# NTSB ATL95LA063: Cessna 172L, N4383Q, Smyrna, TN, March 10, 1995 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: March 10, 1995, 10:20 local (16:20 UTC) - Place: Smyrna, TN - Coordinates: 35.979579, -86.510795 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.9796&lon=-86.5108&mi=10 - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious, 1 uninjured - Status: Completed, report July 31, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 3532 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL95LA063 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/3532/pdf - Page: https://openairdocs.org/ntsb/ATL95LA063 ## Probable cause THE FLIGHT INSTRUCTOR'S FAILURE TO ENSURE THAT THE MAGNETOS WERE NOT ENERGIZED PRIOR TO POSITIONING THE PROPELLER, AND THE DUAL STUDENT'S FAILURE TO PLACE THE IGNITION SWITCH IN THE OFF POSITION AFTER THE FIRST START ATTEMPT. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Propeller/rotor contact to person, standing - starting engine(s) - procedures/directives - not followed, dual student (cause) - procedures/directives - not followed, pilot in command(cfi) (cause) ## Analysis THE FLIGHT INSTRUCTOR WAS 'HAND PROPPING' THE ENGINE DUE TO AN INOPERATIVE STARTER SOLENOID. HIS STUDENT WAS IN THE LEFT COCKPIT SEAT, WORKING THE ENGINE CONTROLS. THE FIRST START ATTEMPT WAS UNSUCCESSFUL. THE INSTRUCTOR POSITIONED THE PROP FOR THE SECOND ATTEMPT, AND THE ENGINE FIRED. NO HAND SIGNALS WERE GIVEN PRIOR TO THE SECOND START ATTEMPT. THE PROPELLER CONTACTED THE INSTRUCTOR'S ARM AND LEG, RESULTING IN SERIOUS INJURIES. THE INSTRUCTOR BELIEVES THAT THE STUDENT DID NOT RETURN THE IGNITION SWITCH TO THE OFF POSITION AFTER THE FIRST START ATTEMPT, CONTRARY TO WHAT WAS BRIEFED. ## Factual narrative On March 10, 1995, at 1020 central standard time, the flight instructor of a Cessna 172L, N4383Q, was seriously injured when he was struck by the propeller during ground start at Smyrna, Tennessee. A dual student pilot, who was in the left, front seat, was not injured. The aircraft was not damaged. The aircraft was operated under the provisions of 14 CFR Part 91 by Geoffrey C. Boshier, of Greenbrier, Tennessee. Visual meteorological conditions existed at the time, and no flight plan was filed for the local, instructional flight. The flight was originating at the time of the accident. The flight instructor reported that he was "hand propping" the engine due to an inoperative starter solenoid. He covered the procedures for hand starting the engine, including hand signals for communication, and the dual student worked the cockpit controls. The first start attempt was unsuccessful. While positioning the propeller for the second start attempt, the flight instructor slightly moved the propeller without any hand signals being given, and the engine fired. The propeller struck him, breaking his right arm, and injuring his right leg. The flight instructor believed that the ignition switch was not returned to the "off" position after the first start attempt. ## Aircraft - Registration: [N4383Q](https://openairdocs.org/aircraft/N4383Q), registered now, S/N 17260283, built 1971 (OpenAirDocs) - Reported make and model: CESSNA 172L - Registry model: [Cessna 172L](https://openairdocs.org/model/cessna-172l) (registry code 2072432) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17260283 - Airframe hours: 3066 - Engines: LYCOMING O-320-E2D 150 horsepower reciprocating - Damage: No damage - Flight: Instructional, Part 91 - Registered owner: Boshier, Geoffrey C. - Airworthiness certificate: Standard, Normal; Standard, Utility - Last inspection: Annual, October 8, 1994, 40 hours before - Departed: MQY - Airport: MQY, Smyrna Airport ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 32; flight engineer, flight instructor, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; flight hours: 5,745 total, 370 in this make and model, 4,809 as pilot in command, 7 in the last 90 days, 3 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 64 °F, dew point 30 °F - Altimeter: 30.00 inHg ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19950310008139A](https://openairdocs.org/incident/19950310008139A), Mar 10, 1995: Cessna 172L, Smyrna, TN. Starter inop. Hand propped engine. No start. Tried to reposition prop engine fired. Prop hit CFI. Switch was on. ## Other investigations on N4383Q (2) From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. - [NTSB ERA11LA105](https://openairdocs.org/ntsb/ERA11LA105), Dec 31, 2010: Cessna 172 (N4383Q), Dublin, NC, substantial damage. Probable cause: The pilot’s improper touchdown speed which resulted in a runway overrun. Contributing to the accident was the undetermined malfunction of the airspeed indicator. - [NTSB CHI76FEE22](https://openairdocs.org/ntsb/CHI76FEE22), Oct 14, 1975: Cessna 172L (N4383Q), Rockfort, IL, substantial damage From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.