WPR19LA259

NTSB accident investigation · Piper PA28 · Marana, AZ · September 14, 2019

Accident · No injuriesClass 3 · LimitedFinal report
Date
September 13, 2019, 17:30 local (Sep 14, 2019, 00:30 UTC)
Place
Marana, AZ
Injuries
4 uninjured
Damage
Substantial damage
Phase of flight
Prior to flight
Aircraft
N4403ZPiper PA28
Defining event
Prior to flight: Fire/smoke (non-impact)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
CAE, AVStar Fuel Systems, Inc, Lycoming Engines, FAA-FSDO, Piper Aircraft, Precision Airmotive LLC
Case key
100261

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

Excessive fuel pressure and temperature throughout the fuel system due to heat soaking, which resulted in an engine fire during engine start.

Findings · 4

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.

Fuel system: fuel pressureAircraft › Aircraft systems · Capability exceededPiper PA-28-181: 1 caseAll aircraft: 16 casesProbable cause
Fuel system: fuel distributionAircraft › Aircraft systems · FailurePiper PA-28-181: 3 casesAll aircraft: 141 casesProbable cause
Fuel system: fuel temperatureAircraft › Aircraft systems · Capability exceededPiper PA-28-181: 1 caseAll aircraft: 4 casesProbable cause
Temp/humidity/pressure: high temperatureEnvironmental issues › Conditions/weather/phenomena · Effect on equipmentPiper PA-28-181: 1 caseAll aircraft: 30 cases

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

During engine start about 30 minutes following the previous shutdown, the engine caught fire, which resulted in substantial damage to the airplane. The operator reported that six of their airplanes experienced flooding and subsequent fires during the engine start process within the previous 6 months. The airplanes that experienced flooding and fires had all previously flown and been parked between 5 and 28 minutes before the engines were restarted and the flooding occurred. During these events, the daily average temperatures were between 85° and 98°F. Testing conducted to simulate the conditions of the engine fire events revealed that, in the minutes following engine shutdown, the temperature of the fuel system components and fuel pressure to the carburetor would rise, most likely as a result of heat soaking from the combination of the hot engine and high outside air temperature. The tests showed that during the engine restart, about 6 to 12 ounces of fuel and vapor emanated from the carburetor intakes. During some of the tests, a whistling sound was heard originating from the carburetor inlet, which is likely from the buildup of fuel vapor as a result of the heat soaking and escaping through the internal passages of the carburetor before exiting out the carburetor intake. The carburetor from the accident airplane was disassembled, and the accelerator pump needle valve showed wear at the valve contact area. This wear was likely a result of the high fuel pressure vapor and fuel escaping past the valve, causing it to chatter excessively. The operator had experienced recent growth in its student population, which resulted in increased frequency of flights during the day. This most likely prevented the engine and fuel system from cooling between flights.

Factual narrative

On September 13, 2019, about 1730 mountain standard time, a Piper PA-28-181 airplane, N4403Z, was substantially damaged when it was involved in an accident near Marana, Arizona. The flight instructor, student pilot, and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to the flight instructor, after landing at Marana Regional Airport (AVQ), Marana, Arizona, they exited the airplane, used the airport facilities, and had the airplane refueled. About 30 minutes later, the instructor completed a preflight inspection, during which he did not see any fuel or liquid leaking from the airframe or engine. They boarded the airplane and performed the engine start checklist. The instructor stated that he attempted to start the engine but was unsuccessful. During a second unsuccessful engine start attempt, the instructor and the two other occupants smelled smoke. They exited the airplane and saw smoke coming from the nosewheel well. The airplane subsequently caught fire and continued to burn for about 15 minutes before the fire department arrived. Postaccident examination of the airplane revealed fire damage to the forward fuselage and cowling. Blue staining was found at the airbox. The carburetor was disassembled, and the accelerator pump needle valve showed wear at the valve contact area. Examination of the engine and airframe revealed no evidence of preaccident mechanical malfunctions or anomalies that would have precluded normal operation. The operator reported that, within a 6-month span, six of their PA-28-181 airplanes experienced flooding and subsequent fires during the engine start process. Five of the airplanes, including the accident airplane, were manufactured in 2013 and one was manufactured in 2019. All of the airplanes that experienced the flooding and subsequent fires had been previously flown then parked for times ranging between 5 and 28 minutes before the engines were restarted. The daily average temperatures at the time of each event were between 85° and 98°F. The operator had been operating for 7 years without any engine fires occurring during the engine start process. The operator also reported that they recently had a significant increase in the student population from about 225 to an excess of 700 students, with an increased frequency of flights per day. Other flight schools in the area that operated the PA-28-181 did not report similar flooding or engine fires during engine start. Testing was performed on the operator’s fleet of PA-28-181 airplanes during hot climate conditions. Engine runs were conducted to establish oil temperatures in excess of 200° F then the engine was shut down. Following shutdown, the temperature of the fuel system components increased and fuel pressure throughout the fuel system to the carburetor rose. After a certain amount of time, the engines were restarted and about 6 to 12 ounces of fuel and vapor were observedemanating from the carburetor intakes. In some of the tests, while vapor was escaping, a whistling sound was heard originating from the carburetor inlet. 100 low lead aviation fuel begins to vaporize at approximately 106°F, and for a given volume, the higher the temperature of the fuel, the greater the ratio of vapor-to-liquid formation. A PA-28-181 manufactured in 1976, which was equipped with a Piper fuel cooling modification installed per Service Letter (SL) 427, Fuel Cooling Kits, was also tested. During the engine run, the engine oil temperature was increased to 230°F and the engine was shut down. The testing could not duplicate the increase in fuel pressure. Piper issued SL427 “Fuel cooling kits” in 1964, which specifies installation of the kit at the owner’s discretion, “in areas where high atmospheric temperatures may be encountered, and additional cooling is desirable.” This modification was discontinued for unknown reasons. None of the operator’s airplanes were equipped with the Piper fuel cooling modification. The operator reported that after installing an ignition modification that increased spark energy during engine start on all of their airplanes, no additional flooding events or engine fires occurred.

Aircraft

Registration
N4403Z
Reported as
Piper PA28 (181)
Category
Airplane
Serial number
2843726
Built
2013
Airframe hours
6,063
Engine
Lycoming O-360-A4M, 180 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Instructional · Part 91
Operator
Cae Oxford Aviation Academy Phoenix Inc
Registered owner
Cae Oxford Aviation Academy Phoenix Inc
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · August 29, 2019
Destination
FFZ · Mesa, AZ
Airport
AVQ · Marana Regional Airport
Equipment
Stall warning system, Satellite tracking device, Electronic primary flight display, Electronic multifunction display, Data recorder, ADS-B, Video recording device

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
23
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
July 22, 2019
Seat
Right
Restraint
3-point
Flight hours
307 total · 28 in this make and model · 248.8 as pilot in command · 76 in the last 90 days · 37.2 in the last 30 days · 1.6 in the last 24 hours
Role
Student pilot
Age
19
Injuries
None
Medical
Class 3, Without waivers/limitations
Seat
Left
Flight hours
66.5 total · 67 in this make and model · 0 as pilot in command · 0 in the last 90 days · 0 in the last 30 days · 1.6 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
320° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
99 °F, dew point 36 °F
Altimeter
29.87 inHg
Observed at
KAVQ

Docket · 16

The files NTSB released with the investigation on May 10, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 210 MB in all.