# NTSB ERA17CA295: Piper PA 28-161, N84175, Palatka, FL, August 25, 2017

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Data collection · Final report
- Date: August 25, 2017, 10:30 local (14:30 UTC)
- Place: Palatka, FL
- Coordinates: 29.658056, -81.689445 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=29.6581&lon=-81.6894&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: 3 uninjured
- Status: Completed, report October 24, 2018
- Report: Approved by Office Director
- NTSB office: Eastern Region Aviation
- Parties: FAA/FSDO
- NTSB case key (mKey): 95894
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA17CA295
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/95894/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=95894
- Page: https://openairdocs.org/ntsb/ERA17CA295

## Probable cause

The student pilot's overpriming of the engine and the flight instructor's delayed remedial action, which resulted in an engine fire.

## 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 · Student/instructed pilot (probable cause); cases with it: [Piper PA-28-161, 12 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7102803), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md)
- [Attention/monitoring: monitoring other person](https://openairdocs.org/ntsb-findings/02021535): Personnel issues › Psychological · Instructor/check pilot (probable cause); cases with it: [Piper PA-28-161, 2 cases](https://openairdocs.org/ntsb-findings/02021535/cases.md?model=7102803), [All aircraft, 200 cases](https://openairdocs.org/ntsb-findings/02021535/cases.md)
- [Engine fuel and control: fuel control/carburetor](https://openairdocs.org/ntsb-findings/01057322): Aircraft › Aircraft power plant · Incorrect use/operation (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)
- [Fire protection system: fire bottle, portable](https://openairdocs.org/ntsb-findings/01022622): Aircraft › Aircraft systems · Not serviced/maintained; cases with it: [Piper PA-28-161, 1 case](https://openairdocs.org/ntsb-findings/01022622/cases.md?model=7102803), [All aircraft, 1 case](https://openairdocs.org/ntsb-findings/01022622/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Landing-landing roll: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Piper PA-28-161, 22 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102803), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md)
- [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 flight instructor, student pilot, and pilot-rated passenger flew on a short cross-country instructional flight to practice stop-and-go landings. On the first landing, after touchdown, the student pilot reduced the engine power to idle, and the engine lost total power. The airplane stopped on the runway, and the student pilot noted that the electric fuel pump was still on from landing and that the mixture control was full forward. He tried to start the engine while he "pumped" the throttle, but it did not start. He stated he thought the engine was flooded, so he turned off the electric fuel pump and pulled the mixture control to the "off" position, but again the engine would not restart. He then pushed the mixture control back to full forward and tried to start the engine while pumping the throttle a couple more times, but the engine did not start. The student pilot then saw smoke coming out of the engine cowling and notified the flight instructor and passenger. The flight instructor performed the "engine fire on start checklist," told everyone to egress, and went to the cargo door to get the fire extinguisher while the passenger opened the engine cowling. When the flight instructor looked at the fire extinguisher, she noticed it was empty. The flight instructor and passenger noted that the fire was at the bottom of the engine around the carburetor and gaining in intensity. The passenger located a fire extinguisher at the airport's fixed-base operator, and when he returned, the engine compartment was fully engulfed by fire. Subsequently, the fire was extinguished by the portable extinguishers and the local fire department. Examination of the airplane revealed that the engine compartment, engine mounts, and firewall were substantially damaged by fire. The flight instructor reported no mechanical malfunctions or failures with the airplane that would have precluded normal operation.

## Factual narrative

The flight instructor, student pilot, and pilot rated passenger flew on a short cross-country instructional flight to practice stop-and-go landings. On the first landing, after touch down, the student pilot reduced the engine power to idle and the engine lost total power. The airplane stopped on the runway and the student pilot initiated an engine start and noted that the electric fuel pump was still on from landing and the mixture control was full forward. He tried to start the engine while he "pumped" the throttle, but it did not start. He stated he thought the engine was flooded so he turned off the electric fuel pump and pulled the mixture control to the off position. Again, he unsuccessfully tried to restart the engine. He then pushed the mixture control back to the full forward position and tried to start the engine while pumping the throttle a couple more times, but the engine did not start. The student pilot then saw smoke coming out of the engine cowling and notified the flight instructor and passenger. The flight instructor performed the "engine fire on start checklist," told everyone to egress, and went to the cargo door to get the fire extinguisher while the passenger opened the engine cowling. When the flight instructor looked at the fire extinguisher, she noticed it was empty. The flight instructor and passenger noted that the fire was at the bottom of the engine around the carburetor and gaining in intensity. The passenger left, located a fire extinguisher at the airport's fixed base operator, and when he returned, the engine compartment was fully engulfed by fire. Subsequently, the fire was extinguished by the portable extinguishers and the local fire department. Examination of the airplane revealed that the engine compartment, engine mounts, and firewall was substantially damaged by fire. The flight instructor reported no mechanical malfunctions or failures with the airplane that would have precluded normal operation.

## Aircraft

- Registration: [N84175](https://openairdocs.org/aircraft/N84175), registered now, S/N 288116274 (OpenAirDocs)
- Reported make and model: PIPER PA 28-161 (161)
- Registry model: [Piper PA-28-161](https://openairdocs.org/model/piper-pa-28-161) (registry code 7102803) (OpenAirDocs)
- Category: Airplane
- Serial number: 288116274
- Year built: 1981
- Airframe hours: 6928.9
- Engines: Lycoming O-320-D3G 160 horsepower reciprocating
- Damage: Substantial damage
- Fire: On-Ground
- Flight: Instructional, Part 91
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, August 25, 2017
- Departed: SGJ, St Augustine, FL
- Destination: 28J, Palatka, FL
- Airport: 28J, Palatka Muni - Lt Kay Larkin F, runway 09, 6,000 × 100 ft, asphalt
- Equipment: Stall warning system

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Flight instructor; age 24; injuries: none; commercial, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review March 13, 2017; seat: right; restraint: 3-point; flight hours: 522 total, 49 in this make and model, 361 as pilot in command, 94 in the last 90 days, 67 in the last 30 days
- Student pilot; age 21; injuries: none; student; medical: class 3, without waivers/limitations; seat: left; restraint: 3-point; flight hours: 64 total, 64 in this make and model, 11 as pilot in command, 64 in the last 90 days, 56 in the last 30 days, 2 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 100° at 7 knots
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 84 °F, dew point 75 °F
- Altimeter: 29.97 inHg
- Observed at: KSGJ, 26 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).

- [Incident 20170825012369I](https://openairdocs.org/incident/20170825012369I), Aug 25, 2017: Piper PA-28-161, Palatka, FL, Minor damage. After landing at the Palatka airport (28J the crew observed that the engine had stopped. While attempting to restart engine, smoke was observed outside the…

## Docket (5 files)

The files NTSB released with the investigation on September 17, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=95894. 5.0 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466679&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF
- Memorandum for Record – Telephone Interview, Flight Instructor (item 2, .PDF, 226 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466680&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20%E2%80%93%20Telephone%20Interview,%20Flight%20Instructor-Master.PDF
- Memorandum for Record – Telephone Interview, Student Pilot (item 3, .PDF, 220 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466681&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20%E2%80%93%20Telephone%20Interview,%20Student%20Pilot-Master.PDF
- Memorandum for Record – Telephone Interview, Pilot Rated Passenger (item 4, .PDF, 124 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466682&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20%E2%80%93%20Telephone%20Interview,%20Pilot%20Rated%20Passenger-Master.PDF
- Investigative Photos (item 5, .PDF, 2 photos, 764 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466683&FileExtension=.PDF&FileName=Investigative%20Photos-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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