NTSB CAROL · Event
Event GAA19CA176
Aircraft involved
Probable cause & findings
The pilot's failure to conduct the engine starting procedures in accordance with the Pilot’s Operating Handbook, which resulted in an engine fire.
Factual narrative
The pilot reported that, during the landing roll, the wind pushed the airplane to the right and he overcompensated with left rudder. The airplane veered to the left, abruptly rotated about 180°, and the engine and airplane stopped on the runway at a taxiway intersection. The tower controller asked if the pilot could restart the engine or if he needed a tow. The pilot attempted to restart the engine 4 to 5 times. While attempting a "hot start", he observed black smoke 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, then 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 automated weather observation station located on the airport 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 contained section 3.7 titled, "Engine Fire During Start", which stated: Engine fires during start are usually the result of overpriming. It continued in section 4.13 titled, "Starting Engine", which stated: 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. 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. 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 policy/procedure-Pilot - C
Verbatim from NTSB's published report. Source file
NTSB_2019_GAA19CA176.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 ↗