 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 92998 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA16LA154 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/92998/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=92998 - Page: https://openairdocs.org/ntsb/ERA16LA154 ## Probable cause The pilot's failure to follow checklist procedures for an engine fire during start. ## 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 · Pilot (probable cause); cases with it: [Piper PA-28-180, 16 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7102808), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-180, 10 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=7102808), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-180, 3 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=7102808), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md) - [Power plant](https://openairdocs.org/ntsb-findings/01057100): Aircraft › Aircraft power plant · Incorrect use/operation (probable cause); cases with it: [Piper PA-28-180, 3 cases](https://openairdocs.org/ntsb-findings/01057100/cases.md?model=7102808), [All aircraft, 198 cases](https://openairdocs.org/ntsb-findings/01057100/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-28-180, 4 cases](https://openairdocs.org/ntsb-events/150/sequence.md?model=7102808), [All aircraft, 504 cases](https://openairdocs.org/ntsb-events/150/sequence.md) ## 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](https://openairdocs.org/deregistered/N16366-2018-10-22), registration cancelled 2018-10-22, S/N 28-7305236, built 1973 (OpenAirDocs) - Reported make and model: PIPER PA28 (180) - Registry model: [Piper PA-28-180](https://openairdocs.org/model/piper-pa-28-180) (registry code 7102808) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-7305236 - Year built: 1973 - Airframe hours: 6336.6 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 79; injuries: none; 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 ## 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 20160327006229A](https://openairdocs.org/incident/20160327006229A), Mar 27, 2016: Piper PA-28-180, West Mifflin, PA, Substantial damage. At approximately 11:00 am at allegheny county airport, the aircraft was parked on the upper west ramp. The airman planned a local flight and had the aircraft… ## Docket (4 files) The files NTSB released with the investigation on July 25, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=92998. 2.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 380 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40465432&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Excerpts from Pilot's Operating Handbook (item 2, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40465433&FileExtension=.PDF&FileName=Excerpts%20from%20Pilot%27s%20Operating%20Handbook-Master.PDF - Photograph - Main Wreckage (item 3, .PDF, 1 photo, 314 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40465434&FileExtension=.PDF&FileName=Photograph%20-%20Main%20Wreckage-Master.PDF - Memorandum for Record - Conversation with FAA Inspector (item 4, .PDF, 114 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40465435&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20Conversation%20with%20FAA%20Inspector-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.