Piper PA28 accident near Marana, Arizona, September 14, 2019
On September 14, 2019, a 2013 Piper PA28, registered N4403Z, was substantially damaged in an accident during prior to flight near Marana, Arizona (Marana Regional Airport). It was an instructional flight under general aviation rules (Part 91). No one was hurt; 4 people were on board or involved. The weather was visual conditions (good weather).
The NTSB's probable cause their words, unchanged
Excessive fuel pressure and temperature throughout the fuel system due to heat soaking, which resulted in an engine fire during engine start.
Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.
What the record shows
- Date
- September 14, 2019
- Place
- Marana, Arizona · Marana Regional Airport · map
- Type
- Accident
- Injuries
- No one was hurt; 4 people were on board or involved.
- Weather
- visual conditions (good weather)
- Aircraft
- Piper PA28 181, built 2013 · all PA28s on the register
- Registration
- N4403Z · registry record · serial 2843726
- Damage
- Substantial damage
- Flight
- Instructional flight · general aviation rules (Part 91)
The NTSB's narrative final · quoted from the NTSB record
During engine start about 30 minutes following the previous shutdown, the engine caught fire, which resulted in substantial damage to the airplane. The operator reported that six of their airplanes experienced flooding and subsequent fires during the engine start process within the previous 6 months. The airplanes that experienced flooding and fires had all previously flown and been parked between 5 and 28 minutes before the engines were restarted and the flooding occurred. During these events, the daily average temperatures were between 85° and 98°F. Testing conducted to simulate the conditions of the engine fire events revealed that, in the minutes following engine shutdown, the temperature of the fuel system components and fuel pressure to the carburetor would rise, most likely as a result of heat soaking from the combination of the hot engine and high outside air temperature. The tests showed that during the engine restart, about 6 to 12 ounces of fuel and vapor emanated from the carburetor intakes. During some of the tests, a whistling sound was heard originating from the carburetor inlet, which is likely from the buildup of fuel vapor as a result of the heat soaking and escaping through the internal passages of the carburetor before exiting out the carburetor intake. The carburetor from the accident airplane was disassembled, and the accelerator pump needle valve showed wear at the valve contact area. This wear was likely a result of the high fuel pressure vapor and fuel escaping past the valve, causing it to chatter excessively. The operator had experienced recent growth in its student population, which resulted in increased frequency of flights during the day. This most likely prevented the engine and fuel system from cooling between flights.
The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.
The factual record from the NTSB's investigation tables, in plain English
What happened, in order
- Fire/smoke (non-impact) during prior to flight defining event
The NTSB's findings
- Aircraft › Aircraft systems › Fuel system › Fuel pressure › Capability exceeded
- Aircraft › Aircraft systems › Fuel system › Fuel distribution › Failure
- Aircraft › Aircraft systems › Fuel system › Fuel temperature › Capability exceeded
- Environmental issues › Conditions/weather/phenomena › Temp/humidity/pressure › High temperature › Effect on equipment
Flight instructor
- Certificate: flight instructor, commercial pilot
- Ratings: multi-engine land; single-engine land; instructor: airplane single-engine; instructor: instrument airplane; instrument: airplane
- Flight time: 307 hours in all; 28 in this make and model; 76 in the last 90 days; 37.2 in the last 30 days; 248.8 as pilot in command; 20.2 on instruments
- Last flight review: July 22, 2019
- Medical certificate: Class 1 (without waivers/limitations)
- Seat: rgt
- Injury: no injuries
Dual student
- Flight time: 66.5 hours in all; 67 in this make and model; 0 in the last 90 days; 0 in the last 30 days; 0 as pilot in command; 0 on instruments
- Medical certificate: Class 3 (without waivers/limitations)
- Seat: left
- Injury: no injuries
Passenger
- Flight time: 65.6 hours in all
- Seat: rear
- Injury: no injuries
The aircraft
- Airframe total time: 6,063 hours
- Last inspection: 100-hour inspection, August 29, 2019
- Maximum gross weight: 2,557 lb
- Seats: 4
- Landing gear: fixed
- Engine: Lycoming O-360-A4M (piston); 3,296 hours total
- Fire on the ground
- Operator: Cae Oxford Aviation Academy Phoenix Inc
The flight
- Destination: FFZ Mesa AZ
- Flight plan: none
Weather at the time
- Light: daylight
- Wind: from 320° at 5 knots
- Visibility: 10 statute miles
- Sky: clear
- Temperature: 99°F (37°C), dew point 36°F (2°C)
- Altimeter: 29.87 inHg
Injuries
| Fatal | Serious | Minor | None | |
|---|---|---|---|---|
| Flight crew | 3 | |||
| Passengers | 1 |
Documents from the investigation the NTSB's docket: the evidence folder behind the report
16 documents, released by the NTSB on May 10, 2022. View them here, or download them; the NTSB redacts some personal details before release, and this site shows the NTSB's own titles rather than its file names.
The same docket at the NTSB · documents without a copy here are fetched from the NTSB when you open them.
Everything on this page comes from the NTSB's public records. The narrative, probable cause and findings are the NTSB's own words; the coded tables behind the report are written out in plain English, with pilots' ages, home towns and medical details left out. The documents and photographs are the NTSB's docket, shown as the NTSB released them. This site's own text never names anyone involved. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.