# NTSB ERA14LA257: P&M Quikr, N428PM, Gulf Shores, AL, May 22, 2014 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: May 22, 2014, 18:30 local (23:30 UTC) - Place: Gulf Shores, AL - Coordinates: 30.285833, -87.675552 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=30.2858&lon=-87.6756&mi=10 - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Defining event: [Standing-engine(s) start-up: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report April 27, 2015 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 89270 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA14LA257 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/89270/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=89270 - Page: https://openairdocs.org/ntsb/ERA14LA257 ## Probable cause The pilot’s failure to maintain aircraft control during engine startup, which resulted in a collision with a parked airplane. Contributing to the accident was the pilot’s failure to follow engine startup procedures and a sudden surge of engine power for reasons that could not be determined because postaccident examination did not reveal any mechanical malfunctions. ## 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: [P&M QUIKR, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=060006X), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Use of equip/info: use of manual](https://openairdocs.org/ntsb-findings/02063020): Personnel issues › Task performance · Pilot (probable cause); cases with it: [P&M QUIKR, 1 case](https://openairdocs.org/ntsb-findings/02063020/cases.md?model=060006X), [All aircraft, 15 cases](https://openairdocs.org/ntsb-findings/02063020/cases.md) - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [P&M QUIKR, 2 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=060006X), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) - [Object/animal/substance: airport structure](https://openairdocs.org/ntsb-findings/03022042): Environmental issues › Physical environment · Compliance w/ procedure (probable cause); cases with it: [P&M QUIKR, 1 case](https://openairdocs.org/ntsb-findings/03022042/cases.md?model=060006X), [All aircraft, 50 cases](https://openairdocs.org/ntsb-findings/03022042/cases.md) - [Object/animal/substance: aircraft](https://openairdocs.org/ntsb-findings/03022040): Environmental issues › Physical environment · Contributed to outcome; cases with it: [P&M QUIKR, 1 case](https://openairdocs.org/ntsb-findings/03022040/cases.md?model=060006X), [All aircraft, 116 cases](https://openairdocs.org/ntsb-findings/03022040/cases.md) - [Physical workspace](https://openairdocs.org/ntsb-findings/03041000): Environmental issues › Task environment · Not specified; cases with it: [P&M QUIKR, 1 case](https://openairdocs.org/ntsb-findings/03041000/cases.md?model=060006X), [All aircraft, 5 cases](https://openairdocs.org/ntsb-findings/03041000/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: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) (defining event); cases with it: [P&M QUIKR, 1 case](https://openairdocs.org/ntsb-events/340/sequence.md?model=060006X), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Standing-engine(s) start-up: Loss of control on ground](https://openairdocs.org/ntsb-events/230); cases with it: [P&M QUIKR, 1 case](https://openairdocs.org/ntsb-events/230/sequence.md?model=060006X), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Standing-engine(s) start-up: Ground collision](https://openairdocs.org/ntsb-events/200); cases with it: [P&M QUIKR, 1 case](https://openairdocs.org/ntsb-events/200/sequence.md?model=060006X), [All aircraft, 618 cases](https://openairdocs.org/ntsb-events/200/sequence.md) ## Analysis The pilot attempted to start the weight-shift-aircraft's engine in an area surrounded by hangars. After about eight attempts to start the engine, it finally engaged and immediately advanced to takeoff power. The aircraft then collided with a parked airplane about 150 ft from its original starting position, spun right, impacted a hangar door, and came to rest. Postaccident examination of the throttle system revealed no mechanical anomalies that would have precluded normal operation. Although two throttle cable snag hazards were identified that could have resulted in a stuck throttle, it could not be determined if either possible hazard caused the throttle to become stuck in the open position. According to the Pilot's Operating Handbook (POH), the aircraft should have been pointing away from people, vehicles, or buildings during startup. The POH also stated that, if the engine does not start after five or six attempts, the pilot should switch the ignition off and investigate the cause of the problem. ## Factual narrative Starting Instructions According to the section entitled "6.3 Starting Engine" in the manufacturer's operating instructions: 6.3 Starting Engine The pilot must always start the engine when sitting in the cockpit with seatbelts secured and helmet worn. Pre-start checks: 1. Passenger should also be strapped in and briefed. 2. Throttles both working and fully shut (never use the hand throttle for engine control on the ground). · If starter interrupt switch is fitted, starter will not operate unless hand throttle is CLOSED. Warning: Engine start-up is always a potentially dangerous time. Make sure that you have done all your checks, that you are not disturbed while doing them, and that you are entirely happy that the aircraft is in a fit state to be started-up. Finally, before start-up, ensure that the aircraft is pointing away from people/vehicles/buildings etc, and that there are no pets or other animals which could panic after start-up. Double check that the propeller is clear and hand throttle is closed before starting the engine. STARTING: check visually again that the propeller area is clear and call "Clear Prop" loudly. Pause. Turn on the key switch, set the contacts to ON, then push the button in 5 seconds bursts. Release the button as soon as the engine fires. If the engine refuses to start after 5 or 6 attempts, close the controls and switch OFF the ignition before investigation. According to the FAA Aircraft Registry, the accident airplane was manufactured in 2009. The special light sport weight-shift-control category aircraft was equipped with a three-bladed Warp Drive propeller and one Rotax 912ULS model four stroke engine, rated at 100 horse-power. The airplane's most recent condition inspection was completed on April 1, 2014, and at that time the airplane had accumulated 179.1 total flight hours. Throttle System The airplane was equipped with a foot throttle that automatically returned to the CLOSED position, similar to the accelerator in an automobile, and a friction-dampened hand throttle. The airplane was also equipped with a starter motor solenoid interrupt switch that prevented the engine from starting with the handle throttle engaged. The throttle cables connected to a splitter, which contained a single piston that was designed to open and close the butterfly valves to both carburetors when the throttles were moved. The carburetors were originally designed by the engine manufacturer to default to the open position in the event of a severed cable, but were altered by the airframe manufacturer to spring-shut. On May 22, 2014, about 1830 central daylight time, a special light sport P&M Aviation QuikR weight shift aircraft, N428PM, was substantially damaged at Jack Edwards National Airport (JKA), Gulf Shores, Alabama. The airline transport pilot sustained serious injuries. Visual meteorological conditions prevailed for the personal flight and no flight plan was filed for the local flight. The flight was conducted under the provisionsof Title 14 Code of Federal Regulations Part 91. According to the pilot's written statement, he performed a preflight inspection of the aircraft and then attempted to start the engine in an area surrounded by hangars. He applied full choke, set the hand throttle to idle, applied full left foot brake and placed the magnetos in the ON position. After making about four unsuccessful attempts to start the engine, the pilot moved the choke back and forth and left it about halfway. He introduced a "little bit of right foot throttle" and, after about four more attempts, the engine started and "immediately" advanced to "takeoff power." The pilot applied full left foot brake, but the aircraft moved forward at increasing speed. He attempted to keep the aircraft on the taxiway centerline by steering the nose wheel. The pilot also held the control bar with his left hand and groped the instrument panel with his right hand for the magneto cutoff. He eventually disengaged one of the two magnetos; however, the right wing of the aircraft impacted the cowling of a parked airplane located to the right of the taxiway centerline. The aircraft spun to the right, impacted a hangar door, and came to rest. Postaccident examination of the accident aircraft by a Federal Aviation Administration (FAA) inspector revealed damage to the left wing spar. The parked airplane also sustained damage to the propeller and nose cowling. Further examination of the engine control system revealed that the foot pedal throttle and hand throttle both operated smoothly with no binding. The 1835 recorded weather observation at JKA included wind from 240 degrees at 9 knots, temperature 27 degrees C, and an altimeter setting of 30.09 inches of mercury. The pilot held an airline transport certificate with ratings for airplane single and multiengine land. He had accumulated about 12,737 total hours of flight time, of which 72 hours were in the accident airplane make and model. The initial impact point was the cowling of a parked airplane located about 150 feet from the accident pilot's hangar. According to the FAA inspector, the left wing spar was broken and there was torn cloth on both the left wing and top center sail. All flight control surfaces remained attached to their respective airframe components, and flight control continuity was traced from each flight control surface to the cockpit. All three carbon fiber propeller blades had separated; blade A was broken outboard, blade B was broke mid-span, and blade C was broken inboard near the hub. Further examination took place in a secure hangar at JKA by a representative of the airframe manufacturer under the supervision of a FAA inspector. The engine case was undamaged and free of oil or fuel leaks. The right throttle foot pedal was operated several times and some abnormal friction was noted; however, both carburetors opened and closed each time the foot pedal was depressed and released. The hand throttle was also advanced to the ON positionand retarded to the OFF position several times, and during each operation both carburetors opened and closed. During each operation of the hand throttle, the hand throttle interrupt switch could be heard, which indicated that the solenoid switch was engaging. The hand choke also functioned normally and no binding or damage was noted. The foot throttle cable extended from the right foot pedal behind a pod support bracket and to the left foot position along the basetube. Postaccident examination revealed two snag hazards that caused the foot throttle to remain in the open position. In one example, when the foot throttle was depressed the throttle cable could be manipulated by hand to snag on a bolt that fastened the pod support bracket to the fuselage. In another example, the foot throttle cable could be manipulated by hand to snag on the pilot's left foot, which unseated the throttle cable end and caused the foot throttle to stick open. ## Aircraft - Registration: [N428PM](https://openairdocs.org/aircraft/N428PM), registered now, S/N 8428, built 2009 (OpenAirDocs) - Reported make and model: P&M AVIATION LTD QUIKR - Registry model: [P&M QUIKR](https://openairdocs.org/model/p-m-quikr) (registry code 060006X) (OpenAirDocs) - Registry engine: [Rotax 912ULS series](https://openairdocs.org/engine/rotax-912uls-series) (registry code 55572, 4 cycle) (OpenAirDocs) - Category: Weight-shift - Serial number: 8428 - Year built: 2009 - Airframe hours: 182 - Engines: Rotax 912 ULS 100 horsepower reciprocating - Damage: Minor damage - Flight: Personal, Part 91 - Operator: Wendelburg Kevin R - Registered owner: Wendelburg Kevin R - Airworthiness certificate: Special, Special light-sport (Special) - Last inspection: Condition, April 1, 2014, 182 hours before - Departed: JKA, Gulf Shores, AL - Destination: JKA, Gulf Shores, AL - Airport: JKA, Jack Edwards ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 45; injuries: serious; airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review March 24, 2014; seat: front; restraint: 3-point; flight hours: 12,737 total, 72 in this make and model, 2,370 as pilot in command, 29 in the last 90 days, 26 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 240° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 81 °F, dew point 66 °F - Altimeter: 30.09 inHg - Observed at: JKA ## 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 20140522008951A](https://openairdocs.org/incident/20140522008951A), May 22, 2014: P&M Aviation Ltd QUIKR, Gulf Shores, AL, Substantial damage. During engine start between two rows of t-hangars, the pilot stated that he had twice tried, but failed, to get the engine to start. He said he then moved the… ## Docket (15 files) The files NTSB released with the investigation on March 24, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=89270. 15.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423791&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Memorandum of Record - Pilot (item 2, .PDF, 911 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423792&FileExtension=.PDF&FileName=Memorandum%20of%20Record%20-%20Pilot-Redacted.PDF - Weather Report and Record (item 3, .PDF, 194 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423793&FileExtension=.PDF&FileName=Weather%20Report%20and%20Record-Master.PDF - FAA Damage Assessment (item 4, .PDF, 222 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423794&FileExtension=.PDF&FileName=FAA%20Damage%20Assessment-Redacted.PDF - FAA Stuck Throttle Notes (item 5, .PDF, 594 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423795&FileExtension=.PDF&FileName=FAA%20Stuck%20Throttle%20Notes-Redacted.PDF - Report from Airframe Manufacturer (item 6, .PDF, 492 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423796&FileExtension=.PDF&FileName=Report%20from%20Airframe%20Manufacturer-Redacted.PDF - Excerpts from Pilot's Operating Handbook (item 7, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423797&FileExtension=.PDF&FileName=Excerpts%20from%20Pilot%27s%20Operating%20Handbook-Master.PDF - Excerpt from Aircraft Logbook (item 8, .PDF, 668 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423798&FileExtension=.PDF&FileName=Excerpt%20from%20Aircraft%20Logbook-Redacted.PDF - Excerpts from Airframe Manufacturer Illustrated Parts Catalogue (item 9, .PDF, 136 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423799&FileExtension=.PDF&FileName=Excerpts%20from%20Airframe%20Manufacturer%20Illustrated%20Parts%20Catalogue-Master.PDF - Certification of Party Representative Forms (item 10, .PDF, 505 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423800&FileExtension=.PDF&FileName=Certification%20of%20Party%20Representative%20Forms-Redacted.PDF - Release of Wreckage (item 11, .PDF, 162 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423801&FileExtension=.PDF&FileName=Release%20of%20Wreckage-Redacted.PDF - Runaway Throttle Article (item 12, .PDF, 6.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423802&FileExtension=.PDF&FileName=Runaway%20Throttle%20Article-Master.PDF - Photo 1 - Carburetor 1 Mixture and Throttle Controls (Courtesy of FAA) (item 13, .PDF, 640 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423803&FileExtension=.PDF&FileName=Photo%201%20-%20Carburetor%201%20Mixture%20and%20Throttle%20Controls%20(Courtesy%20of%20FAA)-Master.PDF - Photo 2 - Carburetor 1 Throttle Control in Closed Position (Photo Courtesy of FAA) (item 14, .PDF, 654 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423828&FileExtension=.PDF&FileName=Photo%202%20-%20Carburetor%201%20Throttle%20Control%20in%20Closed%20Position%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo 3 - Foot Throttle and Cable (Photo Courtesy of FAA) (item 15, .PDF, 603 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423829&FileExtension=.PDF&FileName=Photo%203%20-%20Foot%20Throttle%20and%20Cable%20(Photo%20Courtesy%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.