ERA23LA347

NTSB accident investigation · Piper PA28 · Knoxville, TN · July 27, 2023

Accident · No injuriesClass 3 · LimitedFinal report
Date
July 27, 2023, 14:41 local (18:41 UTC)
Place
Knoxville, TN
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N15417Piper PA28
Defining event
Takeoff: Fire/smoke (non-impact)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20230727012959A
Case key
192929

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

An in-flight fire that resulted from an inadequate 100-hr inspection, which failed to detect and correct improper electrical cable routing in the engine compartment.

Findings · 2

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.

Electrical power system: electrical pwr sys wiringAircraft › Aircraft systems · Incorrect service/maintenancePiper PA-28-180: 1 caseAll aircraft: 44 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelPiper PA-28-180: 6 casesAll aircraft: 320 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

When the flight instructor initiated a takeoff roll, the engine rpm initially increased to 2,200, then decreased to 800, followed by flames emanating from the engine cowling. The flight instructor rejected the takeoff, secured the engine, and exited the airplane on the runway; however, the fire continued in the engine compartment until airport personnel were able to extinguish it. Postaccident examination of the engine compartment revealed that about a 25 to 30-in length of starter motor electrical lead was not clamped and had drooped down on top of the fuel primer line. Metal beads on top of the fuel primer line were consistent with chaffing and welding due to contact from the electrical lead. It is likely that arcing from the lead ignited fuel in the fuel primer line. The airplane had been operated for 73 hours during a 1-month period following its most recent 100-hr inspection. The electrical lead drooping down and resting on top of the fuel primer line was contrary to Federal Aviation Administration (FAA) and aircraft manufacturer maintenance instructions regarding proper routing and should have been identified and corrected during the most recent 100-hr inspection.

Factual narrative

On July 27, 2023, about 1441 eastern daylight time, a Piper PA-28-180, N15417, was substantially damaged when it was involved in an accident near Knoxville, Tennessee. The flight instructor and student pilot were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor reported that the accident flight was the student pilot’s first flight (discovery flight). The flight instructor added that the preflight inspection, engine start, taxi, and run-up were normal. He initiated a takeoff roll on runway 26 by letting the student pilot advance the throttle. The engine rpm initially increased to 2,200, then decreased to 800, followed by flames emanating from the engine cowling. The flight instructor rejected the takeoff, advanced the throttle lever, retracted the mixture level, and turned off all electrical equipment, including the master switch. He also instructed the student pilot to turn the magnetos and fuel selector to off, which he did. They then exited the airplane on the runway and called the fixed based operator for assistance. Examination of the engine compartment by a Federal Aviation Administration inspector revealed substantial damage to an engine mount tube. The inspector also noted that about a 25 to 30-in length of starter motor electrical lead was not clamped and had drooped down on top of the fuel primer line. He also observed metal “beads” on top of the fuel primer line, consistent with chaffing and welding due to contact from the electrical lead. Review of maintenance records revealed that the airplane had been operated for 73 hours during a 1-month period following its most recent 100-hr inspection. FAA Advisory Circular AC 43-13-1, Section 2 Fuel Systems, revealed: “…b Routing. Make sure that the line does not chafe against control cables, airframe structure etc., or come in contact with electrical wiring or conduit…In no case should wiring be supported by the fuel line…” Review of Piper Cherokee Service Manual, Table III-I Inspection Report, B. Engine Group, revealed: “…39. Inspect engine compartment wiring for condition (chafing, cracked insulation, general deterioration), security, proper routing, and correct installation…”

Aircraft

Registration
N15417
Reported as
Piper PA28 (180)
Category
Airplane
Serial number
28-7305073
Built
1972
Airframe hours
8,449
Engine
Lycoming O-360-A4A, 180 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Instructional · Part 91
Operator
Knoxville Flight Training Academy
Registered owner
Bremfour Aviation Group Inc
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · June 27, 2023 · 73 hours before
Airport
DKX · Knoxville Downtown Island Airport, runway 26, 3,499 × 75 ft, asphalt
Equipment
ADS-B, Electronic primary flight display, 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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
25
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
July 21, 2023
Seat
Right
Restraint
3-point
Flight hours
912 total · 300 in this make and model · 848 as pilot in command · 201 in the last 90 days · 78 in the last 30 days · 0 in the last 24 hours
Role
Student pilot
Injuries
Minor
Seat
Left
Restraint
3-point
Flight hours
0 total · 0 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
270° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
90 °F, dew point 70 °F
Altimeter
30.11 inHg
Observed at
DKX
METAR
METAR KDKX 271835Z AUTO 27004KT 10SM CLR 32/21 A3011 RMK A01=

Docket · 5

The files NTSB released with the investigation on June 20, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.2 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.