# NTSB CEN14CA383: Piper PA 28-140, N9789W, St. Louis, MO, July 18, 2014 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Data collection · Final report - Date: July 18, 2014, 18:25 local (23:25 UTC) - Place: St. Louis, MO - Coordinates: 38.699386, -90.469741 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.6994&lon=-90.4697&mi=10 - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Defining event: [Standing-engine(s) start-up: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: Minor injuries - Injuries: 1 minor, 1 uninjured - Status: Completed, report September 2, 2014 - Report: Approved by Office Director - NTSB office: Central Region - NTSB case key (mKey): 89712 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN14CA383 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/89712/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=89712 - Page: https://openairdocs.org/ntsb/CEN14CA383 ## Probable cause The pilot's decision to operate an airplane with a known deficiency and to not properly secure the airplane before hand-starting the engine. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-140, 43 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7102802), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Parking/securing: tie-down/mooring](https://openairdocs.org/ntsb-findings/01011020): Aircraft › Aircraft handling/service · Incorrect use/operation (probable cause); cases with it: [Piper PA-28-140, 1 case](https://openairdocs.org/ntsb-findings/01011020/cases.md?model=7102802), [All aircraft, 33 cases](https://openairdocs.org/ntsb-findings/01011020/cases.md) - [Object/animal/substance: aircraft](https://openairdocs.org/ntsb-findings/03022040): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-28-140, 2 cases](https://openairdocs.org/ntsb-findings/03022040/cases.md?model=7102802), [All aircraft, 116 cases](https://openairdocs.org/ntsb-findings/03022040/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) start-up: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Piper PA-28-140, 38 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=7102802), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) ## Analysis The airplane's engine starter was inoperative so the pilot decided to hand-start the engine with the propeller to get it started. He had his wife, who was not a pilot, sit in the airplane and hold the toe-brakes with her feet. The parking brake was not set. When the engine started, the airplane began to roll forward, and the pilot's wife was unable to stop it from moving. The wife stated she was scared of the propeller striking her husband so she turned the airplane away from him. The airplane traveled off the pavement, through a ditch, across a soybean field, and collided with a parked airplane resulting in substantial damage to the left wing. The parked airplane was also damaged. The pilot said the starter was the only mechanical problem with the airplane prior to the accident. He said it was a poor decision to hand-start the engine with an inoperative starter and he should have secured the airplane until it could be inspected by a mechanic. ## Factual narrative The airplane's engine starter was inoperative so the pilot decided to hand-start the engine with the propeller to get it started. He had his wife, who was not a pilot, sit in the airplane and hold the toe-brakes with her feet. The parking brake was not set. When the engine started, the airplane began to roll forward, and the pilot's wife was unable to stop it from moving. The wife stated she was scared of the propeller striking her husband so she turned the airplane away from him. The airplane traveled off the pavement, through a ditch, across a soybean field, and collided with a parked airplane resulting in substantial damage to the left wing. The parked airplane was also damaged. The pilot said the starter was the only mechanical problem with the airplane prior to the accident. He said it was a poor decision to hand-start the engine with an inoperative starter and he should have secured the airplane until it could be inspected by a mechanic. ## Aircraft - Registration: [N9789W](https://openairdocs.org/deregistered/N9789W-2015-03-12), registration cancelled 2015-03-12, S/N 28-23281, built 1967 (OpenAirDocs) - Reported make and model: PIPER PA 28-140 (140) - Registry model: [Piper PA-28-140](https://openairdocs.org/model/piper-pa-28-140) (registry code 7102802) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-23281 - Year built: 1967 - Engines: LYCOMING 0-320 SERIES reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Peter K L'Esperance - Registered owner: Peter K L'Esperance - Airworthiness certificate: Standard, Normal - Departed: 1H0, St. Louis, MO - Destination: 1H0, St. Louis, MO - Airport: 1H0, Creve Couer ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 30; injuries: none; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; seat: none; flight hours: 141 total, 100 in this make and model, 118 as pilot in command, 7 in the last 90 days, 1 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day ## Docket (3 files) The files NTSB released with the investigation on August 21, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=89712. 637 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 523 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415384&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Record of Conversation - Peter L'Esperance (item 2, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415385&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Peter%20L%27Esperance-Master.PDF - Email From Heidi L'Esperance (item 3, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415386&FileExtension=.PDF&FileName=Email%20From%20Heidi%20L%27Esperance-Redacted.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.