# NTSB CEN15CA324: Aero Commander 100, N5542M, San Antonio, TX, July 23, 2015

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Data collection · Final report
- Date: July 22, 2015, 20:48 local (Jul 23, 2015, 01:48 UTC)
- Place: San Antonio, TX
- Coordinates: 29.336944, -98.471107 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=29.3369&lon=-98.4711&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: Serious injuries
- Injuries: 1 serious, 1 minor
- Status: Completed, report March 14, 2016
- Report: Approved by Office Director
- NTSB office: Central Region
- Parties: Federal Aviation Administration; San Antonio FSDO
- NTSB case key (mKey): 91656
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN15CA324
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91656/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91656
- Page: https://openairdocs.org/ntsb/CEN15CA324

## Probable cause

The pilot's improper decision to attempt flight with an unairworthy airplane and improper starting procedure that resulted in an uncontrolled takeoff without the pilot aboard. Contributing was the inoperative airplane battery/engine starter.

## 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: [Aero Commander 100, 4 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=0140202), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md)
- [Use of equip/info](https://openairdocs.org/ntsb-findings/02063000): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Aero Commander 100, 1 case](https://openairdocs.org/ntsb-findings/02063000/cases.md?model=0140202), [All aircraft, 111 cases](https://openairdocs.org/ntsb-findings/02063000/cases.md)
- [Electrical power system: battery/charger](https://openairdocs.org/ntsb-findings/01022432): Aircraft › Aircraft systems · Inoperative (probable cause); cases with it: [Aero Commander 100, 1 case](https://openairdocs.org/ntsb-findings/01022432/cases.md?model=0140202), [All aircraft, 37 cases](https://openairdocs.org/ntsb-findings/01022432/cases.md)
- [Equipment/furnishings: passenger compartment equip](https://openairdocs.org/ntsb-findings/01022520): Aircraft › Aircraft systems · Not installed/available; cases with it: [Aero Commander 100, 1 case](https://openairdocs.org/ntsb-findings/01022520/cases.md?model=0140202), [All aircraft, 24 cases](https://openairdocs.org/ntsb-findings/01022520/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Aero Commander 100, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=0140202), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md)
- [Standing-engine(s) start-up: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Aero Commander 100, 1 case](https://openairdocs.org/ntsb-events/230/sequence.md?model=0140202), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md)
- [Pushback/tow-engine start-up: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Aero Commander 100, 4 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=0140202), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md)
- [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Aero Commander 100, 6 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=0140202), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## Analysis

The pilot attempted to start the airplane engine by hand propping it because the engine could not be started using the starter because the battery was dead. The airplane had a chock under the left main landing gear wheel, and the pilot side door was propped open with a passenger aboard for the engine start. Upon engine start, the airplane jumped the chock and began to accelerate along the ground. The pilot ran along side of the airplane attempting to open the pilot side door, which had closed. When the airplane speed became too fast for the pilot to run alongside of the airplane, he stood on the main landing gear, holding the strut, and continued to attempt entry into the airplane while telling the passenger to pull the brake, throttle, mixture, or turn off the ignition key switch. The airplane impacted a 10-inch barrier, knocking the pilots legs off the main landing gear, and the airplane ran over the pilot's leg. The pilot pulled up onto the wing strut, still giving instruction to the passenger while attempting to enter the pilot side door, but the prop-wash was making this "feat impossible". About 59 mph, the airplane departed the airfield, becoming airborne, and at 6 feet above ground level, the pilot let go of the wing strut and fell to the ground. The airplane climbed, nosed forward, touched down on the nose landing gear, and impacted a construction dirt pilot before it nosed-over. The airplane sustained substantial damage that included damage to each wing spar and a bent empennage. The pilot sustained minor injuries, and the passenger sustained serious injuries. The airplane was not equipped with shoulder harnesses and was not required to be equipped with shoulder harnesses. The pilot's experience in hand-propping airplanes and the injuries of the passenger were unknown at the time this report was written.

## Factual narrative

The pilot attempted to start the airplane engine by hand propping it because the engine could not be started using the starter because the battery was dead. The airplane had a chock under the left main landing gear wheel, and the pilot side door was propped open with a passenger aboard for the engine start. Upon engine start, the airplane jumped the chock and began to accelerate along the ground. The pilot ran along side of the airplane attempting to open the pilot side door, which had closed. When the airplane speed became too fast for the pilot to run alongside of the airplane, he stood on the main landing gear, holding the strut, and continued to attempt entry into the airplane while telling the passenger to pull the brake, throttle, mixture, or turn off the ignition key switch. The airplane impacted a 10-inch barrier, knocking the pilots legs off the main landing gear, and the airplane ran over the pilot's leg. The pilot pulled up onto the wing strut, still giving instruction to the passenger while attempting to enter the pilot side door, but the prop-wash was making this "feat impossible". About 59 mph, the airplane departed the airfield, becoming airborne, and at 6 feet above ground level, the pilot let go of the wing strut and fell to the ground. The airplane climbed, nosed forward, touched down on the nose landing gear, and impacted a construction dirt pilot before it nosed-over. The airplane sustained substantial damage that included damage to each wing spar and a bent empennage. The pilot sustained minor injuries, and the passenger sustained serious injuries. The airplane was not equipped with shoulder harnesses and was not required to be equipped with shoulder harnesses. The pilot's experience in hand-propping airplanes and the injuries of the passenger were unknown at the time this report was written.

## Aircraft

- Registration: [N5542M](https://openairdocs.org/deregistered/N5542M-2021-07-03), registration cancelled 2021-07-03, S/N 104, built 1967 (OpenAirDocs)
- Reported make and model: AERO COMMANDER 100
- Registry model: [Aero Commander 100](https://openairdocs.org/model/aero-commander-100) (registry code 0140202) (OpenAirDocs)
- Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 104
- Year built: 1967
- Airframe hours: 5000
- Engines: Lycoming O-320 reciprocating
- Damage: Substantial damage
- Flight: Business, Part 91
- Operator: Pilot
- Registered owner: Individual
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, May 1, 2015
- Departed: SSF, San Antonio, TX
- Destination: 7F7, Clifton, TX
- Airport: SSF, Stinson Municipal Airport
- Equipment: Stall warning system

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 52; injuries: minor; commercial; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review April 25, 2014; seat: none; restraint: lap only; flight hours: 2,806 total, 30 in this make and model, 2,764 as pilot in command, 79 in the last 90 days, 30 in the last 30 days, 0 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 140° at 10 knots
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 88 °F, dew point 73 °F
- Altimeter: 29.86 inHg
- Observed at: SSF

## 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 20150722015999A](https://openairdocs.org/incident/20150722015999A), Jul 22, 2015: Aero Commander 100, San Antonio, TX, Substantial damage. On July 22, 2015, at 20:40 hours, an aerocommander 100, N5542M , crashed off runway 14 at Stinson airport. VFR flight conditions prevailed and the pilot did…

## Docket (1 files)

The files NTSB released with the investigation on February 3, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91656. 2.5 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435624&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.

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