# NTSB ERA09CA386: Champion 7AC, N1397E, Westminster, MD, July 3, 2009 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: July 3, 2009, 11:25 local (15:25 UTC) - Place: Westminster, MD - Coordinates: 39.466945, -77.017776 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.4669&lon=-77.0178&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: No injuries - Injuries: 1 uninjured - Status: Completed, report October 19, 2009 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 74223 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA09CA386 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/74223/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=74223 - Page: https://openairdocs.org/ntsb/ERA09CA386 ## Probable cause The pilot's failure to properly set the throttle for start. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Parking/securing: tie-down/mooring](https://openairdocs.org/ntsb-findings/01011020): Aircraft › Aircraft handling/service · Not specified (probable cause); cases with it: [Champion 7AC, 1 case](https://openairdocs.org/ntsb-findings/01011020/cases.md?model=21101MA), [All aircraft, 33 cases](https://openairdocs.org/ntsb-findings/01011020/cases.md) - [Engine controls: power lever](https://openairdocs.org/ntsb-findings/01057603): Aircraft › Aircraft power plant · Incorrect use/operation (probable cause); cases with it: [Champion 7AC, 1 case](https://openairdocs.org/ntsb-findings/01057603/cases.md?model=21101MA), [All aircraft, 95 cases](https://openairdocs.org/ntsb-findings/01057603/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Champion 7AC, 2 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=21101MA), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/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: [Champion 7AC, 4 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=21101MA), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) ## Analysis The pilot stated that he attempted to start the engine by "hand-propping." The engine started briefly and then stopped. The pilot added that he then primed the engine but "forgot the throttle in the full open position." He hand-propped the engine again, and it started. The airplane began to accelerate forward and became airborne. The airplane flew down a ravine and collided into trees. The pilot stated that the accident could have been prevented if the airplane had been tied down during the engine start. ## Factual narrative The pilot stated that he attempted to start the engine by "hand-propping." The engine started briefly and then stopped. The pilot added that he then primed the engine but "forgot the throttle in the full open position." He hand-propped the engine again, and it started. The airplane began to accelerate forward and became airborne. The airplane flew down a ravine and collided into trees. The pilot stated that the accident could have been prevented if the airplane had been tied down during the engine start. ## Aircraft - Registration: [N1397E](https://openairdocs.org/aircraft/N1397E), registered now, S/N 7AC-4959, built 1946 (OpenAirDocs) - Reported make and model: CHAMPION 7AC - Registry model: [Champion 7AC](https://openairdocs.org/model/champion-7ac) (registry code 21101MA) (OpenAirDocs) - Registry engine: [Continental A&C65 series](https://openairdocs.org/engine/continental-a-c65-series) (registry code 17003, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 7AC-4959 - Airframe hours: 4858 - Engines: CONT MOTOR A&C65 SERIES 65 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Utility - Last inspection: Annual, September 1, 2008 - Departed: 2W2, Westminster, MD - Destination: W48, Baltimore, MD - Airport: 2W2, Clearview Airpark, runway 32, 1,840 × 30 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 72; injuries: none; flight instructor, private, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review May 31, 2008; flight hours: 8,600 total, 3,000 in this make and model, 8,500 as pilot in command, 75 in the last 90 days, 25 in the last 30 days, 5 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 320° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 75 °F, dew point 52 °F - Altimeter: 29.84 inHg - Observed at: DMW, 8 nm away ## Docket (2 files) The files NTSB released with the investigation on August 24, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=74223. 750 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 687 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40317237&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Pilot Statement (item 2, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40317238&FileExtension=.PDF&FileName=Pilot%20Statement-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.