GAA19CA176

NTSB accident investigation · Piper PA28 · Savannah, GA · March 20, 2019

Accident · No injuriesData collectionFinal report
Date
March 20, 2019, 15:00 local (19:00 UTC)
Place
Savannah, GA
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Standing
Aircraft
N2667QPiper PA28
Defining event
Standing-engine(s) start-up: Fire/smoke (non-impact)
Weather
Visual (VMC) · Day
Status
Completed · report November 6, 2019
Report
Approved by Office Director
NTSB office
General Aviation Accidents
Parties
FAA
FAA report
20190320001699A
Case key
99165

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 conduct the engine starting procedures in accordance with the Pilot’s Operating Handbook, which resulted in an engine fire.

Findings · 1

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 policy/procedurePersonnel issues › Task performance · PilotPiper PA-28-140: 3 casesAll aircraft: 191 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 pilot reported that, during the landing roll, wind pushed the airplane to the right and that he overcompensated with left rudder. The airplane veered left, abruptly rotated about 180°, and then stopped on the runway at a taxiway intersection. The tower controller asked the pilot if he could restart the engine or if he needed a tow. The pilot attempted to restart the engine four to five times. While attempting a "hot start," he saw black smoke coming from the lower left engine cowling. He leaned forward and saw flames in the same location. The pilot searched for a fire extinguisher to no avail. He egressed the airplane without further incident. The pilot added that, during the multiple restarts, he engaged the starter for 5 to 8 seconds and estimated that the time between attempts was about 5 seconds. He attempted a hot start for the first couple of attempts. After he observed the engine fire, he attempted a flooded start. The airplane sustained substantial damage to the fuselage. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The director of maintenance reported that the fire extinguisher was located in the seat pocket behind the copilot's seat. The airport's automated weather observation station reported that, about 7 minutes before the accident, the wind was from 360° at 10 knots, gusting to 17 knots. The pilot landed the airplane on runway 10. The Pilot's Operating Handbook, Section 3.7, "Engine Fire During Start," stated the following: Engine fires during start are usually the result of overpriming. Section 4.13, "Starting Engine," stated the following: Starter manufacturers recommend that cranking periods be limited to thirty sections with a two minute rest between cranking periods. Longer cranking periods will shorten the life of the starter.

Factual narrative

The pilot reported that, during the landing roll, the wind pushed the airplane to the right and he overcompensated with left rudder. The airplane veered to the left, abruptly rotated about 180°, and the engine and airplane stopped on the runway at a taxiway intersection. The tower controller asked if the pilot could restart the engine or if he needed a tow. The pilot attempted to restart the engine 4 to 5 times. While attempting a "hot start", he observed black smoke from the lower left engine cowling. He leaned forward and saw flames in the same location. The pilot searched for a fire extinguisher, to no avail. He egressed the airplane without further incident. The pilot added that, during the multiple restarts, he engaged the starter for 5 to 8 seconds and estimated that the time between attempts was about 5 seconds. He attempted a hot start for the first couple of attempts, then after he observed the engine fire, he attempted a flooded start. The airplane sustained substantial damage to the fuselage. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The director of maintenance reported that the fire extinguisher was located in the seat pocket behind the copilot's seat. The automated weather observation station located on the airport reported that, about 7 minutes before the accident, the wind was from 360° at 10 knots, gusting to 17 knots. The pilot landed the airplane on runway 10. The pilot's operating handbook contained section 3.7 titled, "Engine Fire During Start", which stated: Engine fires during start are usually the result of overpriming. It continued in section 4.13 titled, "Starting Engine", which stated: Starter manufacturers recommend that cranking periods be limited to thirty sections with a two minute rest between cranking periods. Longer cranking periods will shorten the life of the starter.

Aircraft

Registration
N2667Q
Reported as
Piper PA28 (140)
Category
Airplane
Serial number
28-7725203
Built
1977
Airframe hours
4,867.8
Engine
Lycoming O-320-E3D, 160 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Operator
Bw Aviation Llc
Registered owner
Bw Aviation Llc
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · February 8, 2019
Departed
DYB · Summerville, SC
Destination
SAV · Savannah, GA
Airport
SAV · Savannah/Hilton Head Intl, runway 10, 9,351 × 150 ft, concrete
Equipment
Electronic flight bag or handheld device, 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
59
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
March 20, 2019
Seat
Left
Restraint
3-point
Flight hours
81 total · 81 in this make and model · 15 as pilot in command · 35 in the last 90 days · 17 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
360° at 10 knots, gusting 17
Visibility
10 statute miles
Temperature
66 °F, dew point 43 °F
Altimeter
30.10 inHg

Docket · 6

The files NTSB released with the investigation on May 2, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.2 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.