# NTSB LAX01LA250: Piper PA-34-200, N15120, Chandler, AZ, July 18, 2001 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: July 18, 2001, 08:43 local (15:43 UTC) - Place: Chandler, AZ - Coordinates: 33.239574, -111.78057 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.2396&lon=-111.7806&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 1 minor, 1 uninjured - Status: Completed, report May 28, 2002 - Report: Approved by Office Director - Parties: FAA FLT STNDS DIST OFFICE, TEXTRON LYCOMING, THE NEW PIPER AIRCRAFT, INC. - NTSB case key (mKey): 52760 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX01LA250 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/52760/pdf - Page: https://openairdocs.org/ntsb/LAX01LA250 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Fire, approach - vfr pattern - final approach - fuel system,line fitting - loose - maintenance,installation - improper, other maintenance personnel (cause) - maintenance,inspection - inadequate, other maintenance personnel (contributing factor) - Forced landing, emergency descent/landing - On ground/water encounter with terrain/water, landing - 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](https://openairdocs.org/deregistered/N15120-2002-04-29), registration cancelled 2002-04-29, S/N 34-7350022, built 1972 (OpenAirDocs) - Reported make and model: Piper PA-34-200 - Registry model: [Piper PA-34-200](https://openairdocs.org/model/piper-pa-34-200) (registry code 7103405) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 34-7350022 - Airframe hours: 5832 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 22; injuries: minor; 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 (OpenAirDocs). - [Accident 20010718016879A](https://openairdocs.org/incident/20010718016879A), Jul 18, 2001: Piper PA34200, Chandler, AZ, Substantial damage. (.19) On July 18, 2001, at 0843 hours mountain standard time, a Piper PA-34-200, N15120M made an off-airport emergency landing following onset of an engine… 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.