O/S pax starts fire; missed AD blamed

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Display name:
Dave Taylor
One evening in late summer of 2002, a pilot operating a Piper PA-28-161 Warrior departed on a short flight
OK to TX to pick up some friends for a return trip to Oklahoma. During the return trip the pilot and passengers
would experience a horrific flight due to an in-flight fire.
The aircraft had recently been approved for return to service after an annual inspection. The aircraft
owner stated on a couple of occasions prior to the annual inspection he had reported to his independent maintenance
provider, a local Aviation Maintenance Technician, (AMT) who held both an FAA Airframe and Powerplant
rating with Inspection Authorization (IA), the aircraft had been experiencing electrical problems. Some
of these problems were dimming of panel lights, cabin lighting problems, and other electrical equipment and
charging system anomalies, including the battery not holding a proper charge. A review of the aircraft records
indicated there were several of these effected components replaced as corrective action, but there were no entries
concerning the aircraft
battery inspection, servicing,
or condition.
Upon departing
from TX at 8:42 PM, the
pilot and passengers, one
sitting in the left rear seat,
one occupying the right
front seat, and the other sat
in the right rear seat, all
bound for Oklahoma on a
VFR GPS direct flight assisted
by Air Traffic Control
(ATC) by a flight following.
Shortly after approaching
the airspace over
Oklahoma the pilot noted
the aircraft’s panel lights
dimming and then returning
to normal, followed by
the right rear passenger reporting
a burning smell.
Directly afterward the right
rear seat passenger released their seat belt and slid to the left reporting fire coming up from under her seat.
The pilot declared an emergency, reported the in-flight fire and remained extremely calm communicating with
ATC. ATC provided vectors to a nearby airport, but the pilot responded they would not make it much longer
and opted to land the aircraft off airport. The recording from ATC of the event captured the calmness of the
pilot and the indescribable fear of the passengers. With open flames and smoke in the aircraft cabin the pilot
executed a textbook emergency landing and all were able to exit the aircraft as it filled with thick smoke and
flames without any injuries.

23i9ugl.jpg

The accident investigation showed the aircraft battery positive terminal had come in contact with the rear
seat’s seat springs beneath the seat covers. This caused an electrical short which fused the terminal to the
seat spring and transformed the seat springs into toaster oven like heating coils which ignited the seat
cushion.
Other factors which played into this case were the IA and an assisting AMT who conducted the annual
inspection were not aware of the modification requirements of one time Airworthiness Directive (AD) 81-
23-05 which applied to this aircraft. This one time AD was a corrective action for the battery and seat
spring contact issue that had been originally complied with in 1982.
A review of the aircraft records identified two cabin interior changes that had taken place following the
compliance time of this one time AD between 1982 and 2002. It was determined this aircraft had been
taken out of compliance during one of the interior changes by removing a piece of plywood which had
been installed in accordance with (IAW) Piper Service Bulletin 631B, as instructed by AD 81-23-05, and
was repeatedly missed during all annual inspections conducted after it was taken out of compliance. This
easily verifiable missed item of inspection was also overlooked during periods of battery servicing during
periodic required maintenance during the same time period.
During the post accident investigation, interviews with the AMT who had worked with the IA that
signed off the last inspection, told the Investigating Inspector that the IA had trusted his work and refused
the offer to actually look at the aircraft during the maintenance and inspection.
 
My first plane,,, a Pa 28-151, N4341X was my introduction to what an AD was.... I clearly remember my IA telling me he had to install the "kit" to prevent a shorting accident that happened earlier in another Warrior.. I laughed at the idea of the piece of plywood and then cried when I got the bill for it.:incazzato::incazzato:

I thought EVERY aircraft mechanic knew to look for that piece of plywood... Those mechanics are in deep doo doo..:hairraise::cryin::eek:

Ben.
 
Egads! That is scary! :hairraise:

My first plane,,, a Pa 28-151, N4341X was my introduction to what an AD was.... I clearly remember my IA telling me he had to install the "kit" to prevent a shorting accident that happened earlier in another Warrior.. I laughed at the idea of the piece of plywood and then cried when I got the bill for it.:incazzato::incazzato:

When I would explain to non-aviating friends what an AD was, I told them it was like a "reverse lottery ticket" -- when one comes in the mail, you wonder how much is this gonna cost me, and then pay (not receive) a large sum of money. :sad:
 
This one time AD was a corrective action for the battery and seat
spring contact issue that had been originally complied with in 1982.

So, an inspection of the log books would show that everything was in order...
 
This is why "P/C/W" with ref to ADs in the logs means NOTHING!

(We should be writing something like "PCW, but also visually verified")
 
This is why "P/C/W" with ref to ADs in the logs means NOTHING!

(We should be writing something like "PCW, but also visually verified")

In this case there isn't an excuse for missing AD compliance since it should be obvious when the battery is checked at annual. But what do you do with ADs that cover internal engine parts like the Lycoming oil pump gear AD? I sure wouldn't want to open the engine up unnecessarily and potentially have a maintenance induced failure.
 
When I would explain to non-aviating friends what an AD was, I told them it was like a "reverse lottery ticket" -- when one comes in the mail, you wonder how much is this gonna cost me, and then pay (not receive) a large sum of money. :sad:

That's about the sum of it. It could be small (under $1,000), or in the case of the 400-series Cessna operators who had the wing spar AD, it could be lots, lots more.
 
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