LAX94LA136

NTSB accident investigation · Piper PA-28-140 · Santa Rosa, CA · February 23, 1994

Accident · Serious injuriesLimited investigationFinal report
Date
February 23, 1994, 10:50 local (18:50 UTC)
Place
Santa Rosa, CA
Injuries
1 serious, 1 uninjured
Damage
No damage
Phase of flight
Standing
Aircraft
N20BSPiper PA-28-140
Weather
Visual (VMC) · Day
Status
Completed · report November 14, 1994
Report
Approved by Office Director
FAA report
19940223010579A
Case key
28675

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

A failure of the pilot-in-command to ensure that the powerplant controls were configured properly before moving the aircraft propeller. Inadequate planning/decision making was a factor in this accident.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Propeller/rotor contact to personStanding - engine(s) not operating
Powerplant controls - improperPilot in command(cfi)Cause
Planning/decision - inadequatePilot in command(cfi)Factor

Analysis

Prior to departing on a training flight, the flight instructor and a student were seated in the airplane attempting to start the engine. The engine turned over slowly, but failed to start. The flight instructor believed the problem to be with the starter. She decided to exit the airplane to reposition the propeller in order to free the starter. In the process, the propeller rotated and struck the head and shoulder of the flight instructor. The student inside the airplane did not manipulate the controls while the instructor was outside. Examination of the cockpit controls revealed that the master switch was off, mixture and throttle controls at idle, and the magneto switch was on.

Factual narrative

On February 23, 1994, about 1050 hours Pacific standard time, the instructor pilot of a Piper PA-28-140, N20BS, was struck by the propeller of the airplane at the Sonoma County Airport, Santa Rosa, California. The airplane was to be operated as a visual flight rules (VFR) instructional flight to Sacramento, California. The airplane, registered to the pilot and operated by Redwood Aviation Enterprises, Santa Rosa, was not damaged. The certificated commercial pilot/certified flight instructor received serious injuries. A student pilot seated in the airplane was not injured. Visual meteorological conditions prevailed.

A Federal Aviation Administration (FAA) operations inspector, Oakland Flight Standards District Office, reported that the pilot and student were preparing to depart on their flight. The student attempted to start the airplane; however, the engine was cranking too slowly to start. The instructor exited the airplane to arrange for an electrical "jump" start. The student inside the airplane did not manipulate the controls while the instructor was outside. The instructor turned the propeller to position it for the start. The engine caught and rotated the propeller, striking the instructor in the head and shoulder. Examination of the cockpit controls revealed that the master switch was OFF, mixture and throttle controls at idle, and the magneto switch was ON.

The pilot reported that she was unsure whether the propeller was stopped at the top of a compression stroke causing it to rotate suddenly when it was moved, or whether the engine actually fired.

Aircraft

Registration
N20BS
Reported as
Piper PA-28-140
Category
Airplane
Serial number
28-22373
Airframe hours
4,298
Engine
Lycoming O-320, 150 horsepower, reciprocating
Damage
No damage
Flight
Instructional · Part 91
Operator
Redwood Aviation Enterprises
Registered owner
Lindholm, Berit
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 4, 1993 · 59 hours before
Destination
SMF · Sacramento, CA
Airport
STS · Sonoma County Airport

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
26
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
780 total · 600 in this make and model · 685 as pilot in command · 82 in the last 90 days · 22 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
320° at 10 knots
Visibility
25 statute miles
Lowest ceiling
None
Temperature
50 °F, dew point 36 °F
Altimeter
30.00 inHg
Observed at
STS

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.