# NTSB GAA19CA176: Piper PA28, N2667Q, Savannah, GA, March 20, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: March 20, 2019, 15:00 local (19:00 UTC) - Place: Savannah, GA - Coordinates: 32.128334, -81.198333 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.1283&lon=-81.1983&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 November 6, 2019 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 99165 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA19CA176 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99165/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99165 - Page: https://openairdocs.org/ntsb/GAA19CA176 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: use of policy/procedure](https://openairdocs.org/ntsb-findings/02063032): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-140, 3 cases](https://openairdocs.org/ntsb-findings/02063032/cases.md?model=7102802), [All aircraft, 191 cases](https://openairdocs.org/ntsb-findings/02063032/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-28-140, 2 cases](https://openairdocs.org/ntsb-events/150/sequence.md?model=7102802), [All aircraft, 504 cases](https://openairdocs.org/ntsb-events/150/sequence.md) ## 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](https://openairdocs.org/deregistered/N2667Q-2019-09-24), registration cancelled 2019-09-24, S/N 28-7725203 (OpenAirDocs) - Reported make and model: Piper PA28 (140) - Registry model: [Piper PA-28-140](https://openairdocs.org/model/piper-pa-28-140) (registry code 7102802) (OpenAirDocs) - Category: Airplane - Serial number: 28-7725203 - Year built: 1977 - Airframe hours: 4867.8 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 59; injuries: none; 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 ## 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 20190320001699A](https://openairdocs.org/incident/20190320001699A), Mar 20, 2019: Piper PA-28-140, Savannah, GA, Substantial damage. On March 20, 2019 about 1506 eastern daylight time, a Piper cherokee, P-28-140, N2667Q, was substantially damaged after losing control on runway 01 during… ## Docket (6 files) The files NTSB released with the investigation on May 2, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99165. 5.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472416&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot's Statement (item 2, .PDF, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472417&FileExtension=.PDF&FileName=Pilot%27s%20Statement-Master.PDF - Record of Conversation - Pilot (item 3, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472418&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Pilot-Master.PDF - Record of Conversation - Director of Maintenance (item 4, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472419&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Director%20of%20Maintenance-Master.PDF - Pilot's Operating Handbook Excerpt (item 5, .PDF, 342 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472420&FileExtension=.PDF&FileName=Pilot%27s%20Operating%20Handbook%20Excerpt-Master.PDF - Accident Photos (item 6, .PDF, 3 photos, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472421&FileExtension=.PDF&FileName=Accident%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. --- 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.