Pilot Debrief

PIPER PA-32R-301T near Fort Lauderdale, FL — 2009-09-20

Final reportERA09FA526
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Date
2009-09-20
Location
Fort Lauderdale, FL, USA
Aircraft
PIPER PA-32R-301T
Registration
N2467Y
Category
Airplane
Highest injury
Fatal
Fatalities
4
Phase of flight
Descent

Probable cause

Fatigue failure of the No. 5 engine cylinder fuel supply line, which resulted in an engine compartment fire. Also causal was the pilot's failure to immediately secure the engine/perform a forced landing after discovery of the fire, which resulted in the pilot's loss of control of the airplane.

NTSB narrative

While en route to the destination airport, about 3,800 feet over swampy terrain, the pilot declared a mayday and advised air traffic control that there was fire in the engine. The controller asked the pilot's intentions, noting that there were two airports about 25 nautical miles from the airplane's position. The pilot stated that he would like to continue to one of the airports. The controller instructed the pilot to descend to 3,000 feet, and during the next 4 minutes, the pilot made multiple transmissions, including; that he thought he had lost a cylinder, that there was still fire coming off the nose of the airplane, they were getting smoke in the cockpit, and he may have to land on the highway. Approximately five minutes, 45 seconds after his first transmission, the pilot stated "we're on fire." There were no further transmissions from the pilot. A witness subsequently observed the airplane on fire, in a 20-degree nose-down, 40-degree left bank before it impacted terrain. Postflight examination of the wreckage revealed that the fire had emanated from a fuel leak caused by a fatigue fracture in the No. 5 pressurized fuel supply line. The pilot's operating handbook and Federal Aviation Administration publications noted that in case of fire, the pilot should immediately terminate the fuel flow to the engine and perform a forced landing. Although the failure of the fuel line would have, by itself, likely resulted in an accident, the pilot's loss of control of the airplane was a direct consequence of his failure to immediately perform the required emergency procedures.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have shut off fuel supply earlier to prevent fire escalation.

NTSB coding

Evidence available

  • ATC audio
  • ADS-B / radar
  • Photos
  • 43 docket documents
View NTSB final reportView NTSB docket

Docket documents43

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