# NTSB CEN19LA223: Cessna 177, N29516, Elkhart, IN, July 14, 2019 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: July 14, 2019, 11:00 local (15:00 UTC) - Place: Elkhart, IN - Coordinates: 41.720535, -85.979141 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.7205&lon=-85.9791&mi=10 - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Defining event: [Standing: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: Minor injuries - Injuries: 2 minor, 3 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA - NTSB case key (mKey): 99833 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19LA223 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99833/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99833 - Page: https://openairdocs.org/ntsb/CEN19LA223 ## Probable cause An inadvertent engine start of the airplane and subsequent takeoff without the pilot on-board for reasons that could not be determined based on available evidence. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine starting](https://openairdocs.org/ntsb-findings/01058000): Aircraft › Aircraft power plant · Unintentional use/operation (probable cause); cases with it: [Cessna 177, 1 case](https://openairdocs.org/ntsb-findings/01058000/cases.md?model=2073704), [All aircraft, 7 cases](https://openairdocs.org/ntsb-findings/01058000/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot; cases with it: [Cessna 177, 4 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=2073704), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Cessna 177, 4 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=2073704), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Standing: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Cessna 177, 11 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=2073704), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) ## Analysis The pilot preflighted the airplane for a flight with two passengers. The passengers sat in the airplane with their seatbelts secured when the pilot lowered the propeller blade by manually “smacking it down” in a clockwise direction. The engine started, and the airplane began to move forward under its own power. The pilot attempted to board the airplane while it was rolling but was unable to. The airplane traveled across a ramp area, through a grassy area, over a taxiway, and up a slight grade where it became airborne momentarily before it came to rest in a field. The airplane sustained substantial damage. Postaccident examination of the airplane found the mixture and throttle in the full-forward position and the ignition key removed from the ignition. The key’s position before the accident could not be confirmed. When the pilot rotated the propeller an inadvertent engine start occurred. The reason for the inadvertent start could not be determined based on available evidence. ## Factual narrative On July 14, 2019, about 1100 central daylight time, a Cessna 177 airplane, N29516, was substantially damaged when it was involved in an accident near Elkhart, Indiana. The pilot and two passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, he placed two passengers into the airplane (a child was in the rear right seat and an adult in the front right seat) and had them secure their seatbelts. He then began a preflight, which he completed while the passengers waited in the airplane. While standing in front of the airplane’s nose and checking the tension on the propeller belt, the pilot lowered the propeller blade by “smacking it down” in a clockwise direction. The engine started, and the airplane began to move forward under its own power; the pilot jumped out of the way. The airplane proceeded toward the grass between the ramp and the taxiway, then continued over the taxiway and over the grass between the taxiway and the runway, and up over the runway where it became airborne. The airplane came back down on the other side of the runway and stopped in an adjacent wheat field. The airplane received substantial damage to the forward fuselage structure. According to the adult passenger, the pilot was standing in the front of the airplane and spun the propeller “a little” and “all of a sudden, the airplane came roaring to life.” The pilot jumped and tried to run around to get in the airplane but was unable. She tried to reach the brake pedals with her feet to stop the airplane, but she could not reach the pedals. The pilot stated the key was in the ignition but not turned to “START,” and he could not recall the configuration of the mixture and throttle during his preflight walkaround. According to an FAA inspector, the mixture and throttle were in the full forward position during the on-scene examination. The ignition key had been removed from the ignition after the accident and was sitting on the right seat, so the position of the switch at the time of the accident could not be verified. The inspector did not remove the engine cowling or examine any components within the engine compartment. ## Aircraft - Registration: [N29516](https://openairdocs.org/deregistered/N29516-2019-12-23), registration cancelled 2019-12-23, S/N 17700938, built 1968 (OpenAirDocs) - Reported make and model: Cessna 177 (Undesignat) - Registry model: [Cessna 177](https://openairdocs.org/model/cessna-177) (registry code 2073704) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17700938 - Year built: 1968 - Engines: Lycoming O-320 SERIES 150 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Airport: EKM, Elkhart Muni - Equipment: Handheld GPS, Electronic flight bag or handheld device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 52; injuries: none; private; airplane ratings: single-engine land; medical: sport pilot, without waivers/limitations; last flight review July 1, 2019; seat: none; restraint: none; flight hours: 2,200 total, 2,200 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 70° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 81 °F, dew point 63 °F - Altimeter: 30.15 inHg - Observed at: KSBN, 15 nm away - METAR: KSBN 141454Z 07007KT 10SM CLR 27/17 A3015 RMK AO2 SLP203 T02670172 51002 ## 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 20190714011629A](https://openairdocs.org/incident/20190714011629A), Jul 14, 2019: Cessna 177, Elkhart, IN, Substantial damage. On or about July 14, 2019 at approximately 11:00 eastern daylight time, a Cessna 177 aircraft, N29516, registered to [privacy data omitted], received… ## Docket (5 files) The files NTSB released with the investigation on December 13, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99833. 2.3 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 565 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12313714&FileExtension=pdf&FileName=CEN19LA223%206120%20completed%20w%20blocks_Redacted-Rel.pdf - Record of conversation with pilot (item 2, PDF, 1 page, 121 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12313669&FileExtension=pdf&FileName=Record%20of%20Conversation%20with%20Pilot-Rel.pdf - Passenger statement (item 3, PDF, 2 pages, 207 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12313258&FileExtension=pdf&FileName=Jennifer%20Rentfrow%20-%20PAX%20Statement-Rel.pdf - Record of conversation with FAA inspector (item 4, PDF, 1 page, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12313381&FileExtension=pdf&FileName=Record%20of%20Conversation%20with%20FAA%20Inspector-Rel.pdf - Photographs (item 5, PDF, 2 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12313573&FileExtension=pdf&FileName=Photos%20for%20Docket-Rel.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.