# NTSB CEN09CA469: Piper PA-25-235, N6689Z, Miller, MO, July 23, 2009 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Data collection · Final report - Date: July 23, 2009, 11:30 local (16:30 UTC) - Place: Miller, MO - Coordinates: 37.266666, -93.933334 - Nearby events: https://openairdocs.org/map.md?lat=37.2667&lon=-93.9333&mi=10 - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Defining event: [Standing-engine(s) operating: Ground handling event](https://openairdocs.org/ntsb-events/080) - Highest injury: Serious injuries - Injuries: 1 serious, 1 uninjured; on the ground: 1 serious - Status: Completed, report October 19, 2009 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 74386 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN09CA469 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/74386/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=74386 - Page: https://openairdocs.org/ntsb/CEN09CA469 ## Probable cause The failure of the operator to shut down aircraft while conducting servicing which resulted in a ground person being struck by the rotating aircraft propeller. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Oversight: oversight of operation](https://openairdocs.org/ntsb-findings/04032015): Organizational issues › Support/oversight/monitoring · Operator (probable cause); cases with it: [Piper PA-25-235, 1 case](https://openairdocs.org/ntsb-findings/04032015/cases.md?model=7102504), [All aircraft, 61 cases](https://openairdocs.org/ntsb-findings/04032015/cases.md) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Ground crew (probable cause); cases with it: [Piper PA-25-235, 4 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=7102504), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Aircraft](https://openairdocs.org/ntsb-findings/01010000): Aircraft › Aircraft handling/service · Incorrect use/operation (probable cause); cases with it: [Piper PA-25-235, 1 case](https://openairdocs.org/ntsb-findings/01010000/cases.md?model=7102504), [All aircraft, 21 cases](https://openairdocs.org/ntsb-findings/01010000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Standing-engine(s) operating: Ground handling event](https://openairdocs.org/ntsb-events/080) (defining event); cases with it: [Piper PA-25-235, 1 case](https://openairdocs.org/ntsb-events/080/sequence.md?model=7102504), [All aircraft, 108 cases](https://openairdocs.org/ntsb-events/080/sequence.md) - [Standing-engine(s) operating: AC/prop/rotor contact w person](https://openairdocs.org/ntsb-events/081); cases with it: [Piper PA-25-235, 1 case](https://openairdocs.org/ntsb-events/081/sequence.md?model=7102504), [All aircraft, 61 cases](https://openairdocs.org/ntsb-events/081/sequence.md) ## Analysis The aerial application airplane completed its last flight for the day and was parked with the engine running for cooling purposes before it was shut down. A ground support person, who was an aircraft loader, assisted in the cleaning of the airplane with the engine running. The loader began rinsing underneath the airplane and progressed inwards toward the wing root. The loader received serious injuries when he stood up and was stuck three times by the rotating propeller. ## Factual narrative The aerial application airplane completed its last flight for the day and was parked with the engine running for cooling purposes before it was shut down. A ground support person, who was an aircraft loader, assisted in the cleaning of the airplane while the engine was still running. The loader began rinsing underneath the airplane and progressed inwards toward the wing root. The loader received serious injuries when he stood up and was stuck three times by the rotating propeller. ## Aircraft - Registration: [N6689Z](https://openairdocs.org/aircraft/N6689Z), registered now, S/N 25-2302 (OpenAirDocs) - Reported make and model: PIPER PA-25-235 - Registry model: [Piper PA-25-235](https://openairdocs.org/model/piper-pa-25-235) (registry code 7102504) (OpenAirDocs) - Category: Airplane - Serial number: 25-2302 - Airframe hours: 5475 - Engines: Lycoming O-540 235 horsepower reciprocating - Damage: No damage - Flight: Aerial application, Part 137 - Operator: Plane Cents Aviation - Registered owner: Kingsley Kiman J - Airworthiness certificate: Special, Restricted (Special) - Last inspection: Annual, June 12, 2009 - Departed: PVT, Miller, MO - Destination: PVT, Miller, MO - Airport: PVT, Kingsley Field ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 21; injuries: none; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review April 16, 2009; flight hours: 921 total, 180 in this make and model, 639 as pilot in command, 250 in the last 90 days, 0 in the last 30 days, 5 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day ## 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 20090723013209A](https://openairdocs.org/incident/20090723013209A), Jul 23, 2009: Piper PA25235, Miller, MO, No damage. (-23) One of the ground crew was washing down the airplane while the engine was running, with the pilot in the airplane and at the controls, when he backed… ## Docket (1 files) The files NTSB released with the investigation on August 28, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=74386. 534 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 534 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40317941&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF 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.