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Aviation safety reports, made easier to study

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NTSB Report

February 23, 1994 · Piper PA-28-140 · N20BS

Santa Rosa, CA

Overview

Report Status
Final with probable cause
Event Type
Accident
Date
February 23, 1994
Injury Outcomes
1 injury (1 serious injury), 1 uninjured
Location
Santa Rosa, CA
Aircraft
Piper PA-28-140
Tail Number
N20BS
Operator
Redwood Aviation Enterprises
Injuries
Serious
NTSB Number
LAX94LA136

PRIOR TO DEPARTING ON A TRAINING FLIGHT, THE FLIGHT INSTRUCTOR AND A STUDENT WERE SEATED IN THE AIRPLANE ATTEMPTING TO START THE ENGINE. THE ENGINE TURNED OVER SLOWLY, BUT FAILED TO START. THE FLIGHT INSTRUCTOR BELIEVED THE PROBLEM TO BE WITH THE STARTER. SHE DECIDED TO EXIT THE AIRPLANE TO REPOSITION THE PROPELLER IN ORDER TO FREE THE STARTER. IN THE PROCESS, THE PROPELLER ROTATED AND STRUCK THE HEAD AND SHOULDER OF THE FLIGHT INSTRUCTOR. THE STUDENT INSIDE THE AIRPLANE DID NOT MANIPULATE THE CONTROLS WHILE THE INSTRUCTOR WAS OUTSIDE. EXAMINATION OF THE COCKPIT CONTROLS REVEALED THAT THE MASTER SWITCH WAS OFF, MIXTURE AND THROTTLE CONTROLS AT IDLE, AND THE MAGNETO SWITCH WAS ON.

NTSB Probable Cause

A failure of the pilot-in-command to ensure that the powerplant controls were configured properly before moving the aircraft propeller. Inadequate planning/decision making was a factor in this accident.

Full Narrative

On February 23, 1994, about 1050 hours Pacific standard time, the instructor pilot of a Piper PA-28-140, N20BS, was struck by the propeller of the airplane at the Sonoma County Airport, Santa Rosa, California. The airplane was to be operated as a visual flight rules (VFR) instructional flight to Sacramento, California. The airplane, registered to the pilot and operated by Redwood Aviation Enterprises, Santa Rosa, was not damaged. The certificated commercial pilot/certified flight instructor received serious injuries. A student pilot seated in the airplane was not injured. Visual meteorological conditions prevailed. A Federal Aviation Administration (FAA) operations inspector, Oakland Flight Standards District Office, reported that the pilot and student were preparing to depart on their flight. The student attempted to start the airplane; however, the engine was cranking too slowly to start. The instructor exited the airplane to arrange for an electrical "jump" start. The student inside the airplane did not manipulate the controls while the instructor was outside. The instructor turned the propeller to position it for the start. The engine caught and rotated the propeller, striking the instructor in the head and shoulder. Examination of the cockpit controls revealed that the master switch was OFF, mixture and throttle controls at idle, and the magneto switch was ON. The pilot reported that she was unsure whether the propeller was stopped at the top of a compression stroke causing it to rotate suddenly when it was moved, or whether the engine actually fired.

Flight

Event TypeAccident
Event Time10:50 PST
Nearest AirportSonoma County Airport (0nm)
Runway0
Flight Plan FiledNone
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftPiper PA-28-140
Tail NumberN20BS
Aircraft CategoryAir
OperatorRedwood Aviation Enterprises
Operating RulePart 91
Engines1
Engine TypeReciprocating
Engine DetailsLycoming · O-320 · Reciprocating · 150
Seats2

People & Injuries

Injury Summary1 injury (1 serious injury), 1 uninjured
Fatal0
Serious1
Minor0
Uninjured1
Total2
Crew 1Age 26 · Second Class

Conditions

ConditionsVMC
LightDaylight
Wind320° @ 10 kt
Visibility25 sm
CeilingNone
Temperature / Dew Point50 / 36 C
Altimeter30.00 inHg
Observation Time18:45

Appendix: Source Data