Thursday, March 21, 2019

Fire / Smoke (Non-Impact): Piper PA-28-140, N2667Q; accident occurred March 20, 2019 at Savannah/Hilton Head International Airport (KSAV), Georgia

Aviation Accident Final Report - National Transportation Safety Board 

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Atlanta, Georgia

Investigation Docket - National Transportation Safety Board:

Location: Savannah, GA
Accident Number: GAA19CA176
Date & Time: 03/20/2019, 1500 EDT
Registration: N2667Q
Aircraft: Piper PA28
Aircraft Damage: Substantial
Defining Event: Fire/smoke (non-impact)
Injuries: 1 None
Flight Conducted Under: Part 91: General Aviation - Personal 


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.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's failure to conduct the engine starting procedures in accordance with the Pilot's Operating Handbook, which resulted in an engine fire.


Personnel issues Use of policy/procedure - Pilot

Factual Information

History of Flight

Standing-engine(s) start-up Fire/smoke (non-impact) (Defining event)

Pilot Information

Certificate: Private
Age: 59, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 Without Waivers/Limitations
Last FAA Medical Exam: 10/02/2018
Occupational Pilot: No
Last Flight Review or Equivalent: 03/20/2019
Flight Time:  (Estimated) 81 hours (Total, all aircraft), 81 hours (Total, this make and model), 15 hours (Pilot In Command, all aircraft), 35 hours (Last 90 days, all aircraft), 17 hours (Last 30 days, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: Piper
Registration: N2667Q
Model/Series: PA28 140
Aircraft Category: Airplane
Year of Manufacture: 1977
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 28-7725203
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: 02/08/2019, 100 Hour
Certified Max Gross Wt.: 2150 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 4867.8 Hours as of last inspection
Engine Manufacturer: Lycoming
ELT: Installed, not activated
Engine Model/Series: O-320-E3D
Registered Owner: Bw Aviation Llc
Rated Power: 160 hp
Operator: Bw Aviation Llc
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation:
Distance from Accident Site:
Observation Time: 1853 UTC
Direction from Accident Site:
Lowest Cloud Condition: Scattered / 4800 ft agl
Visibility:  10 Miles
Lowest Ceiling:
Visibility (RVR):
Wind Speed/Gusts: 10 knots / 17 knots
Turbulence Type Forecast/Actual: None / None
Wind Direction: 360°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30.1 inches Hg
Temperature/Dew Point: 19°C / 6°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Summerville, SC (DYB)
Type of Flight Plan Filed: None
Destination: Savannah, GA (SAV)
Type of Clearance: VFR; VFR Flight Following
Departure Time: 1400 EDT
Type of Airspace: Class C

Airport Information

Runway Surface Type: Concrete
Airport Elevation: 50 ft
Runway Surface Condition: Dry
Runway Used: 10
IFR Approach: None
Runway Length/Width: 9351 ft / 150 ft
VFR Approach/Landing: Full Stop; Traffic Pattern 

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 None
Latitude, Longitude: 32.128333, -81.198333 (est)

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