NTSB CAROL · Event
Event ERA16LA154
Aircraft involved
Probable cause & findings
The pilot's failure to follow checklist procedures for an engine fire during start.
Factual narrative
On March 27, 2016, about 1100 eastern daylight time, a Piper PA28-180, N16366, was substantially damaged after a fire occurred during engine startup while the airplane was parked on the ramp at the Allegheny County Airport (AGC), West Mifflin, Pennsylvania. The private pilot was not injured. Visual meteorological conditions prevailed and no flight plan was filed for the intended local personal flight that was to be conducted under the provisions of Title 14 Code of Federal Regulations Part 91.The pilot stated that on the morning of the accident, he called the fuel supplier and asked for the airplane to be topped-off, in preparation for a local flight. After performing a preflight inspection, he attempted to start the engine but it would not start. He tried three additional times, without success. On the fifth attempt, he followed the "starting engine when flooded" checklist. As the propeller was turning with the starter, he noticed white smoke "pouring out" of the engine cowl. He turned off the master switch and exited the airplane. He then opened the top engine cowling, and flames suddenly emanated from the left side of the engine, and the color of the smoke changed from white to dark black. He returned to the cockpit to retrieve a handheld fire extinguisher; however, the cockpit was filling up with heavy black smoke and he was forced to egress and unable to suppress the engine fire. The pilot added that there were no preaccident mechanical malfunctions with the airplane. According to Federal Aviation Administration and maintenance records, the airplane was manufactured in 1973. The airplane's most recent annual inspection was completed on September 8, 2015. At the time of the accident, the airplane had accumulated 6,336 total hours of flight time. Examination of the airplane by an FAA inspector revealed that the engine and compartment had incurred substantial fire and heat damage. Inside the cockpit, the fuel primer knob was found in the out/unlocked position. Additionally, review of a pilot's operating manual for the make and model airplane revealed: "…Engine Fire (During Start): Engine fires during start are usually the result of overpriming. The following procedure is designed to draw the excess fuel back into the induction system. a. If engine has not started: (1) Mixture – Idle Cut-Off (2) Throttle – Open (3) Turn engine with starter (This is an attempt to pull the fire into the engine.)…" The private pilot stated that he attempted to start the airplane's engine but that it would not start. On the fifth attempt, he followed the "starting engine when flooded" checklist. As the propeller was turning with the starter motor engaged, white smoke began to emanate from the engine cowling. He then turned off the master switch, exited the airplane, and opened the engine cowling. Flames suddenly emanated from the left side of the engine. The engine and compartment subsequently sustained substantial fire and heat damage. The pilot added that there were no preaccident mechanical malfunctions with the airplane; examination of the wreckage revealed that the primer control was not in and locked. Review of a pilot's operating manual for the airplane revealed that, if an engine fire occurs during start, the pilot should move the mixture control to idle, move the throttle control to full open, and continue to turn the engine with the starter motor in an attempt to pull the fire into the engine. If the pilot had followed this procedure, it is likely that the fire would have been extinguished and prevented further damage to the airplane. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).
- C Personnel issues-Task performance-Use of equip/info-Use of equip/system-Pilot - C
- C Personnel issues-Action/decision-Action-Incorrect action performance-Pilot - C
- C Personnel issues-Task performance-Use of equip/info-Use of checklist-Pilot - C
- C Aircraft-Aircraft power plant-Power plant-(general)-Incorrect use/operation - C
Verbatim from NTSB's published report. Source file
NTSB_2016_ERA16LA154.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (maintenance). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- Embry-Riddle Scholarly Commons 2026 · Journal article (IJAAA)
From Reactive to Predictive: A hybrid Trust-Mediated Adoption Framework for Data-Driven Maintenance in Distributed-Authority Aviation Environments
Modern aviation maintenance operates within increasingly data-intensive technological environments, yet the operational integration of predictive maintenance into routine decision-making remains incon…
- Semantic Scholar 2025 · Article (Applied Sciences)
Decision-Making Framework for Aviation Safety in Predictive Maintenance Strategies
The implementation of predictive maintenance (PM) in aviation presents unique challenges due to strict safety requirements, complex operational environments, and regulatory constraints.
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
Low-Resource Automatic Speech Recognition Domain Adaptation – A Case-Study in Aviation Maintenance
With timeliness and efficiency being critical in the aviation maintenance industry, the need has been growing for smart technological solutions that optimize and streamline the different underlying ta…
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
A New Trajectory in UAV Safety: Leveraging Reinforcement Learning for Distance Maintenance Under Wind Variations
In the field of aviation, safety is a critical cornerstone, and the operation of Unmanned Aerial Vehicle (UAV) systems is deeply connected with this principle.
- Embry-Riddle Scholarly Commons 2024 · Journal article (IJAAA)
Just Culture in Aviation: A Metaphorical Study on Aircraft Maintenance Students
Just Culture, a sub-dimension of safety culture, has been a prominent and debated topic in aviation safety in recent years.
- Embry-Riddle Scholarly Commons 2024 · Journal article (IJAAA)
Performance PRISM: A Comprehensive Framework For Performance Measurement In Aircraft Maintenance
Aircraft maintenance is governed by rigorous safety requirements and high operational complexity, demanding robust performance measurement frameworks to ensure optimal maintenance practices.
Browse the full corpus — academia portal ↗