LAX01LA250

NTSB accident investigation · Piper PA-34-200 · Chandler, AZ · July 18, 2001

Accident · Minor injuriesLimited investigationFinal report
Date
July 18, 2001, 08:43 local (15:43 UTC)
Place
Chandler, AZ
Injuries
1 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N15120Piper PA-34-200
Weather
Visual (VMC) · Dawn
Status
Completed · report May 28, 2002
Report
Approved by Office Director
Parties
FAA FLT STNDS DIST OFFICE, TEXTRON LYCOMING, THE NEW PIPER AIRCRAFT, INC.
FAA report
20010718016879A
Case key
52760

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The failure of maintenance personnel to properly tighten a fuel line fitting during an engine installation resulting in a fuel leak and fire during the maintenance checkflight. A factor in the accident was inadequate inspection of the installation prior to return to service.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

FireApproach - vfr pattern - final approach
Fuel system,line fitting - loose
Maintenance,installation - improperOther maintenance personnelCause
Maintenance,inspection - inadequateOther maintenance personnelFactor
Forced landingEmergency descent/landing
On ground/water encounter with terrain/waterLanding - roll

Analysis

A fire erupted in the right engine nacelle during a maintenance check flight following replacement of the engine. The pilot shutoff the engine and feathered the propeller; however, before he could complete the emergency checklist, black smoke began entering the cockpit via a fresh air vent in the leading edge of the wing near the nacelle. The visibility in the cockpit dropped to about 1 foot and the pilot couldn't see outside, or the instrument panel, or any controls. He declared an emergency and opened the pilot's window. He instructed his passenger to crack open the main door; however, his passenger couldn't find the door handles in the dense smoke. After a period of time he got the door cracked open and the smoke cleared. At that point they were down to 300 or 400 feet agl, and he identified an open field in which an emergency landing was made. Examination of the right-hand engine revealed it was mechanically intact; however, a hose-end "B-nut" at the inlet to the engine driven fuel pump exhibited an unusual number of exposed threads. The B-nut was loose and required 1 1/8 turns to finger-tighten and 1 1/4 turns to snug tighten with a wrench. When the B-nut was unscrewed from the fitting, the threads of the fitting and the B-nut itself did not exhibit any cracks or stripped threads. No other mechanical anomalies were found.

Factual narrative

On July 18, 2001, at 0843 hours mountain standard time, a Piper PA-34-200, N15120, made an off-airport emergency landing following onset of an engine nacelle fire in flight near Chandler, Arizona. The commercial certificated pilot received minor injuries and the sole passenger was not injured. The airplane was substantially damaged. The local area, post maintenance checkflight was operated by Garrison Aviation, Inc., under 14 CFR Part 91. The airplane departed from Chandler at 0745, and was returning to land when the fire commenced. Visual meteorological conditions prevailed and no flight plan was filed.

The pilot told the Safety Board investigator that the purpose of the flight was to functionally test the aircraft following repairs performed after a landing incident in which the nosewheel collapsed. The repairs to the aircraft included replacement of both engines and propellers. His passenger was a mechanic. The early portion of the flight was routine. The fire occurred after about 1 hour of flying as they were returning to land. Both engines were operating normally. The pilot had reduced the power during the descent and lowered the landing gear while on a 3- or 4-mile straight-in approach. After lowering the landing gear, he advanced the throttles and sensed a loss of power in the right engine by yawing of the aircraft. He did not recall any roughness or other abnormality in the right engine up to that point; however, when he looked at the right engine he saw black smoke coming from under the top cowl seam at the firewall and black streaking on the top of the nacelle. He secured the engine by pulling the throttle to idle, the prop to feather, and the mixture to idle cutoff. When he looked back at the engine, flames were visible on the outboard side of the nacelle and the cabin rapidly filled with black smoke. The visibility in the cockpit dropped to about 1 foot and he couldn't see outside, or the instrument panel, or any controls. He declared an emergency to Chandler air traffic control tower and opened the pilot's window. He instructed his passenger to crack open the main door; however, his passenger couldn't find the door handles in the dense smoke. After a period of time he got the door cracked open and the smoke cleared. At that point they were down to 300 or 400 feet agl, and he identified an open field as an emergency landing site. He reduced power on the left engine, pulled up to fly over power lines, and landed in the field. The airplane encountered a berm during the landing roll, which collapsed the landing gear, and the airplane slid to a stop. As they exited through the door on the right-hand side, flames were still visible from the right engine, accompanied by black smoke. The fire expanded to envelop the right engine nacelle and wing. Fire department trucks arrived soon and extinguished the fire.

The pilot said that, because of the rapidness with which the cabin filled with smoke and the rapidness of subsequent landing events, he never completed the engine shutdown checklist. He never turned off the fuel selector valve or the electric fuel boost pump. He said the fresh air vent had been open at the time of the fire and it draws air in through an inlet in the leading edge of the wing outboard of the right engine. He believed that the smoke entered the cockpit by means of the fresh air vent system. He said that after the event was over his clothes smelled of avgas.

The airplane was further examined at the facilities of Air Transport Company in Phoenix on July 24, 2001. The right-hand engine was mechanically intact; however, a hose-end "B-nut" at the inlet to the engine driven fuel pump exhibited an unusual number of exposed threads. The B-nut was loose and required 1 1/8 turns to finger-tighten and 1 1/4 turns to snug tighten with a wrench. When the B-nut was unscrewed from the fitting, the threads of the fitting and the B-nut itself did not exhibit any cracks or stripped threads. No other mechanical anomalies were found.

Aircraft

Registration
N15120
Reported as
Piper PA-34-200
Category
Airplane
Serial number
34-7350022
Airframe hours
5,832
Engine
Lycoming IO/LIO-360-C1, 200 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Flight test · Part 91
Registered owner
Garrison Aviation inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 27, 2000 · 78 hours before
Departed
CHD · Chandler, AZ
Airport
CHD · Chandler Municipal, runway 4L, 4,395 × 75 ft, asphalt

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
22
Injuries
Minor
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
March 6, 2001
Seat
Left
Flight hours
492 total · 26 in this make and model · 441 as pilot in command · 173 in the last 90 days · 49 in the last 30 days · 10 in the last 24 hours

Weather

Conditions
Visual (VMC) · Dawn
Wind
Calm
Visibility
40 statute miles
Lowest ceiling
None
Temperature
93 °F, dew point 72 °F
Altimeter
29.95 inHg
Observed at
CHD, 2 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.