CEN17LA135

NTSB accident investigation · Luscombe 8F · Vicksburg, MI · March 20, 2017

Accident · FatalLimited investigationFinal report
Date
March 20, 2017, 16:44 local (21:44 UTC)
Place
Vicksburg, MI
Injuries
1 fatal
Damage
No damage
Phase of flight
Prior to flight
Aircraft
N2007BLuscombe 8F
Defining event
Prior to flight: AC/prop/rotor contact w person
Weather
Visual (VMC) · Day
Status
Completed · report October 1, 2018
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA
FAA report
20170320002809A
Case key
94894

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's inadvertent contact with the propeller while hand propping the engine, which resulted in a fatal injury.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Action: incorrect action performancePersonnel issues › Action/decision · PilotLuscombe 8F: 1 caseAll aircraft: 1,386 casesProbable cause
Workload management: task allocationPersonnel issues › Task performance · PilotLuscombe 8F: 1 caseAll aircraft: 12 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The commercial pilot was found lying on the ground under the nose of the airplane with a fatal head injury from a propeller strike. Normal engine start for this airplane required hand propping the engine. The airplane was found with the left wheel chocked, and the magneto, throttle control, primer, and fuel tank selector settings as expected for an engine start. It is likely that, during hand propping, the pilot inadvertently entered the path of the propeller. The Federal Aviation Administration advises pilots that hand propping should only be attempted with two properly trained people, and the pilot was alone when he was fatally injured.

Factual narrative

On March 20, 2017, about 1644 central daylight time, the pilot of a Luscombe 8F, N2007B, was struck by the airplane's propeller as he attempted an engine start at Thrall Lake Airport (7MI3), Vicksburg, Michigan. The commercial pilot was fatally injured, and the airplane did not sustain damage. The airplane was registered to a private individual and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed for the flight that was originating when the accident occurred, and no flight plan was filed. According to the local police report, on the afternoon of the day of the accident, the pilot's wife called a friend of the pilot to inquire about the whereabouts of her husband. After attempting to contact the missing pilot, the friend drove to the airport where he observed the pilot lying on the grass under the nose of the airplane with a fatal head injury. The friend reported the accident to the police about 1844. The airport owner responded to the airport at the request of the police; he thought the pilot was attempting to start the airplane by hand propping it when he was injured. The magneto switch was in the "Both" position; the throttle was at idle; the primer was in the unlocked position; and the fuel tank selector "was in the 'ON' position." Additionally, the owner stated that it appeared that the pilot was intending to fly the airplane given that the airplane was refueled, and the left tire was chocked as the pilot always did when preparing for a flight. According to the airport owner, the accident occurred after his employees left the airport about 1600. The owner of the airplane stated that the pilot had been flying the airplane for about 15 years. He believed that the pilot "had extensive knowledge of the use and precautionary measures needed" to hand prop the engine, which was the normal starting procedure for the airplane. According to the owner, there were no known malfunctions or failures with the propeller, airframe, or engine that would have precluded normal operation. The Federal Aviation Administration's (FAA) Airplane Flying Handbook states that hand propping an airplane "is a critical procedure never [to] be attempted alone. And propping should only be attempted when two properly trained people, both familiar and experienced with the airplane and hand propping techniques, are available to perform the procedure." The handbook describes the recommended procedure and communication/commands to be used when hand propping. The Department of Pathology, Western Michigan University, Kalamazoo, Michigan, performed an autopsy of the pilot and determined that the cause of death was craniocerebral injuries. The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing on specimens from the pilot. The toxicology results were negative for ethanol and drugs.

Aircraft

Registration
N2007B
Reported as
Luscombe 8F (E)
Category
Airplane
Serial number
6434
Built
1948
Engine
Continental C-90-18F, reciprocating
Damage
No damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Departed
7MI3 · Vicksburg, MI
Airport
7MI3 · Thrall Lake
Equipment
Unknown

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
52
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Seat
None
Toxicology
Performed
Flight hours
1,180 total

Weather

Conditions
Visual (VMC) · Day
Wind
140° at 6 knots
Visibility
10 statute miles
Temperature
45 °F, dew point 30 °F
Altimeter
30.29 inHg
Observed at
KAZO, 7 nm away

Docket · 3

The files NTSB released with the investigation on August 27, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.1 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.