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NTSB Report

December 12, 2003 · Piper PA-23-250 · N40259

Buffalo, NY

Overview

Report Status
Final with probable cause
Event Type
Accident
Date
December 12, 2003
Injury Outcomes
No injuries (1 uninjured)
Location
Buffalo, NY
Aircraft
Piper PA-23-250
Tail Number
N40259
Operator
Northeast Aviation
Injuries
None
Aircraft Damage
Substantial
NTSB Number
NYC04LA047

After landing, as the pilot pulled into the ramp area, he noticed an orange glow at his feet, and notified airport personnel over the radio that he had a fire in the airplane. The pilot brought the airplane to a stop, and airport crash fire rescue extinguished the fire. Examination of the airplane revealed the fire burnt a hole through the fuselage skin in the area of the Janitrol heater, just aft of the left wing root. The entire area forward of the Janitrol heater, including the wiring and plumbing of the heater, as well as the cockpit and cabin was consumed by fire. The pilot reported that his normal procedure for using the Janitrol heater was to turn it off at the same time he extended the landing gear while on approach. The Pilot's Operating Handbook (POH), Description and Operations section stated, "The three positions of the cabin heat control switch are 'HEAT,' 'FAN,' and 'OFF'...It is advisable to place the switch in the fan position for several minutes after the heater has been operating to allow the unit to cool down before it is turned off." The Normal Procedures section of the POH required that the switch be turned to the "FAN" position while completing the Before and After Landing checklists. The Shutdown checklist called for the switch to be switched to the "OFF" position.

NTSB Probable Cause

The pilot's improper procedure with regard to the cabin heater, which resulted in the over temperature of the heater and subsequent fire.

Full Narrative

On December 11, 2003, at 2115 eastern standard time, a Piper PA-23-250, N40259, operated by Northeast Aviation Inc., was substantially damaged by fire at the Buffalo Niagara International Airport (BUF), Buffalo, New York. The certificated airline transport pilot was not injured. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed for the flight which originated at the Morristown Municipal Airport (MMU), Morristown, New Jersey. The on-demand cargo flight was conducted under 14 CFR Part 135. According to the pilot, after landing at BUF, while taxiing to the ramp, he smelled a burning smell coming from the airplane. He checked the cockpit gauges, and noticed no abnormalities. As the pilot pulled into the ramp area, he noticed an orange glow at his feet, and notified FBO personnel over the radio that he had a fire in the airplane. FBO personnel brought hand-held fire extinguishers to the airplane, and attempted to extinguish the fire until airport crash fire rescue arrived. A Federal Aviation Administration (FAA) inspector examined the airplane after the accident. According to the inspector, the fire burnt a hole through the fuselage skin in the area of the Janitrol heater, just aft of the left wing root. The entire area forward of the Janitrol heater, including the wiring and plumbing of the heater, as well as the cockpit and cabin area was consumed by fire. The pilot stated that his normal procedure for using the Janitrol heater was to turn it off at the same time he extended the landing gear while on approach. He stated he followed the same procedure during the accident flight. The pilot reported 2,800 hours of total flight experience, 500 of which were in make and model. According to the Piper PA-23-250 Pilot's Operating Handbook (POH), Description and Operations section: "...The three positions of the cabin heat control switch are 'HEAT,' 'FAN,' and 'OFF'...It is advisable to place the switch in the fan position for several minutes after the heater has been operating to allow the unit to cool down before it is turned off." The Normal Procedures section of the POH required that the switch be turned to the "FAN" position while completing the Before and After Landing checklists. The Shutdown checklist called for the switch to be switched to the "OFF" position. The expanded Normal Procedures section, BEFORE LANDING, stated: "...If the heater has been in operation, turn the heater control switch to 'FAN' to allow unit time to cool down." The AFTER LANDING section stated: "...If the heater has been in operation, check that the heater control switch is in the 'FAN' position. The heater should never be turned 'OFF' unless it has had time to cool down." The SHUT DOWN section stated: "...If the heater has been used and has been allowed to cool down, turn it to 'OFF'."

Flight

Event TypeAccident
Event Time21:15 EST
Nearest AirportBuffalo Niagra International (0nm)
Runway23
Runway Length8102 ft
Runway Width150 ft
Flight Plan FiledIFR
Flight Plan ActivatedYes
Aircraft FireGrd
Aircraft ExplosionNo

Aircraft

AircraftPiper PA-23-250
Tail NumberN40259
Aircraft CategoryAir
DamageSubstantial
OperatorNortheast Aviation
Operating RulePart 135
Engines2
Engine TypeReciprocating
Engine DetailsLycoming · IO-540 · Reciprocating · 250 | Lycoming · IO-540 · Reciprocating · 250
Seats2

People & Injuries

Injury SummaryNo injuries (1 uninjured)
Fatal0
Serious0
Minor0
Uninjured1
Total1
Crew 1Age 39 · First Class · None

Conditions

ConditionsVMC
LightNight
Wind260° @ 20 kt, gusting 25 kt
Visibility10 sm
CeilingBroken clouds 4500 ft
Temperature / Dew Point32 C / 25 C
Altimeter29.77 inHg
Observation Time01:54
Weather SourceWFAC

Appendix: Source Data