Pilot Debrief

Piper PA28 near Savannah, GA — 2019-03-20

Final reportGAA19CA176
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Date
2019-03-20
Location
Savannah, GA, USA
Airport
SAV
Aircraft
Piper PA28
Registration
N2667Q
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Landing

Probable cause

The pilot's failure to conduct the engine starting procedures in accordance with the Pilot’s Operating Handbook, which resulted in an engine fire.

NTSB narrative

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.

Analysis

Primary failure mode
Loss of control
First missed decision gate
Pilot could have avoided overcompensating with left rudder during landing roll.

NTSB coding

Evidence available

  • Photos
  • 6 docket documents
View NTSB final reportView NTSB docket

Docket documents6

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