# NTSB ERA12CA323: Beech A36, N1819L, Paducah, KY, May 8, 2012 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: May 8, 2012, 10:00 local (15:00 UTC) - Place: Paducah, KY - Coordinates: 37.05611, -88.770278 - Nearby events: https://openairdocs.org/map.md?lat=37.0561&lon=-88.7703&mi=10 - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Defining event: [Standing-engine(s) start-up: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report September 13, 2012 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 83583 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA12CA323 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/83583/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=83583 - Page: https://openairdocs.org/ntsb/ERA12CA323 ## Probable cause The pilot’s failure to properly secure the airplane before turning the propeller by hand. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech A36, 8 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=1151604), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/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: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) (defining event); cases with it: [Beech A36, 10 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=1151604), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Standing-engine(s) start-up: Ground collision](https://openairdocs.org/ntsb-events/200); cases with it: [Beech A36, 3 cases](https://openairdocs.org/ntsb-events/200/sequence.md?model=1151604), [All aircraft, 618 cases](https://openairdocs.org/ntsb-events/200/sequence.md) ## Analysis The pilot stated that the airplane's starter had been malfunctioning for about 1 month. On the day of the accident, he unsuccessfully attempted to start the engine from inside the airplane, then exited the airplane, and turned the propeller "slowly." The pilot’s intent in turning the propeller was not to start the engine. However, the engine started unexpectedly, and the airplane traveled across the ramp and impacted a parked airplane, resulting in substantial damage. ## Factual narrative The pilot stated that the airplane's starter had been malfunctioning for approximately one month. On the day of the accident, he unsuccessfully attempted to start the engine from inside the airplane, then exited the airplane and turned the propeller "slowly," but stated he did not intend to hand-prop the engine. He stated that the engine then started unexpectedly, traveled across the ramp, and impacted a parked airplane, resulting in substantial damage. ## Aircraft - Registration: [N1819L](https://openairdocs.org/aircraft/N1819L), registered now, S/N E-838 (OpenAirDocs) - Reported make and model: BEECH A36 - Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: E-838 - Airframe hours: 4955 - Engines: CONT MOTOR IO550 SERIES 300 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Carl Marquess - Registered owner: Momar LLC - Airworthiness certificate: Standard, Normal; Standard, Utility - Last inspection: Annual, January 20, 2012 - Departed: PAH, Paducah, KY - Destination: PAH, Paducah, KY - Airport: PAH, Barkley Regional Airport ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review November 8, 2010; flight hours: 1,924 total, 1,690 in this make and model, 1,819 as pilot in command, 32 in the last 90 days, 4 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 330° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: 7,000 ft overcast - Temperature: 70 °F, dew point 57 °F - Altimeter: 29.95 inHg - Observed at: PAH ## 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 20120508009131A](https://openairdocs.org/incident/20120508009131A), May 8, 2012: Beech A36, Paducah, KY, Substantial damage. The pilot attempted to start his aircraft engine, but found that the starter would not engage. Having had similar issues in the past, the pilot exited the… ## Docket (3 files) The files NTSB released with the investigation on July 10, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=83583. 2.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40370243&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Memorandum for Record - FAA Inspector (item 2, .PDF, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40370245&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20FAA%20Inspector-Master.PDF - Photo (Courtesy of FAA) (item 3, .PDF, 250 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40370247&FileExtension=.PDF&FileName=Photo%20(Courtesy%20of%20FAA)-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.