# NTSB ERA13CA091: Piper PA28R, N3915T, Newport News, VA, December 15, 2012 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: December 15, 2012, 14:31 local (19:31 UTC) - Place: Newport News, VA - Coordinates: 37.131942, -76.493057 - Nearby events: https://openairdocs.org/map.md?lat=37.1319&lon=-76.4931&mi=10 - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Defining event: [Standing-engine(s) start-up: Ground collision](https://openairdocs.org/ntsb-events/200) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report April 3, 2013 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 85832 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA13CA091 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/85832/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=85832 - Page: https://openairdocs.org/ntsb/ERA13CA091 ## Probable cause The pilot’s failure to properly monitor the flight controls (toe brake pedals) during engine start. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28R-180, 17 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102809), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Attention/monitoring: monitoring equip/instruments](https://openairdocs.org/ntsb-findings/02021525): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Piper PA-28R-180, 1 case](https://openairdocs.org/ntsb-findings/02021525/cases.md?model=7102809), [All aircraft, 142 cases](https://openairdocs.org/ntsb-findings/02021525/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: Ground collision](https://openairdocs.org/ntsb-events/200) (defining event); cases with it: [Piper PA-28R-180, 1 case](https://openairdocs.org/ntsb-events/200/sequence.md?model=7102809), [All aircraft, 618 cases](https://openairdocs.org/ntsb-events/200/sequence.md) ## Analysis The pilot stated that he positioned his feet on the toe brake pedals during engine start. After starting, the engine accelerated to a higher rpm than the pilot expected, and the airplane began to roll forward. The pilot pressed down with his feet, but the airplane continued to roll. After reducing the throttle to idle, the pilot attempted to steer the airplane with the rudder pedals, but they were fixed and would not move. As the airplane neared a hangar, the pilot shut down the engine with the fuel mixture control and turned the magneto switch off. The airplane then impacted the hangar, resulting in substantial damage to both wings. Postaccident examination revealed no anomalies with the rudder pedal or toe brake systems. In a postaccident statement, the pilot offered that, rather than placing his feet on the brake pedals, he inadvertently pressed on the torque tube assembly, which is part of the airframe structure located above the toe brake pedals. ## Factual narrative The pilot stated that he positioned his feet on the toe brake pedals during engine start. After starting, the engine accelerated to a higher rpm than expected, and the airplane began to roll forward. The pilot pressed down with his feet, but the airplane continued to roll. After reducing the throttle to idle, the pilot attempted to steer the airplane with the rudder pedals, but stated that they were fixed and would not move. As the airplane neared a hangar, the pilot shut down the engine with the fuel mixture control and turned the magneto switch off. The airplane then impacted the hangar, resulting in substantial damage to both wings. Postaccident examination by a Federal Aviation Administration inspector revealed no anomalies of the rudder pedal or toe brake systems. The pilot offered that he inadvertently pressed on the torque tube assembly, which was part of the airframe structure located above the toe brake pedals. ## Aircraft - Registration: [N3915T](https://openairdocs.org/deregistered/N3915T-2013-01-07), registration cancelled 2013-01-07, S/N 28R-30251, built 1967 (OpenAirDocs) - Reported make and model: PIPER PA28R (180) - Registry model: [Piper PA-28R-180](https://openairdocs.org/model/piper-pa-28r-180) (registry code 7102809) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28R-30251 - Airframe hours: 1133.5 - Engines: LYCOMING IO360 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Rick Aviation, Inc - Registered owner: Rick Aviation, Inc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, April 2, 2012 - Departed: PHF, Newport News, VA - Destination: PHF, Newport News, VA - Flight plan: VFR - Airport: PHF, Newport News International ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 52; injuries: none; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review April 14, 2012; seat: left; flight hours: 199 total, 18 in this make and model, 163 as pilot in command, 20 in the last 90 days, 11 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 100° at 4 knots - Visibility: 6 statute miles - Lowest ceiling: none - Temperature: 54 °F, dew point 32 °F - Altimeter: 30.23 inHg - Observed at: PHF ## 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 20121215027289A](https://openairdocs.org/incident/20121215027289A), Dec 15, 2012: Piper PA-28R-180, Newport News, VA, Destroyed. During the starting process the airman intended to apply the aircraft brakes but instead placed his feet high enough to have is toes on the cross-tube of the… ## Docket (4 files) The files NTSB released with the investigation on January 28, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=85832. 3.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 722 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384923&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Memorandum for Record - Pilot (item 2, .PDF, 115 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384924&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20Pilot-Master.PDF - Photo 1 - Damage to airplane (Courtesy of FAA) (item 3, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384925&FileExtension=.PDF&FileName=Photo%201%20-%20Damage%20to%20airplane%20(Courtesy%20of%20FAA)-Master.PDF - Photo 2 - Rudder/brake pedals and torque tube (Courtesy of FAA) (item 4, .PDF, 929 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384926&FileExtension=.PDF&FileName=Photo%202%20-%20Rudder%2Fbrake%20pedals%20and%20torque%20tube%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.